All fingers and thumbs (counting down to Christmas)

( mid November to December) This is no doubt going to be a boring blog, few pictures just graphs, and the subject matter will  move between statistics and  pure maths, (or math for our  American readers). Words, incidentally, are not the only things that change between cultures, how you count with your fingers and thumbs also does. How do you do it? (Guardian Weekly 6/7/12) Starting with the fist closed or open? Little finger first or thumb? Most Western Europeans usually use closed fist and thumb as starting points. A local builder started palm open and counted from his little finger .  Mostly my Chadian colleagues prefer to use the calculators in their mobile phones, so perhaps the world is changing and these little cultural  differences will disappear.

 The title, all fingers and thumbs, is a bit strange  for a letter written by a couple of doctors who spend much of their lives doing surgery. Andreas dexterity was much in evidence as I assisted her at one o clock one morning as she rapidly did a caesarean section, her 3rd in 3 days after a fifteen day period when none were required. No fingers and thumbs but plenty of counting needed, checking the swabs before closing the operation and again the baby who  was the 56th so far in November. I risk being accused  of repeating myself, but here is an update of a graph from our September blog, the green line is a computer generated estimate for the future. In reality it looks like an underestimate with over 3 babies born each day so far, we may even reach a hundred.  We can be thankful for all the women and babies helped but it makes the unit very crowded busy place.

I don't know how my computer generated the rapidly rising  trend line. I have however recently learned that  Descartes, famous for 'I think therefore I am' was also the inventor of  analytical geometry, which uses algebra to describe geometry in graphs. Ruth and I have been getting to grips with this as she works through her homework. Maths is fine, and many Dads must try to recall their teen age education to help out.  But Maths from another angle and in a foreign language can be a bit challenging. I am usually alright and able to help  once I have understood the question. Running the hospital can be like that too.

What are we supposed to be doing? This question  has to be asked before we can decide whether we are doing it well. Planning is important and therefore 'I think therefore I am' may be practically useful as well as being a  profound piece of philosophy. We have been planning, budgets especially for the pharmacy, malnutrition programs, an X-ray dept ,a possible safe motherhood project and the recurrent problem of how to keep the hospital clean, with only one relative sleeping with each patient overnight.

 Plenty of planning  but surely what we do is more important in the real world, 'I do therefore I am' is an apt paradigm for modern  mission where we want to measure outcomes. We are seeing record numbers of patients, and having record receipts(but still remain financially dependent on outside aid for 20% of expenditure)  But despite this good news as the letters hit the page an alarm is ringing we follow a God whose name is ' I am what I am' not ' I am what I do'.

Back to the counting, we are in Advent waiting to celebrate the beginning of His greatest expression of this,  Jesus ,God with us. A highlight in our count down to the festivities will be a hospital nativity play and songs followed by the Jesus film on the 20th December. Pastor Djibrine is organising it we hope it will go well and that more people will come to understand the true importance of the baby in the manger. Jesus didn't set out to  change the world by building institutions , but he came as the servant of all, taking the way of love.(I Corinthians 13)  This should surely  be our ultimate plan and outcome measure, to become loving servants like Him. I sometimes feel that I am only just beginning.

Mark and Andrea

PS: Since the first part of this blog was written November has ended, we counted exactly 100 women in childbirth, so much for predictive graphs! There were 103 babies born, the first one pictured below is the first for Charlot and Sarah both of whom work as nurses here at GII,  there was one set of triplets, also pictured  and the hundredth mother had premature twins.  They sadly died shortly after birth which made for muted celebrations of the milestone. Individuals mean so much more than statistics both in their joy and their sadness.

Shipping containers, black gold and the Hallelujah chorus.

Handels  Messiah has probably been played in some improbable places , perhaps someone has it as  a polyphonic ring tone? If not , why not? Anyway  I have it as  musical  quote in a Rick Wakeman keyboard solo on a 1970's progressive  rock album which  I always played it to celebrate good news. Usually at a loud volume. So I shouldn't have been surprised when a contemporary, presumably African, version of it  suddenly blurted out from our rather crackly rented PA system during a ceremony at the hospital last Friday. How many of the assembled dignitaries recognised it? Would Handel even manage it?  I don't know. More importantly what were we celebrating? The arrival of 2 forty foot shipping containers on a tide of black gold.

 

Crude oil, has bought many benefits to Chad. Although the oil reserves had been located in the late 1960's it wasn't until 2004 that Exxon-Petronas-Chevron managed to complete a 1500 km pipeline from southern Chad through Cameroon to the Atlantic coast to enable oil exports to begin. It can't be coincidence that since then the per capita per day income for Chad has risen from about a dollar  to nearly 3 dollars a day . In fact payments by the consortium  account for about 70% of government revenues and has fuelled a major expansion of government funded projects changing the face of N'djamena such as a huge parade ground with a massive  triumphal arch and lawns  opposite the palace. Before we start to criticise imagine the living conditions of the average  Victorian Londoner when the great monuments were being built, or for that matter the needs of the world when men walked on the moon in 1969.   Thankfully there are also  tarmac roads with storm drains replacing for the simple  tracks that turned to mud each tear during the rains; new schools and a probably best of all  major new mother and child hospital and medical school  in the city centre. It may only be trickle down development but it must be making a difference.

And so we come to our celebration, two massive forty foot shipping containers filled with supplies by donors and volunteers at Cutting edge Foundation, southern USA and transported as a gift by ESSO and partners all the way from Houston to Ndjamena. The cost is one thing,  the logistic capacity was equally important and they organised  it all right to hospital compound. Shipping , customs, road transport through Cameroon and the crane to finally lift them into place.  All done as a gift to the people of Chad. So we held a party to open the container with the press, Ministry of Health, local village elders, local imams, national church leaders and of course the head of EXXON Petronas Chevron Chad. Ndilmbaye, our Chadian administrator organised it all, and very efficient it was too.

 

   

 After the speeches were done, the Coca Cola drunk and the sandwiches eaten, what did we find in the containers. Treasure, such asan unusedset of WWII field surgery instruments in perfect condition, many other surgical instruments, about 15 drip stands , 2 theatre trolleys, wheel chairs, crutches, ECG machines and medical furniture for an office. Essential supplies, much needed swabs, operating packs, gowns, clothes and much more besides. We still have loads more to unpack. There is apparently even a lawn mower! (just what every Englishman abroad  needs after a teapot.) A heavy duty one could come in useful after the heavy rains and associated growth of the grass this year. Perhaps best of all saved till last , a portable X-ray machine plus accessories modified to use an up to date digital system. So in the near future our patients won't have to drive 9 km for their films.

All these things will really make a difference to the way that we are able to deliver care, we still need to improve, but these things will help. So why not say 'Hallelujah' Praise God.

Is this the 12 millionth Chadian?

A happy event at Guinebor II and though he may not actually be the 12 millionth Chadian, he will always be very special to his Mum, Anastasie, one of our nurses. Some time earlier this year Chad managed to achieve a tripling of its population from 4 to 12 million in just over 50 years since independence. It is set to double again in the next 20 years. Each women having on average 7 children must help overcome the worst under 5 mortality figures in the world ( about 20%). Al Jima is also smiling in the picture she has the satisfying job of helping mothers have safe deliveries, its a big job. Look at the map below, look for the reddest part, that is Chad; once again in the headlines for the wrong reason with a scandalous MMR (maternal mortality ratio) of 1.1 deaths for every hundred pregnancies.

  Maternal Mortality Rate worldwide (2010) Deaths per 100 000 pregnancies

So it is no surprise that our maternity services are becoming busier. They started slowly just  over 18 months ago and last month we had 58 deliveries. this month will be even more. Forty four  deliveries already is more than last years whole month  and it is only the 21st October. It means  plenty of work for Andrea, there have been 5 caesareans so far this month and lots of other cases needing help, close observation, forceps, oxytocin drips etc .

 

 ^{The first week of this month was especially busy and Andrea worked for 88 hours, many of them at night. Clearly this is not sustainable long term, so we have now decided that we will take alternate weekends off. Any patients arriving requiring specialist obstetric or surgical care will have to be taken to the referral centre in the city. This is not ideal, but we can't work 24/7/365.  It would however be good to have more surgical members of the team, perhaps you could pray for this.}

^{Another problem is that the temporary maternity delivery unit that we created from part of the operating theatre is becoming too small for the women in labour and outpatients that are there every day. We have added an extra bed for the women in labour and in the near future we need to find more space.}

 

^{Meanwhile give thanks for the 4 women who have live babies after their caesareans and pray for the unfortunate lady with polio who can't walk, her baby was already dead when she arrived. At least her life was saved. She has always crawled on the floor from childhood and has never had a wheelchair, we hope to find way of making her life better.}

 

^{We can also  thank God for healing of a baby with tetanus despite our minimal resources. She was  born in unhygienic conditions at home to an non vaccinated mother. She presented with severe spasms and unable to feed due to 'lock jaw'  at 6 days of life, Now after 3 weeks of heavy sedation in a darkened room being tube fed she is breast feeding again and will be  ready for home in a couple of days. It is good to know that  in addition to the sterile instruments and clean delivery room, all the babies born at Guinebor II are fully protected against this often fatal illness by vaccines either before or after birth .}

 

Big drop in children under five dying, says UN report: BBC August 2012

The good news is that the health of the little children of the world is improving according to UNICEF, that means that instead of 12 million deaths in 1990, there were only 7.6 million last year. The numbers are overwhelming, and  we shouldn't lose sight of the fact that each one is an individual tragedy.

Our hospital at Guinebor has always had a special place for children, that is at the front of the queue: the same place that Jesus put them . Like him  we got some  initial protests  from the adults who didn't understand, but is now  accepted that the under fives can' push in' at the front as they are often our sickest and most vulnerable patients.

I was initially going to start this blog share with the  exciting news that   we have recently  operated on 2 very young babies and they have both  survived. . One aged about a week  had a meningocoele , a fragile  pouch of spinal cord lining over her lower back; and the other a pyloric stenosis aged 5 weeks , a blockage to the stomach that causes persistent vomiting. Both will now have a normal life expectancy, for Chad. I hadn't done either operation before so as a surgeon I am encouraged because  the reality is that there are now 2 young children who will have the chance to grow up loved by their parents. We can all rejoice and give thanks to God.

However as a project manager I need to see things a bit  differently and keep things in perspective. I need to remember that the vast majority of children die of preventable disease such as  malaria, diarrhoea, malnutrition, pneumonia measles and tetanus. World wide 21 000 die each day and each week some of them are at our hospital .  Unfortunately the  good news  of the title to this blog doesn't apply  if you are born in Chad.  iIt  now reports the highest childhood death rates in the world  209/1000 (over 20%) and  actually is one of 10 countries that are getting worse.

What can we do?  Operating on newborns feels good but isn't the answer. According to UNICEF/WHO  the children of the rest of the world are doing better because of better access to health care and well run immunisation programs so we need  to keep the children at the front of the queue and we need to get integrated into the fledgling national immunisation program.  Last year just before the re-launch there were no vaccines in the country, I know that  has changed and we need to play our part. I will take some time off from clinical medicine each week to visit offices, write letters and establish projects so that we can get involved. Administration saves lives.  

We will also step up our identification and treatment of malnourished children suffering due to the famine following on from poor rainfall in the Sahel last year, BMS are again  collecting special funds for that. And finally what about a really crazy  idea passed on to me by a retired GP friend  whilst I was in the UK ;  using good malaria prophylaxis as well as a  mosquito net prevents deaths in seasonal malarial ( BMJ news section august ) Giving my patients the same protection my children have always had, what a strange idea!

 Whatever next?

Chad is wetter than Britain! (at least some of the time)

Having spent a very enjoyable time on UK assignment with its unpredictable weather, we returned to Chad last Thursday and guess what- it's raining So I thought I would stick to our national stereotype and send you a  quick email  postcard.

 

Everywhere is green and the any slight dip in the  usual baked mud of the roads has turned into  pools of  deep slurry. That is not  what you would probably  expect  me to say about this place just south of the Sahara that is so hot and dry for most of the year.  But a look at the table below will show you that this  is normal; N'djamena gets an astonishing  76% of the annual rainfall of our home town, Wakefield UK.  Nearly all this water  is crammed into 3 very wet months with up to  7 completely dry months each year.

average rainfall mm / month

 

This annual deluge makes   travelling to and around the  city difficult,  for example  a couple of our vehicles have been dug out in the past week, but  all this rain  not a bad thing: it brings life. Last year the rains were light but thankfully  this year has been the wettest since we have been in Chad, and as a consequence there should be l be a much better crop of millet and other essential foodstuffs.

In a normal year  the WHO estimates that 40% of Chadian children are stunted due to poor diet and it doesn't take much to make them fall into frank malnutrition The  consequences of  last year's  failed crops are still being felt  with  famine declared from west to east right  across the Sahel including Chad.  This has  resulted in increasing numbers of severely  malnourished children attending our hospital. BMS is committed to seeking funds to enable us to carry on with our refeeding program so that we can continue to give the needed high energy/protein (milk, sugar and oil) feeds to the hospitalised children for up to 3 weeks of intensive treatment. The diet of those less severely affected can be supplemented as outpatients  with a flour made of  dried beans, carrot, sweet potato , millet, and peanuts..  Let us hope that this year's harvest will be better and that the children won't go hungry next year. Meanwhile we will continue splashing through the puddles.

Snail-mail from Chad

Imagine a time not too far in the past, that this blog came to you as a letter by airmail from Chad posted in the first week of the New Year, with a bit of luck you would have been recieving it about now mid February. So here it is, a blog written by Andrea that lay unposted hope it is not too late to count as news. 

                                                ---------------------

Mid January
Ndjamena                                    

Well Christmas is over and New Year too but we thought a few pictures of our Chadian Christmas might be of interest.

The play for the patients and relatives went well after a few false starts quite a bit of encouragement and some confusion about the shepherds following the star from the East. About 100 people were watching, one patient even walked from her private room the first day after her operation. The Christmas story relayed in Arabic was mimed out by angels in white (lab coats)  and Mary in a laafée .Others in Jalabeers borrowed from our Muslim guards and nurses and one of the shepherds in a turban. This all helped to fix it in Chad and relevant;  and a comment was heard ‘Oh so Christmas is about the birth of Issa’ so we did get the message over! Food of course followed, meat and donuts not quite mince pies but tasty.

  We attended a concert the following day in the French cultural centre it was a selection of choirs and groups from all over Ndjamena a great venue in a theatre out under the stars. There was some excellent chorale singing, the dancing very Chadian,  and sometimes not clear how it fitted with Christmas but still good fun.

Our real treat was on Christmas Eve when we had a camel ride we’ve been talking about it since we arrived but it has to be the right season(not too wet for the camels feet) and also not too windy as we found out when our first date  was cancelled. It was good fun and nowhere near as scary as I imagined there’s quite a bump as the camel goes up but otherwise it’s very sedate. The place is down by the river in Ndjamena but being Chad here’s the bizarre element you ride around a golf course! Not that you would recognize it no grass just beaten mud for greens and sand in between.

We then went on to Church where the service lasted until 5am .We didn’t manage the whole time I have to say and came home in time to sleep before covering the hospital on Christmas day. It was quiet and we handed out some presents and sweets to patients which were well received, apart from one little girl who was terrified by the small doll we gave her The day finished with a great Christmas dinner including tinned sprouts(not to be recommended) but sticky toffee pudding to finish was very tasty.

Our New Year started with a cancelled weekend away due to a patient with post op problems(now doing well at home) We still had fun with a walk to the grand canyon ( a big man made crater ex rubble mine for the roads,  just where we turn off the main road to get here) and a chinese meal but we are now back to work properly with plenty to do. Rob is now here to stay for 6 months to do admin and also Mike a doctor who covered our leave in the summer has come for a couple weeks to help. Just as well as we seem to get busier all the time deliveries are now around 40 a month and the operating log has 41 cases in it already for this month.

We pray that your new year starts well and continues under Gods guidance, with his peace and Joy.

PS 19th February, time flies, another busy month, a TV news program paid us a visit just after the blog was written. It is a bilingaul program, they wanted to interview me in Arabic as well as French, they were disapointed my Arabic is very limited. Apparently the half hour emission was good, but we don't have a TV so havn't seen it.