Awaken

If George Orwell had been writing in the year 1984, rather than post war 1948, he wouldn’t have died of the chronic pulmonary tuberculosis that was already destroying his lungs. It was the start of the age of antibiotics and Orwell did get to try the new wonder drug, streptomycin. He initially responded to treatment but then relapsed due to drug resistance and died in 1950. A generation later, in 1984 when I was first seeing patients, TB was no longer the feared killer that it had been in the UK. It was by then unusual to see a case on the chest unit in Leeds. Multi drug therapy (4 antibiotics for 2 months and 2 antibiotics for 6 months) had evolved from the early trials including Orwell, and led to cures for millions of people. The special TB hospitals and sanatoria, had all been closed down.

That’s enough history form the UK, now let’s look at Chad, in the present. I met Adam on my first day back from holiday, a 6 year old boy, lying in bed unconscious and fitting,. He had been a bit unwell at home in Guinebor 1 over the past 6 months. No one had thought much about it, he had a hard lump in the middle of his back, it caused a bit of pain but he had continued walking around and coughed a bit. About a week before his admission he had become drowsy with a fever, he first stopped walking, then talking, and after a couple of days was bought to the hospital unconscious. On admission he was put on antibiotics for meningitis, given drugs to control his fits and his unrelated Potts disease (TB of the bones of the spine) was noted.

Three days later on the Monday morning, I met him, he was no better and as I examined him he was breathing poorly with deep snores, still had a high fever and was completely unrousable. Reviewing the story I realised that the classical TB of his spine was also likely to be the cause of his meningitis rather than a second incidental disease. It seemed to me that the disease which had been localised in his spine for months had burst out showering germs everywhere, lungs, liver, and brain causing his sudden deteriortion. (It’s probably the same sequence of events that killed my maternal grandmother in the 1930’s when my mother was a small child).

Unlike pre-war Britain when it was incurable, it was possible to save Adam but time was short and he needed specific anti TB drugs if we were to recover him from his coma. We are not part of the National TB program and it wouldn’t have been wise to transfer him to another hospital which has the tablets. He couldn’t have swallowed them anyway. So his father was sent to buy some Kanamycin (a drug very similar to the streptomycin given to Orwell), a once daily injection. I was amazed at the price 1000CFA a dose, a mere £1.20! He also needed very high doses of injectable steroids for brain swelling. After a couple of days he was breathing better, but was still unconscious, and  a feeding tube was put in so that he could have milk and sugar.

Slowly he improved, he had no more fits, the fever went away and little by little he began to awaken. After a week he was just about rousable and would sometimes take hold of an object placed in his hand. One TB drug could improve him but it would not be enough to cure him and so he was taken by ambulance to the local government hospital where he was given the necessary tablets for a month and returned to us. The tablets were crushed and put down the feeding tube. After another 3 days he began to speak and drink small amounts. Earlier this week he took his first steps and today after 4 weeks of treatment he is walking around the ward by himself, he’s even starting to smile (sometimes but not for the camera).

He will need to complete 2 months daily supervised treatment, but he will soon be well enough to do that as an outpatient, living in the small ‘village’ we have built just outside the hospital, followed by another 6 months of home care.

Why do we not have our own TB service? After all the lung disease is very common here. The District medical officer is very keen for us to join the National Program which would give us free drugs. I have the experience to run it after my time in Guinea at the TB /Leprosy referral hospital at Macenta, but we don’t yet have sufficient medical staff to run it properly. It needs careful supervision to do well. There would no doubt be many cases requiring a separate clinic room and nurse plus some isolation rooms for hospitalised infective cases. So for the time being we continue to refer the cases we find but continue to the sickest treat by special arrangement.

We will continue to explore the possibility of young doctors from a Cameroonian mission and recently trained Chadian government doctors so that we can improve our services and capacity. We look to a future, thankfully not an Orwellian dystopia, but a time when wondrous stories are told of what God has done here, and that includes treating TB.

PS: Adams mother is very happy for his story and pictures to be shared and  when asked  said  'Yes ,we like the hospital very much, anything we can do to help'

Reasons to be cheerful one two three?

 

Plenty of cause to be cheerful this week as we walked out the back of the hospital to see the site of the new maternity building . The site has been cleared and foundations are being dug. It’s hard to believe it’s started at last but soon we will be in our new building and have enough space for all our women to deliver in privacy and comfort.

Reason two- last week we held our first community outreach meetings, lots of women coming and many very interested in what is being said and keen to learn how to improve their own and their families health. Again something we have been waiting for and it’s great to see it happening. 
 

 

 Then we have the 8^th of March what does that mean to you- here in Chad it’s time to celebrate put on our new clothes and march in front of the presidents palace for International Womens Day. This years theme womens independence. Unfortunately we were advised not to march in a large crowd due to the security situation. We explained this to our Chadian staff and were happy when they said well lets meet to pray for peace, eat and dance instead. So last Sunday that’s what we did. At Rachels house, (one of the midwives) we all met and celebrated and prayed for peace in the region. It was fun and we had plenty of energy to dance as we had not been in the sun for hours waiting to march. In the end fortunately the march was peaceful but security remains an issue here many are not able to celebrate. Prayers are still needed for peace in the region.

The sound of silence

It was early on a Saturday morning in February at half past seven and  the peaceful silence of my lay in was disturbed by a low throbbing hum that increased  and made the whole house vibrate as it passed overhead. It’s not the lawn mowers that wake you up round here but the helicopters.

Later after breakfast a couple of jets roared low in the sky as they returned to the airbase This happens  several times a day, they have presumably the same destination as the helicopters and are a reminder of a major news story that is not very far away. I won't speak of that now, you can look it up for yourselves.

As the sound of the planes died away, I entered the emergency room to see a boy,  a silent echo from the same events.

I thought I knew the story already from a nurse who had come to the house earlier on. The boy had been bought in by his father, he hadn’t spoken or indeed done anything for four days but apparently he was still eating and drinking what was put in front of him and going to the toilet; but nothing else, just laying down. He had been carried to the hospital. His pulse temperature and blood pressure were all normal. So he had been waiting to see me for an hour or so, triage category important enough to see the doctor but not urgent, as I said to the nurse whilst cooking the eggs for our family breakfast.
 

The boy was laid immobile on the bed eyes open starring into space, about 7 years old. I said hello and asked his name, no reply. So I sat him up and gave him a quick physical check. He looked normal to me,  and now  he was looking at me, watching me carefully but he wouldn’t talk. I asked a few questions of his father,

Had there been any bad news or shocks at home? ‘No’,

Had he been fighting or arguing with anyone? ‘No’

Had he problems at school? I am his school master and there are no problems.

Where are his father and mother?  His family lives up by Lake Chad but they have sent him to my religious school.

I remembered, how could I forget, that a village on Lake Chad had been attacked a few days before, could  this the cause of the behaviour?  No, he is sick.

 

The response of the powerless and weak is often silence round here. How to give them a voice?

I agreed that  he was sick and suggested that the master  step outside so that I could try to find out the cause.  In the quiet I spoke to the boy  again and this time asked him if he was worried about his parents. Perhaps it was the surprise being addressed by a white man, or perhaps just that someone understood? Tears welled in his eyes and rolled down his cheeks and he said yes. He told me his name, Moussa, that his mother had died a couple of years ago, he hadn’t seen his father for 18 months since he came to school. His father is a fisherman on Lake Chad and he agreed he was worried for his safety. I prayed for him, his father and for peace.

The nurse was surprised to see the change and suggested that the master would now beat him for wasting time. Not an ideal solution, and hopefully simply the prejudiced view of a Christian nurse of a Muslim family, but who knows?  Anyway the master, who seemed to really care for Moussa, (why else had he come to the hospital?),  was invited back.  I explained to him that  Moussa had a bad shock with the news from his home area that made him unable to speak. The best solution would be to get Moussa to talk to his father on the phone. That won’t be difficult he said I have his number he is my brother. As often happens the phones wouldn’t connect so he said he would try again later and they went home. Moussa walked out by himself.  I hope it all went well.

This case was, in my experience, unusual; in that a child was involved and he was male. Much more commonly, at least two or three times a month, we see young women who come in mute, laying stiff in a wheelchair and looking unconscious. With experience it is relatively easy to distinguish this psychiatric syndrome from physical disease. Sometimes there is a minor physical illness and they have excessive fear, death can comes surprisingly quickly here. More often there is a history of family trauma, arguments with husband, mother in law, a death in the family or the arrival of a second wife. Difficult situations for women in a society where they have little right to speak for themselves. We try and get people talking to each other so that the issues can be addressed and if necessary can act as place of safety for a cooling off period.

Conversion disorders used to be termed hysteria and were often considered a disease of females. Even the name, hysteria, comes from the Greek for uterus which was supposed to move and cause the disturbance. Of course this is not the true cause and it’s not just down to the hormones either, but it is true that  in my practice women are more frequently affected. I think that these phenomena, and especially psychological mutism has much more to do with a sense of powerlessness and being in a low position where you aren’t usually heard than with gender. Typically in patriarchal societies it is the women, especially the young who find themselves in this situation but  It is interesting to note that it was common amongst the ordinary soldiers in WW1. Unable to endure the horrors of the trenches they became mute and withdrawn. Interestingly  it was uncommon amongst officers who had different physical manifestations of post-traumatic stress disorder (shell shock), such as unexplained paralysis. Perhaps the ordinary infantryman couldn’t find the words to describe so numbed by events he spoke no more. The voiceless lose the power of speech, but remember  it is  not a choice ,they simply cannot speak.

Changes in our society in the UK have meant that the typical reactions that I see in Chad are much less frequent than they were a century ago. People, especially women are better educated, and have learnt to have a voice. The change for the better, but there are still problems. Theoretically people, women and even children, are used to expressing themselves but sometimes they can’t find the words. Instead of becoming passive and withdrawn there is a still a desire to express themselves to cry out and so there is an often hidden epidemic of self-harm seen in NHS Emergency Departments most nights of the week; the taking an overdose of tablets or cutting of the skin.  

So it was a surprise to me when last month when I was called to a young women had swallowed petrol. That is not a normal response to stress in Chad, but then no rule is absolute. She felt trapped in an arranged marriage where she suffered verbal and sometimes physical abuse. Earlier in the week had taken refuge with her parents. She was due to return to her husband,  her father was to take her  that morning, and saw the petrol as the solution even accepting death if necessary. After a period of observation it was clear she was in no medical danger but stayed with us a couple of days as a way forward was worked out.

Our societies differ and people use different ways to cry out, sometimes with a silent cry and other times with acts against themselves. These people, especially the powerless young women unhappy, abused and exploited in all our societies, need help the world over.  Let us all see what we can do to help on this International Women’s Day.