Thursday, 7 June 2018

Lessons from the market - Part 4


Lessons from the market -  part 4

‘Give us this day our daily bread’


Fresh bread baked in our solar cooker
Whether that be a quiet prayer to God, or the cry of a hungry revolutionary mob demanding social justice, bread is seen as essential for life, either as blessing or as a right. It is an everyday staple in many parts of the world, and comes in many different forms. Some types are better for you than others, white flour fortified with iron, wholemeal, multigrain, sour dough are all beneficial in one way or another, but none, as far as I am aware is usually considered a harmful part of our diet. (Gluten-free bread is hopefully still available to those in need it as treatment on the NHS).



When we lived in Ndjamena we could get fresh baguettes each morning from the local lock up store. This is rather surprising as there is little or no grain grown in the French speaking parts of sub-Saharan Africa that I have visited, but in all of them, as a hangover from colonial times, subsidised flour is used to bake a standard priced baguette that is widely available. It presumably helps with social justice and the maintenance of a peaceful society. (Can all this really date back to the famous quote from Marie Antoinette and the hunger riots prior to the French revolution? I like to think so, but it is probably a convenient fiction)

At our home in Bardai, a mountainous mid Saharan oasis, you rarely see a baguette, but you may remember from a previous post that there is delicious local flat bread that the Teda women make using an oven of a simple half oil drum buried in the rocky hillside.

Teda bread being baked
What is really surprising is that until 20 years ago the people here used to grow their own wheat using the underground water from the wadi to irrigate the crop. They now use cheap white flour imported from Libya and many women make not only enough for their family but supplement their income by supplying bread to the growing number of shops and restaurants that are springing up due to the gold rush.

Bread is a daily staple, but can I ask how many days a week do you eat meat?
Every day? Twice a week? Never?
Some of you will be vegetarian, as are mountain gorillas, others will be meat eaters as are chimpanzees. Both are our close evolutionary relatives so what are we supposed to be?
I understood from school that it natural for us to eat meat as we have canine teeth to seize our prey and incisors to cut it, but they seem to work quite well on an apple so I don’t think we can argue either way based on our dentition.


A platter of special Ramadan food
Having a regular source of fresh meat in Bardai is something new. We mentioned frozen chickens last time, no doubt there always were a few chickens scratting around in the sand but never enough to sell. Red meat was even rarer, until last month when Ramadan began there was no meat stall on the market; it may well close at the end of the month.
Traditionally meat would be eaten after sacrifices at religious festivals or special events such after a birth, a death or a wedding. Knowing all of this last November, in preparation of our time in the north, and being carnivores seeking a balanced diet, we dried 8 kg of minced beef in Ndjamena. It looks like coffee granules, and we have been adding it a couple of times a week to our stews. It is fine but we have especially enjoyed the times that we have been invited to a wedding and had roasted camel.



Hay arriving from Libya
It is difficult to keep large herds here for even weekly meat, but the recent arrival of large trucks with hay again from Libya, to feed a growing number of goats, sheep and camels, suggests that, brought about by market forces, a change may be afoot. The power of gold is creating an increasing number of shack like restaurants, and they need meat to sell and not only chicken. Maybe I am wrong and the hay is normal and it is just enough to fatten the one sheep needed for every family to sacrifice at the Festival of Tabaski. (The Muslim commemoration of Abraham’s sacrifice of a ram in the place of his son on Mount Moriah Jerusalem.)

The world is changing, as it has done before.  The megafauna (elephants, rhino’s, and giraffes) along with herds of cattle carved into the rocks of the Tibesti at the time of the green Sahara, 5-10 000 years ago, attest to that.

Ancient rock carvings
 According to the British Medical Journal, in a commentary, (BMJ 2017;357: j2190) another great change has happened in the industrialised world over the last few generations. Instead of the estimated 5-10 kg of meat a year in ancient Greece and traditional European agricultural societies, our supermarkets now supply us with 10 times that amount, to the tune of 110-120kg a year (U.S.A/ Australia). Cheap meat is produced in large factory farms, using grain to fatten up corralled beef cattle. These are on the increase in the UK and have recently been in the news due to justified questions about animal welfare. The article in the BMJ points to even greater dangers. In a world of limited resources, it apparently takes up to 110 000 litres of water to make a kg of meat and fresh water is getting scarcer not only in the Sahara. In addition, a staggering 97% of global soy meal production is used as cattle feed, even though soya also tastes good as human food. We have mixed it 50/50 with our dried meat and as a consequence we still have 2 kilos of dried mince left after 7 months. In a world where protein energy malnutrition is common can we in all conscience use the worlds soy protein supply on the inefficient transformation of vegetable into animal protein simply because we prefer the taste of meat?

All of this is not necessarily new to you, and some have disputed the figures. A Swiss bio-farmer, grazing beef cattle on the mountainside, says he uses no outside water to make his beef as it all falls on his land and they eat only grass and forage from the farm.  A Guardian Data blog gave a more conservative estimate that on average 15000 litres of water is needed to make a kilogram of beef, which still sounds a lot to me. That is compared to chicken which uses a mere 4000 litres per kg. Soon a cry of

 ‘Four legs bad, two legs good,
Four legs bad, two wings good’

will be heard through the land. (apologies to George Orwell)

However, the BMJ commentary accompanied a piece of original peer reviewed research ‘Meat consumption and risk of mortality’ (BMJ/ 2017;357: j1957). The bottom line is that eating a diet rich in red and processed meats increased death rates due to heart attacks, diabetes, liver and kidney disease and cancer. So, it is not only the altruistic who should change their habits but also those with an enlightened self-interest.

The chimpanzee which I mentioned earlier as a meat eater is really only an occasional meat eater, if he could talk, he would probably call himself a flexitarian. Flexitarianism, which I only Iearnt about last year, is a mainly vegetarian diet with some meat. It could be seen as the latest faddy diet, but it seems to me that it is not the case; it is how we are really supposed to eat. Perhaps you, we and the Teda could all do well to resist the market change bought on by supermarkets and post WWII agricultural policy, or the gold rush, and help the planet by eating 10-20 kg of meat a year. That would be a big increase for the average Teda and a big decrease for the average westerner. It is something that we have been forced to do by circumstances, but not only that it seems like the right choice. Why not be part of a revolution as we say ‘pray with the world ‘

                                        ‘Give us all this day our daily bread’.

If that’s not for you, then at least in a spirit of self-interest, stick to chicken. It carries a lower personal risk than red meat and, as you know, it is the latest fashion in Bardai.

Saturday, 24 March 2018

Lessons from the market – part 3

The entrance to one of the restaurants on the main street, Bardai

Chicken is popular the world over and it makes a welcome addition to our diet at Bardai. It is not surprising to find them as, in Africa, a few chickens around the home are good as they eat scraps, lay the odd egg, and are ideal as gifts. The meat takes a bit of time to get used to, there is less of it   and it can be a bit tough, with prolonged boiling or pressure cooking needed to soften it up.

But the deep-fried chicken in Bardai is a bit of a surprise, all the chickens weigh about 1.2 kg in weight and are nice and plump.  It comes frozen from Brazil (yes really, I have seen the packaging). The chicken presumably is shipped across the Atlantic and into the Mediterranean, arriving at a port in Libya, Tripoli or Benghazi. It is then delivered by a refrigerated truck to a depot in Murzuk, a Teda town in southern Libya.  The last 600 km of the journey are the most interesting, a dash across the desert and through the mountains in a large domestic freezer strapped to the back of a Toyota pick-up truck. It takes about 14 hours and so they often set off at dusk and travel by night to avoid the heat of the day.
The chicken split down the breast bone is cooked in a large vat of oil heated on a wood fire, up to 10 at a time.  This is great from a food hygiene point of view as it is much easier to cook it through this way. It is then served with bread, salt, and some tomatoes and onions on a metal plate. It is not cheap costing 5000 CFA (£6.50) for a whole chicken but It is popular with the gold diggers who are in town for a break from their hard life on the gold fields and a monotonous diet of macaroni with tomato paste and tinned tuna. There are now four chicken restaurants in town and it is the presence of these mainly young men   that has made such business’ profitable. Men and women have very separate social lives in Bardai and the restaurants are very much a male preserve, and so sometimes I go and buy a take away on Sunday after church.  

Last month I had to go to a different restaurant as the one I had been to before had no chicken (They were serving omelettes but I can make those at home). They helpfully pointed out their competitor down the street. At the new restaurant, they were very friendly and even allowed me to take a few photos of the kitchen to go with this blog, I think I may well go back there, especially as they actually do have some chicken.

The supply chain is all important and if it fails the business is in trouble and customers are not satisfied as Kentucky Fried Chicken found out in the UK last month. At one time they had 420 of their 750 franchises shut due a lack of chicken.  Colonel Saunders had decided to cut costs and presumably increase profits by changing the company that distributed their frozen products to the fast food outlets. The supply chain completely failed making very unflattering headlines. Some people clearly thought it was a disaster prompting Tower Hamlets police to Tweet
Please do not contact us about the
 #KFCCrisis - it is not a police matter if your
 favourite eatery is not serving the menu
 that you desire
 Tower Hamlets MPS(@ MPSTowerHams)
 February 20, 2018.

It is however much more serious when a hospital runs out of essential medicines. You can imagine what happens when there is no insulin in Bardai as happened last December.  We are a long way from Ndjamena and the Central Pharmacy (CPA}, communication is not easy and, even there, stock levels there are sadly at an all-time low. At Guinebor we used to supplement the CPA supplies with purchases at private depots and pharmacies. The latter, situated opposite the Central hospital and medical school are well stocked albeit with rather expensive medicines and make lots of money as often the medicines prescribed in the hospitals are not available in the hospital pharmacy. In Bardai, we have less choice, there are just some common remedies for sale on the local market, many of dubious provenance.

Claire Bedford BMS pharmacist at Guinebor II has helped us out with an emergency stock of insulin and other essential drugs, including those to stop severe bleeding after childbirth to prevent a repeat of the earlier tragedy. She also supplied us with one 6-month treatment course for TB tablets for a newly diagnosed patient. The small package of medicines arrived in early January on a MAF flight and has been useful.

 Dr Abdul Kerim has just returned from his annual leave in Ndjamena and has managed to come with a year’s supply of TB and HIV drugs so we are making some progress. But as the hospital gets busier and attracts sicker patients the supply chain will have to improve. Small amounts of medicines from the Northern Regional depot in Faya and from Ndjamena will not be enough. We need a proper system of stock control, ordering and delivery.

There is already a supply chain for vaccines which is independent of the hospital structures. It’s a bit like the chickens, a dash up from Ndjamena with special cool boxes to maintain the supplies in good condition. The rest of the space in the vehicle could be used to send up drugs, it just requires some coordination, and organisation of the finances. Other avenues still need to be explored. Meanwhile Claire has made a brief visit to Bardai, using a spare place on the plane. She met our local pharmacist, it may be a fruitful relationship as they share experiences and contacts. Hopefully she will be able to help us out from time to time.

My brother Nick summed up the problem yesterday in a WhatsApp message
‘a chicken restaurant without chicken is not a chicken restaurant’

It may be obvious, like the emperor’s new clothes, but it needed saying and sorting out before it became an embarrassing problem.

And more importantly:
What of a hospital without drugs?
                                                    -----------------------------------------------

PS: One of the most spectacular improvements that has happened in my lifetime is the near eradication of polio from the African continent. I remember seeing acute polio a couple of times in Guinea in the early 1990’s and saw many more young children who came with paralysed legs requiring operations for contractures. The annual mass vaccination programs where all children under 5 years of age get doses of oral vaccine over a 3-day period in every, town and village each year have had a major impact in halting this disease.

It is a major distribution challenge, getting vaccines to places like Bardai and then having trained health workers, many local assistants, going from door to door. Most African countries including Chad have not had any confirmed cases in recent years. I think the last cases in Chad were due to refugee movements from war torn Northern Nigeria in 2014.  Vigilance is still required especially as most babies still do not access their routine childhood vaccinations and so the immunity of the population relies on these special campaigns.
A week after the rest of the country the campaign started in the Tibesti mountains, the vaccines had arrived late and also Dr Abdel Kerim had not been here to organise it.  Due to the dispersed population and lack of staff it took a week rather than the allotted 3 days. There was a modest ceremony at the hospital to start the campaign with the governor of the region giving a speech and vaccinating the first child and giving a dose of de-worming medicine. Various other dignitaries were called forward to give a dose of vaccine to a line of children many in their mother’s arms. Last of all I was called forward, and I didn’t immediately recognise the young child that had been set aside specially, it was Bardai Eli, the young baby with facial burns from last November. Even with the de-worming medicine smeared on his lips he does look amazingly better.

Sunday, 18 February 2018

Lessons from the market – part two

The market at Bardai consists of a street with lock up stores on it, they are roughly divided into food/hardware shops selling a curious mixture of tinned goods, rice milk and flour,pick axes, lightbulbs, simple electrics, buckets; and mens clothes/furnishing shops selling miscellaneous trousers, socks, shirts jalabeers, rugs, blankets and mattresses.

Of late rather smart heavy faux ‘camel skin’ coats from China have been in great demand. A must for the older man wanting to keep warm but look at the same well dressed. I have been wearing a jumper and T-shirt under my jalabeer a hidden addition which makes people think I am hardy and don’t need a coat. The market functions all day and on into the night.

There is a newer separate market where goods from Libya are sold from the back of pick up trucks. The number varies each day and they arrive with a variety of fresh goods, tomatoes, apples, bananas, oranges, potatoes, onions. Some days there are 5 or 6 others there are none, it just depends on the state of the frontier and the relative values of the Libyan dinar and the CFA (Central African Franc) They also sell the same tins and sacks as the main market, but this time in bulk. My adventures in bulk buying have not always been successful, I bought 25kg of flour, but the bread which Andrea made with it tasted of petrol, not a good buy.

Fresh eggs are a good part of our diet, but sometimes there are none to be found. If you find them on the smaller market they are sometimes hardboiled already (useful tip if language is difficult, check by spinning an egg on a tin, raw eggs don’t spin well, boiled ones spin like a stone. Also  remember that the last few eggs on a market stall are less likely to be fresh, so it is best to buy them in bulk as they arrive on the pick ups.) 

A few weeks ago, I came across a pick-up with a large carton of eggs all on trays of thirty. There was no queue and I asked to buy a tray but was surprised when the man said that they were expensive, 2500 CFA, so I should go to the next stall where they were cheaper at 2000 CFA. He had to say it twice as the first time it didn’t make sense to me. So I walked to the next stall, and waited in the queue, it was a bit of a wait. A Teda friend came up and so I asked him what it was all about, were these eggs not going to be fresh, where was the catch. He simply wants to be kind as his eggs cost more was the unexpected reply. 
I was still waiting after about 5 minutes and, typical westerner, beginning to think I would rather pay more for a quicker service. The man with the expensive eggs must have seen my frustration so he came over got me a tray of eggs took my money, gave it to the stall owner and then went back to his stall.  No doubt he sold his higher priced eggs later on in the day  when the other stall had sold out. An unusual way of doing business and really not what you would call a competitive  market rather it is a nice one  to visit.

So far the lessons from the market are quite simple and uncontroversial, smell flour for petrol, spin eggs to make sure they’re not already boiled and perhaps more usefully, take stall holders advice , they may actually be being nice to you. The next story, actually from a missionary cookbook, is a bit more provocative; it too is about buying a tray of eggs.

A US national working in Nigeria went to market, she was well versed in the local language and culture, and she observed the lady in front of her buy 3 eggs for 300 Naira. (sorry I don’t recall the exact figures but it is not important). She then asked for a tray of eggs and was asked for 4500 Naira. Quickly doing the maths she pointed out that her 30 eggs cost 150 Naira each whereas the other lady had only been charged 100 Naira per egg. So she asked whether the seller had made a mistake. No came the reply, anyone who can afford to buy a whole tray of eggs can afford to pay a bit more.

How do you feel about that? Was she really being ripped off? We in the west come from a culture where bulk buying saves money and  are more used to the idea of buy one get one half price offers. That is how free market capitalism is supposed to work, encouraging consumption,  usually to the advantage of the rich. 
Let's look at an everyday example of how the market works in the UK.
Your electricity and gas is cheaper if you can afford to pay on contract a regular monthly sum through out the year. If you are less well off and pay what you use each quarter it is more expensive per unit used.  Most expensive are the meters that require payment tokens to make the system work. I noticed that when we moved into our home in Wakefield in 2005 and being rich, quickly got that changed. So in essence the more money you have available to pay bills the cheaper they are. It seems right or at least normal doesn’t it? Although perhaps a bit unfair?

(Now in the following examples I am using idealised figures as living in Bardai I don’t have access to either gas or electricity to get  current prices, but the principle behind the figures is a reality in Chad)
In Chad if you buy a small 8 kg bottle of gas it will cost say 4000 CFA, if you buy a 15 kg bottle it costs 10 000 CFA, which makes the bigger bottle more expensive for each kilo of gas. The logic is that the government want to encourage people to buy gas for small hob burners, decreasing the use of firewood and charcoal, and also helping the poorer people in society. The larger bottles are good for gas cookers, fridges and water heaters so you pay more for the gas, it is after all use with for luxury items.

The electricity bill is structured in the same unusual way, the first 20 kw each month are at a cheaper rate than the next 30 kw and then more expensive again after 50 KW. It’s a graduated system in the same way as income tax.  The poor person who struggles to pay the bill for an electric light is helped and the rich pay more for their air conditioning. Seems a fair deal to me.

Finally the same is true of water bills, so effectively the main 3 utilities are subsidised.
I can imagine the outcry in the UK if any one of the political parties proposed such a change, it would be a scandalous meddling in the near sacred ‘free market’. I guess it would be, but that doesn’t stop it being a good idea. Perhaps we can learn an economic lesson from Chad, (yes really- the west can’t be right all the time can it?) Cheaper water, electricity, gas and public transport for the less well off.
The idea is utopian, but it is not new.  I do seem to remember that in the temple at Jerusalem there was a graduated scheme for an offering to ask God for forgiveness, a young bull for the high priest, a male goat for a leader, a female goat for a common person, two doves or pigeons for a poor person, or one and a half kilos of the finest flour for a very poor person. Perhaps that form of ‘progressive pricing’ for essential  is a lesson that we need to rediscover.

Sadly it is more likely that in the future that external forces perhaps the World Bank or IMF will insist that Chad implements market reforms, in return for a financial relief package to cushion the economy against the effects of the lower oil price. In other countries this has meant privatisation of state assets, removal of subsidies on foodstuffs and fuel and a free competitive market, for whose benefit? 
-Something to think about.

Tuesday, 23 January 2018

Lessons from the market- part one

Football, a  world wide frachise. Sign outside a video club in Bardai, about 60p a match, same as a can of Coca Cola
Last Saturday at about 5 pm with the sun setting behind the mountains there was a light breeze which made the 18C air temperature feel a bit cool. Last chance for a wash and a shave towards the end of a busy day, visiting patients, pulling teeth and helping Andrea do the washing by hand.  The solar cooker had some nice warm water so whilst Andrea cooked tea I showered and at the same time listened to the football on BBC short wave. (we are one hour ahead of GMT so it was the second half)

‘and there’s a  goal in the Championship, 10 man Leeds have levelled  Leeds United 2 -  Millwall 2’’

A few minutes later

‘’ and another goal at Elland Road, what a fight back by Leeds in front of their home crowd, it’s      Leeds 3 Millwall 2’’

And then Andrea called me for tea, reception is not great so I heard no more, you have to catch the score as the goals go in as they only read the final scores for the Premiership, Bundersleague, Serie A and La Liga. It is after all the World service. Our 2G phone signal can download simple emails and Whats app text messages but we can’t surf the net for news, hence the need for the wireless.
Later I spoke to my Mum and Dad on the phone, they said they would send me the result if I could send them my email address (they’ve just got reconnected after technical difficulties). 
The connection wasn’t good and I don’t think my message got through. So next day passing Whats app  messages  with our daughters, Ruth and Rebecca, they let me know the final score

 Leeds united 3 – Millwall 4

Sadly eleven players against ten usually wins. (I presume that Leeds didn’t lose another player!)  The difference between the sides a man, which makes, as far as I can see, a player worth 3 points.
Footballers are of course worth a lot more than that, they are worth real money. I remember in 1980 seeing Justin Fashenu of Norwich scoring the goal of the season, a volley from about the half way line that beat the Liverpool goal keeper, next year he was sold to Nottingham Forest as the first one million pound player. A few years later, in 2000,  I saw Rio Ferdinand presented as a new signing at Elland Road for a record £18 million fee. This was in the days before Leeds financial meltdown. The market decides how much players are worth, and our ascendant neo liberal economic model encourages  free markets. ‘’ In God we trust’’ but are we trusting Yahweh or the golden calf?                                           

Last weekend Arsenal and  Manchester United  finally made a realistic evaluation of the true  value of a player.  How much is a player worth? Answer: one player. You have to admire the logic. After all these years of ever inflating prices, a transfer that cost no money, they simply swapped players. (I am choosing to use the BBC headline and ignore the fact that there was still the agents fees to calculate on the deal, which apparently will not be an insignificant sum, not sure how they can do the sum I always thought 5% of zero was zero) So one man is worth one man, a brief outbreak of sanity in a mad market place.

Of course, instead of hard currency as is usual or bartering as above, they could have done the deal using Bitcoin instead.  But then the player might loose 50% of his value in a month even without breaking his leg.  Perhaps something old fashioned and tangible like  gold would be more sensible way of measuring worth. A typical premiership  footballer is worth ten times his  weight in gold, 25 million pounds. A golden calf has to make more sense than the idea of a golden calf in computer code.
A small local gold nugget worth about £200



So how does this blog have anything to do with Chad, besides the short wave radio and dodgy internet connections? I mentioned gold in the paragraph above, personally I can think of nothing that I would less like to invest in right now, bar the international arms trade.  Bardai is changing, the centuries old traditions of subsistence farming, (dates, wheat and market gardens) and trade in salt through camel trains have been largely replaced by gold mining and now Toyotas traffic market goods across the desert. The market is booming, the town is growing and people are richer than ever before but the human cost is high.

How much is one gold digger worth? Not much, life is harsh, brutal and cheap. Of 4 gold diggers in hospital at the moment, (they are the only hospitalised patients at the moment), one broke both legs in a rock fall that killed his friend, one was shot in in the leg when an argument was settled with an AK-47, and one was deliberately burnt on the legs to get information on a theft: only the last one has a normal everyday medical problem.

The world markets are thirsty for gold,  as an investment in uncertain times,  for jewellery and no doubt some for manufacturing useful electronic devices.  It has to come from somewhere but at what cost?

It seems to me that for every person that benefits and is happy someone else has to pay and suffer. On the whole the rich get richer and the poor…………………?  Is that how markets are supposed to work? In the next post I will have some interesting, somewhat surprising examples from Chad, which can teach us all some positive ways of doing business. You may think them odd and impractical, but in reality football transfer fees and Bitcoin probably make less sense and we all seem to get along with them as ideas.

Match at Bardai, can you spot the next George Weah?

Monday, 25 December 2017

Simple things matter

November 20 th 2017 was time to face the future, the first day back at Bardai hospital and at last working full time.; would there be any patients to see? There have been plenty but here is the story of one from that first morning.

His name is Bardai Eli, an unusual name perhaps the only one. It was chosen by his parents, part of the military garrison, who are far from their home in the south of Chad. He learnt to walk early as children often do here and at 9 months of age eager to explore the world he fell into a cooking fire. He suffered burns to 2% of his body, not much in terms of size, but the burns were to his entire face and forehead. Two days later I saw him on my first morning, his face was a mess having first been painted with gentian violet to dry it at the hospital and then an additional treatment of goats fur had been stuck on at home creating a thick black matted crust. The wound was getting infected and he had a fever.
Dr Abdul Karim with Bardai

His worried parents agreed to a hospital admission, and I told Andrea we already had a case for the operating theatre and so she set about cleaning it up, sterilising instruments and swabs and getting equipment ready for an anaesthetic. The hospital generator can no longer power the autoclave so she had to make do with the hot air oven for the instruments and clean but non sterile swabs and towels. Meanwhile he had some pain relief, anti tetanus serum and antibiotics. The hospital has no creams or ointments so his father went to town to get some Vaseline, but came back with some perfumed very yellow petroleum jelly. This was not a good idea, so he went back to town and came back with a tube of fusidic acid cream from a little shack of a pharmacy on the main street.  

Bardai was first on the list of 3 patients for the next morning. (The notion of a list in itself was a novelty as only one case had been operated in the 4 months of our absence, a victim of a landmine who unfortunately lost his leg.) Once Bardai was asleep we gently soaked and peeled away all the crust and found that there was raw burnt tissue all over his forehead, nose and upper lip. He must have had his eyes tight shut and this had protected his eyelids which were simply blistered. Once it was as clean as we could make it his face was lathered in cream and left open with this moist potentially healing dressing.

Twice more that week he went to theatre and at last it was clean. He was clearly feeling much better running around outside the ward oblivious of his white and pink face, Thankfully the wounds were only deep partial thickness and being young he had extraordinary healing capacity and soon his red raw bleeding cheeks were healing and he was able to go home. I didn’t take a photo at the beginning, you wouldn’t have wanted to see it anyway, but here he is as an outpatient coming back for a check just 2 weeks after his accident when his Mum said she was very happy for me to share his story. It’s not normal to smile for photos round here.

It was such simple medicine, but in my experience of strange dressings of toothpaste, tomato puree and probably worse gentian violet, can lead to infected wounds and full skin loss so simple things can make a big difference. Two adults, gold miners, with much larger burns to legs (10%) and arms and chest (20%) are also doing well, this time with home made non perfumed petroleum jelly (vaseline) gauze dressings. Clearly teaching our colleagues burns care is going to be an important part of our work and thankfully our colleagues are keen to learn.

As you can see from the description above even doing simple things takes time as supplies are not automatically to hand and many things need organising to make the hospital efficient. We are a long way from Ndjamena, in need of help, and so were delighted to receive a large pressure cooker which MAF were able to put on one of their flights chartered by the EU for a fact finding trip. They were followed by a UNHCR team who came in their own plane. Both teams were interested in displaced people, be they gold diggers plenty of whom are coming from all over Chad and beyond; or migrants who don’t seem very common in this part of the Sahara. After looking round the hospital the lady heading the UNHCR team noted we were sterilising in a pressure cooker. She had also received a request for a young boy that we were treating for a septic arthritis and probable osteomyelitis ( bone and joint infections) to be flown on to their next stop Abeche where he could have an X-ray as our generator is too weak to make the brand new machine function. Her not surprising conclusion for her report was that for the hospital to function well it needs a good 15KW generator for general power such as lighting but especially so that the good equipment in the sterilisation and X-ray dept are able to work.


 The report will probably just gather dust, things tend to do that in Chad! However it was good to see that although they really there to assess the bigger picture they could also make the effort to help a small child get access to care about 1000 miles away. So last Saturday morning. Dr Abdul Karim and I were able to take our young patient and his father to the airstrip. (His mother and younger brother had to stay behind.) and put him on their plane. We had done a lot to improve his situation, operating to drain the pus and giving antibiotics, but because of the lack of a simple thing like electricity we were unable to complete the care he required.

Simple things matter.

Saturday, 4 November 2017

One planet, two worlds



 We spent a lot of time this summer seeing what it is like to be on the receiving end of care in the NHS, and quite frankly we have been very impressed. On holiday Mark’s mum slipped on a grassy bank and broke her ankle badly. It was a bit of a shaky start with a 1 hour wait in the cold and rain for a paramedic due to excess demand for services on a Sunday afternoon. Fortunately Mark had already put the badly dislocated ankle straight and we had got under cover by the time he arrived. The car born paramedic was excellent , but his car was so full of life saving equipment that he couldn’t provide transport; and so although a stretcher was really needed, he escorted our car to hospital with Marks Mum across the back seat us as there were no ambulances available.
 
 


Thereafter the care was excellent. Surgery was performed on Mums broken ankle and she was quickly mobilised and within 2 weeks was back at home. Community care provided impressive array of different carers, physiotherapists, occupational therapists and nurses who have all been coordinating with each other and providing exactly what has been needed for Mum and Dad and now 3 months later she is walking and we are heading back to Chad.

Ambulance at market next to pickup
As you can guess that set us thinking about what would have happened in Chad. First of all of course there aren’t so many octogenarians around; average life expectancy being 52 years. Given that there are still some older people, how long would you expect to wait for an ambulance? The ambulances at our hospital can be difficult to start. Mark needed one for an emergency and as the ambulance driver was absent, tried to start it up. No luck, it seemed that the battery was flat or the wires loose but on opening the bonnet that the battery was simply not there. It had been removed the night before to start the hospital generator. The driver may well have been absent on one of his trips to buy supplies for his market business from Libya. The vehicles are often used to ferry officials around the town or to get supplies of firewood from the countryside to cook for the hospital staff. Sometimes they take sick patients who need evacuation to Ndjamena, a tortuous journey of 1700km. We remember the one occasion that an ambulance arrived with seven young children from 2 families from a nearby village. They were suffering from food poisoning and were all sent home later in the day. However as there is no 999 service most patients arrive at the hospital, following road crashes, military events, or other emergency in the back of their own or someone else’s pickup.

Mark checking out equipment in
 the operating theatre
Having arrived at the hospital with a broken ankle what could have been done. Well there is no X ray available yet, the equipment is there but no radiographer, developing fluids or films. There is not even someone who is used to putting ankles straight either in or out of theatre. We do have plaster in the pharmacy but that wouldn’t have really helped. So it would have meant a 3 day journey with a simple splint to Ndjamena or 12 hours over the desert to Libya. At Ndjamena there is some good care available but often patients choose to use bamboo splints put on by local healers. So even having survived the trip across the desert an 80 year old might still struggle to get a good result.

 


A typical group of homes in Bardai, including
including ours with a thatch.
The family would be there to support the matriarch but they would be untrained with no knowledge of how best to rehabilitate and get their mother walking again. The patient would simply rest in bed and hope for the best. One young girl we met in Bardai has a slow growing tumour causing paralysis and  has spent the last 2 years of her life in bed. Unsurprisingly she has bed sores and life is not easy. The family are there showing their care and concern so at the end of Ramadan the family held their celebration around her bed and the room she was in was full of women chatting and eating. A moment of joy in a difficult life.




So as you can see, now that we will be working full time in the hospital there is going to be plenty for us to do when we get back to Bardai. It will be interesting to see what we can do to make the orthopaedic care better. However that won’t be all we need to do, there will be plenty of medical cases too. Even with our short time there we have already seen serious cardiac disease, alcohol related disease, plenty of fevers and much where we can provide care with our Chadian colleagues.    

The maternity unit
Since we have been in Bardai  the maternity services have been quite quiet.  All deliveries have been normal except for one poor lady who went into labour, unattended and at home. She had a breech delivery all alone which ended with a still birth. Despite living close to the hospital she didn’t get good care till the next day and was still slowly getting better when we left. We did help quite a few women having difficulty during miscarriages and were supported by one of the local Teda workers when she encouraged her daughter in law to have the care she needed and wasn’t keen to have.  

So far we have not had any Caesareans but the need for these to be done well and good care afterwards has been brought home by the death of a friends wife whom I delivered in her first pregnancy by Caesarean for pre-eclampsia and twins. She recently bled after surgery for a second delivery and tragically died. Another missionary also mentioned in prayer letter of the death of a previous colleague in the North of Chad in the same way.

Two different worlds on our shared planet. In the UK , despite ambulance delays, there is no doubt we are very privileged. Meanwhile health care in Chad remains difficult to access and when you do arrive at the hospital the care provided may lack the quality and level of provision that is really needed. We need to continue to aim for a just future- One planet, one world.
Aerial view of Bardai hospital which is on the edge of the town
 

 

Monday, 2 October 2017

A picture is worth a thousand words



A not so  old camel
 
Art in Bardai has been around for a long time, 5-10 thousands of years in fact. Pictures of elephants ostriches and panthers together with their hunters are found all over the rocks near the town. Not quite so old, but equally fun to see are pictures of camels also etched on the rocks a mere 2500 years ago.

But you don’t need to go back thousands of years to see art in Bardai just 30 years ago a French Artist decided to make an art installation not far from Bardai. We visited twice while we were there, huge rocks in a valley painted with what seemed to be red, white and blue a peaceful place to spend a Sunday afternoon. One day we hope we will walk there, the last time Mark played golf with some of the other missionaries and Chadian friends -only 2 clubs and dig the holes yourself so interesting.


Art in the desert
 
Amazing views
 
 
 
 
 
 
 
 
 
 
 

Browsing the internet whilst back in England ,we even came across a copy of the guide to the rocks as they were in the beginning, bright colours startling against the austere brown rocks which surround the valley. We discovered that they had been purple as well and that there were small signs on some of them-we’ll have to look and see if they are still there next time.
Nature too brings its own art work as the colours of the mountains change under the light of the setting and rising sun from brown to orange to yellows. The view from our house is stunning each evening as the sun sets behind the mountains.

Setting sun on the rocks

Occasional clouds too change how the mountains are perceived  and highlight layers previously unseen.


View from our house

 
 
 
 
 
 
 
 




The local people may not be so aware of the colours of the mountains or the changes of light, they have been watching it for a long time. However they are aware of the changes of the colours of the ripening dates and our Teda language lessons are teaching us all the names for the dates as they change from white to green, then yellow and brown and we’ve also found out how the different seasons are closely tied in with the date harvest. Showing how the Teda have always been so dependent on the dates for their livelihood.


How to pollinate dates
It’s hard to remember all the words and that’s not the only complex thing about the language. The first thing we had to remember was that the sentence seems to be the wrong way around with the verb at the end – not a totally unusual thing but needs remembering. Then you have the same word meaning more than one thing depending on how you say it- was that a cloud in the sky or a dog or a drum? Well it all depends on the tone.

The verbs too have proved fun with each verb having two forms depending on whether you are putting down or buying or picking up or so on, one or more things and the two words  don’t even bear any resemblance to each other. Add in the fact that if I give you or I give him something the verb also changes at the front and our brains are swimming.
Nature walk as a lesson looking at  parts of trees
 

Looking at the volcanic rocks












So we thought we’d be sensible and concentrate on the medical terms for a bit as that’s why we especially want to know the language. However, still more complication it’s not as simple as saying I am vomiting but rather the vomiting is happening to me which makes the verb extremely long and almost impossible to say never mind remember.

Despite all this we are making some progress, someway towards a thousand words, or one picture. It always seems worthwhile when we are able to use a little and get a smile from our patients and neighbours.

We are hoping we have not forgotten it all and looking forward to getting back to our hill top house but we have to be a little patient and wait until mid November as at present we are ensuring that Marks Mum and sister who have both been unwell are back on their feet again and not needing us around.

That means chance to see more art work as the seasons change here in England and the Autumn colours begin something we haven’t seen for 7 years.
Autumn beginning in Scotland