It’s hard to believe that we will leave the village next week to accompany our gap year student to Dar on her way home. Three months has flown since we met Fenella at Heathrow and touched down at Kilimanjaro airport on the way here.
Having cheerful English-speaking company has added a new dimension to our lives, including the cake, board game and rabbit-food-collecting dimensions. She has also strengthened our connection with Moreton Hall School and those there who continue to support the hospital laboratory. A successful Zoom event with the school’s geography and medical/nursing societies added further interest for both parties. While in Milo she has spent some time analysing birth trends in surrounding villages which will provide the focus of discussion with Milo hospital staff before she leaves.
I recall the joy of student life in Liverpool Oxford Street Maternity Hospital when we were each entrusted with delivering 20 babies and repairing perineal tears and episiotomies. Nowadays laboratory simulation has become the focal point of medical student practical training and I cannot imagine the same sense of satisfaction although I dare say the women of Liverpool are relieved. In Milo however, Fenella has already been able to assist at several Caesarean operations and has been learning to sew up the abdominal wound. This week she witnessed the premature birth of a baby with several birth defects – a cleft lip, rudimentary left ear and talipes (club foot). The mother aged 46 has had several other children who are alive and well and it is a mercy this one was too small to survive. She was scanned at an early stage in one of our outreach clinics but these defects are not easily seen in the time available for each scan and there is nothing we can do if we find them. Fenella also has a wonderful short-term memory, readily answering questions during the ultrasound outreach clinics such as, ‘Where was the placenta?’ and ‘How much did that cyst measure?’ making up for my own inattention or short-term memory loss. Happily, I can still describe the dorsal columns of the spinal cord and their malfunction in Tabes Dorsalis, a manifestation of tertiary syphilis. So much of what I learned as a student has remained and can be passed on.
Sexually transmitted infections and their sequelae are encountered every day here. Pregnant women are tested at their first antenatal visit for HIV (10-15% are positive) and syphilis (not infrequent) and women unable to achieve pregnancy because of the damage caused by pelvic infection attend the hospital OPD every week. I am constantly reminded of the vast gulf between our respective health care systems and the ease of accessing IVF through the NHS. Assisted reproductive technology is in its infancy here and will be way beyond the reach of all but the privileged few for the foreseeable future. Last week we drained a huge pelvic abscess at laparotomy in an unfortunate woman whose reproductive days are now over. I used to see these in Liverpool in the 1970s, caused by gonorrhoea, but rarely ever since that time until we came here.
Pathology is so much more advanced in this context before patients seek help. Today a 40-year-old woman came to our outreach clinic with advanced cervical cancer. There is a rudimentary screening program in this district but no cervical cytology service (Pap smear) or colposcopy and biopsy for diagnosis or laser for treatment of pre-invasive disease. She has been referred for biopsy but the nearest histopathology service is in Mbeya, almost on the Malawian border. She will need to go to Dar es Salaam for radiotherapy treatment as the stage of the disease is not amenable to surgical correction.
I am happy to say that the other patients in the outreach clinic were doing well and so was Severin, one of the nurse-midwives who is learning obstetric ultrasound. He took the lead in the clinic and did all of the scans, under supervision and occasional instruction. It takes a long time to become competent in sonography and is good to see him growing in confidence and ability.
Last week we accompanied our other regular ultrasound outreach nurse-midwife to Lugarawa RC Hospital where he was trained and qualified in 2018. He had failed to pay the final year fees but the assistant bursar had insisted he continue the course and pay later. We discovered that many were in the same position as James. He sifted through a large stack of certificates awaiting redemption by other students, seeking for his own. James had been orphaned early in life and brought up by grandparents who told him ‘Education will be your mother and father’ and they supplied the funds for his nurse training until his grandfather fell ill and could do so no longer. We were able to pay his overdue fees and relieve his debt, and also learn that we are but one link in a chain of people investing in his future. It was a delight to see his joy at receiving his certificates and membership card, evidence of his successful completion. It does mean that he is now able to apply for a substantive post elsewhere and no doubt, one day, he will move on. Meanwhile he continues to provide an excellent service for which he receives a small income as a volunteer nurse with St Luke’s.
A training course for Sunday School teachers has just completed in the Bible School and for the first time I have delivered a 5 session training on ‘Godly Play’. Based on the premise that children are spiritual and are as capable of experience the presence of God as an adult if not more so, recognising that we must all ‘become like little children to enter the Kingdom of Heaven’ and that ‘the Kingdom of Heaven’ belongs to them, Godly Play helps children engage with the story of the Christian Faith from the time of Abraham to the birth and growth of the early church through story telling and play using models and other visual aids. The SST students became very involved in the story of the Great Family – the call of Abram and the promise of blessing through his descendants for all nations. It was a good time and I hope many have been inspired to use some of the materials and methods in their own storytelling.
We are well into the cold season and hot water bottles are frequently required at night. Until this week we would sit round a charcoal brazier in the lounge each evening to keep warm, but we now have workmen rebuilding our fireplace. It is a noisy and dirty process but they are doing a great job and we hope that the new design will send smoke up the chimney instead of pouring it into the room. All our firewood was given away months ago and there is nowhere in Milo like the lakeshore of Llyn Tegid where driftwood can readily be gathered. Besides, everyone is competing for the limited supply as most people cook over open fires. We belong to that privileged class who can and must pay for their supply of fuel.
With the cold season has come the usual coughs and colds and hospital admissions with chest infection. The current episode is a particularly nasty and debilitating night-time cough which resulted in the admission of a school teacher’s wife (still breast-feeding her baby) with a chest infection causing her oxygen saturation to fall to the mid-40s. As it is very like the ‘happy hypoxia’ of Covid19, we were very concerned for her well being and for the whole community. She has recently been to a big town on the main bus route to Dar. She has responded well to antibiotics, steroids and nasal oxygen and is holding her own. Many school children and some of the adults have the same symptoms but are not so ill. We are hoping this is just the annual seasonal respiratory affliction and, from what we gather on the grape vine, the third wave of Covid has not really progressed beyond the bigger conurbations.
Our training doll is keeping well despite the lack of resuscitation attempts. We had scheduled a training session this week but three normal vaginal deliveries in maternity coincided and most of the staff who needed to refresh their skills were unavailable, practicing their skills elsewhere. And so the training never happened. I had hoped our student would see this before her departure but there is now only one Tuesday left for her to present her village birth trends survey and to say goodbye to the staff.
Now the end of her time with us is in sight, and although our journey to Julius Nyerere airport will be relieved by a three-day detour into Ruaha wildlife park, it will be sad to say farewell to Fenella. We wish her well with her sojourn in France, where she will spend time with relatives until cleared to return home, rather than quarantine in a designated UK hotel, and of course with her medical studies which she will commence in September. Her departure will be followed swiftly by our welcome of Joseff, our next gap year student, from Bala. When he arrives, we expect to receive another, more ethnically appropriate, doll and will reschedule the resuscitation training. And before long, I expect our European doll will also be on a flight back to UK…
brechdan 