Vaccine 4. Prevention is better than cure

The Covid-19 satellite hospital at Bardai, a  re-purposed police station. 

Cast your minds back to April 2020, the first lockdown had begun on 23rd March, but despite this the deaths  due to Covid-19 were still rising at an  alarming rate.What could be done to stem the tide of the pandemic? 

 

Hopes were already being pinned on a vaccine, but would it be possible to make one? How much would it cost?  And more importantly how long would it take? According to the Welcome Trust, in normal circumstances $500 million over 10 years. The quickest ever was 5 years for a mumps vaccine. However fortunately there were new technologies, mRNA and adenovirus vectors, and so Sir Patrick Vallance, UK Chief Scientific Officer, was suggesting 12-18 months. There were grounds for hope but a long and anxious wait was just beginning.  

Meanwhile what could be done to help people before a vaccine would become available? The first response was already in place, an unprecedented lockdown to slow the rate of transmission, the second was to boost the capacity of the NHS to cope with the number of patients needing hospital treatment especially lifesaving oxygen treatment.

On the 3rd of April, 11 days into the first UK lockdown, to prevent the risk of NHS hospitals being overwhelmed, NHS Nightingale London was declared operational. The Excel conference centre had been converted into a hospital in  less than 2 weeks. The  initial capacity was 500 hospital beds with  the possibility of 4000.  More complex equipment was harder to come by,  innovative manufacturing was needed and in the meantime some came from surprising places, such as working ventilators given by the BBC's Holby City film set. The cost of the conversion and equipment was £57 million and 6 more provincial centres were to follow. 

In Bardai, at the hospital, we were trying to respond to the situation, by delivering health education messages on hand washing, mask wearing and social distancing in the community and improving hospital hygiene and infection control. Our ADP linguist colleagues made a health education film in Teda that passed from phone to phone.

We also realised that our small hospital was at risk of being overwhelmed by even a small number of cases due to  inadequate separation of Covid and non-Covid patients and uncontrolled visiting fuelling any epidemic. The local authorities offered a very good solution; the disused police station with a perimeter wall could be transformed into a separate Covid satellite hospital. Help from the WHO and Ministry of Health would eventually arrive but in the meantime BMS supported the rapid organisation of a water supply, triage area and other changes. The main  hospital had basic equipment such as beds and trolleys in storage and so within a couple of weeks we had a unit. We even had a small quantity of disposable PPE that had arrived by chance 6 months before, that was initially supplemented by surgical gowns and scrubs made in town and eventually further supplies from the Ministry. 

Orders for plenty of oxygen masks and other essential medical equipment were made from the UK and these eventually arrived along with essential medicines such as dexamethasone, paracetamol and antibiotics from N'Djamena.  

 

Rather like the UK Nightingale hospitals, our satellite hospital has been little used, although we did have a handful of highly probable cases in the town (we had no tests to confirm them). Thankfully we didn’t get sustained transmission, but having seen the scenes from the UK, Europe and the US we were right to prepare as much as possible. Despite all our preparations the day a more transmissible variant arrives in Bardai we will be at risk and  still would have difficulty coping. The reason for this is the same as one of the drivers of the unfolding tragedy in Nepal and India, a lack of oxygen.

From the outset we were aware that this was a major weakness. In the UK we assume that nearly every bed in a hospital has a piped oxygen supply, and if not, there is a full oxygen cylinder nearby. There is no chance of replenishing our empty oxygen cylinders in Bardai, but we do have four individual patient oxygen concentrators, an amazingly high number for such a small hospital but only two were working. Fortunately, one was repaired by missionary colleagues from Germany and the Ministry of Health sent us another one. BMS bought 2 small generators that could run 6 hours on, 6 hours off to supply the necessary electricity 24 hours a day.  Large numbers of oxygen concentrators have been given by the WHO and other donors to Chad, and hundreds of thousands throughout the world but as an article in today’s Guardian shows, once an epidemic strikes there is usually not enough oxygen to meet the 10 to 100 fold increase in demand. As a consequence  Covid is no longer a disease predominantly affecting the older population, many people of all ages die. We must of course help in any way we can to get oxygen and supplies  to everyone  that need it, but the volume of equipment and the training and skill required to do anything other than the simplest oxygen mask treatments means that this can never be the best solution for most of the population in low and low middle-income countries. Building Nightingale hospitals in advance all around the world is just not possible.

What is needed is a vaccine freely and equitably available for all, after all prevention is better than cure.  

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VACCINE 3: The present

Bardai 2018: Launch of  National Polio Vaccination day

 At the end of the last post I encouraged you to sign a BMS petition which expresses solidarity with those countries who are proposing a TRIPS (patent) waiver.  This would enable production of COVID vaccine in sufficient quantity so that it  can be rapidly  and  equitably available throughout the world. BMS, through the  Peoples Vaccine Alliance, are partnering with many organisations ,one of whom has produced a 5 minute video that explains the gravity of the situation and offers a solution, Manifesto for Life.

The problem over commercial medicines may seem to be enormous: changing international treaties to allow patent free drugs may seem a very difficult thing to do. But actually it is not  necessary, because it has already been done.  The TRIPS waiver mechanism was negotiated at the 2001 WTO talks in Doha as a response to the AIDS epidemic sweeping southern Africa and elsewhere. It paved the way for widespread distribution  of low cost HIV treatment. Previously the  annual cost of branded triple therapy of $10,000 per year made it impossible for all but the citizens of the  richest nations to be treated.  Suddenly, with a generic equivalent made in India, the price fell to $350 per year. This has  saved many millions of lives in middle and lower income countries. By 2018 the price was as low as  $75 a year, that is 15p (20 cents US) a day; as a consequence effective  drugs to treat HIV are supplied by the Ministry of Health to all hospitals in Chad, including Bardai, for free distribution. 

 Dr Tedros Ghebreyesus, the Director General of the World Health Organisation, recently said 'the gap between the number of vaccines administered in rich countries and COVAX (supplying low income countries) is growing every single day and becoming more grotesque every day' He proposes using the same already established mechanism of the TRIPS waiver to address this situation,saying, ' These provisions are there for use in emergencies......if now is not a time to use them, then when?' 

The recent posts on this blog have been exploring the history of the campaign against polio and there is at least one more lesson that we can usefully apply to the current situation with COVID-19 

                                'NO ONE IS SAFE UNTIL EVERYONE IS SAFE'

In 2011, one year after our family's arrival in Chad to live, work and attend school, there was a spike in polio infections. One hundred and thirty two cases of paralytic polio were recorded and probably many more cases were missed. That amounted to 41% of the total cases in Africa, and Chad was considered a reservoir of infection that risked contaminating the neighbouring countries. A new programme of National Vaccination days was started, the first being inaugurated by President Debi Itno, with representatives from WHO and UNICEF, plus, from GAVI, Bill Gates in person.

The campaigns rapidly bought the situation under control and by 2014 there were no reported cases. The photo at the top of the blog is of the last mass campaign in Bardai, 2018. After that routine polio coverage was continued through routine childhood vaccinations.

In 2019 there were a concerning  10 cases of paralytic polio and then in February 2020 (not on the graph)  a serious outbreak began resulting in 99 cases across the country. This spread across the borders to Sudan and The Central African Republic. The Chadian epidemic accounted for about a quarter of the worlds cases. Due to the COVID-19 pandemic it was difficult to get the resources to mount a response, but finally in November 2020, two vaccination campaigns 14 days apart managed to vaccinate 3,3 million children across the country including Bardai and the Tibesti.

This rapid reversal of the progress in eradication of polio  shows that the WHO estimate of 200,000 cases of polio a year worldwide , if we fail to eradicate it in the last remaining endemic countries,is not a fiction, but an alarming reality. As we noted before.

                             'NO ONE IS SAFE UNTIL EVERYONE IS SAFE'

The Covid-19 virus presents a much greater problem than polio. It is spread by aerosol and that makes it much more difficult to control by simple hygeine measures than a disease like polio which is spread by food and water .In addition the Covid-19 virus is also capable of mutating and so can escape from the  antibodies that are produced  by vaccines. The polio virus does not mutate and the vaccines have remained effective for many years. Therefore for COVID even completely  vaccinated  countries could be reinfected by a vaccine resistant strain coming from non vaccinated countries. Logically We need to seize this opportunity to vaccinate everyone in the whole world. Then we can hopefully eliminate the disease. If not we will spend the next few years or decades with intermittent  lock-downs, always be  chasing a new vaccine and adding increasingly complex and expensive travel restrictions.

A year ago, when fear reigned at the height of the first wave, vaccines were but a distant hope. The President of the European Commission spoke for many when she said ',We need to develop a vaccine. We need to produce it and deploy it to very single corner of the world. And make it available at affordable prices. This vaccine will be our universal common good'

Even now, as vaccine nationalism takes hold and the vaccine gap between the haves and the  have-nots widens every day, let us get back to a spirit of true international co-operation, pass the TRIPS waiver and organise technology transfers so that as many doses as possible of vaccine can be made this year.

If the moral imperative to alleviate suffering and death overseas is no longer enough to motivate the WTO and world leaders then surely long term self interest economic and social should lead them to the same conclusion.

                                   'NO ONE IS SAFE UNTIL EVERYONE IS SAFE' 

Today is Easter, a day of hope for new way of life, as we are writing this we received a Franciscan blessing from a friend, it speaks of striving for justice, we pass the last part on to you.

...may God bless you with the foolishness to think

that you can make a difference in the world,

so that you will do the things which others tell you

cannot be done

VACCINES 2: Thirty years later

Macenta, Guinee Forestiere, where we arrived to work in 1993,  Polio was still rife.

In my last post I explained  how polio, a disease that was feared by my mothers generation, was rapidly bought under control in the western world by new vaccines which, as they were not patented, were able to be made rapidly available by multiple pharmaceutical companies. This is an interesting lesson for dealing with the current COVID-19 pandemic.  Are there any  other lessons that we can we learn from this story?

By the time that I first went to school, although there still were occasional cases, the threat of annual polio epidemics in the UK was already the memory of a previous generation.  Later in my final year at medical school (1984),the last case of polio in the UK caused by transmission of the wild virus was recorded. 

However despite the amazing generosity of Jonas Salk and Albert Sabin the problem worldwide was still a massive one. In 1988 there were still an estimated 350,000 cases of paralytic polio each year, with about 10% of the children dying. That was the year  that the WHO launched the Global Polio Eradication Initiative.  

Five years later, Andrea and I arrived in the hot and humid town of Macenta, Guinee Forestiere. It was forty years since  the discovery of the vaccine, yet tragically polio was still endemic. Each year I would see young children who had been either recently  paralysed or were living with the consequences of contractures. Often they were  crawling on their knees unable to use any  muscle strength that they had regained to walk. At the Centre Medical we worked together as a team; the physiotherapists taught exercises, the orthopaedic workshop made callipers and splints, and in the operating theatre we did tendon release procedures guided by the newly published WHO manual.

Thankfully prevention was also beginning,  polio vaccines were being distributed to  the fridges in the  new health centres that the Mission Philafricaine were building in collaboration with the Ministry of Health. For the first time the people of the region had access to  routine childhood vaccinations. In addition each year, on two special national vaccination days, every child under 5 in the country received a dose of oral polio vaccine. Healthcare workers passed from door to door with a polystyrene insulated cardboard vaccine carrier emablazoned with "KICK POLIO OUT OF AFRICA" No-one was exempt,my daughters must have recieved a total of 12 doses by their fifth birthday. Within a couple of years of the campaigns beginning I no longer saw newly paralysed children, but there were still plenty who needed help from the time before the vaccine. Similar campaigns were taking place everywhere with dramatic results, the graph below shows the global situation. 

In Macenta the  dramatic change was bought about by the arrival of the cold chain. In 1991, just prior to our arrival, there had been an epidemic of meningitis and the only way to get vaccines into the region had been in a truck from the capital alongside deliveries of frozen fish.These were being made by a family of Lebanese traders to a chain of depots selling fish to the local markets. Thanks to this unusual support lives were saved, but the need for the provision of a dedicated medical cold chain had become clear.

The WHO estimates that their polio campaign has lead to 80% of the worlds population now living  in polio free countries and that 18 million less children have been paralysed as a consequence.  There were only 22 cases of wild polio virus reported in 2017, a great success but we  not quite there yet, and it has taken 60 years.

Sadly despite the potential supply of large volumes of patent free vaccines it took 30  years before adequate supplies arrived in Guinea because of the lack of development of the healthcare systems in low and middle income countries, notably, cold chains. Thankfully cold chains are in place now even in remote places such as  Bardai, our current somewhat dryer home mid Sahara.

The Provincial hospital where we work  has  an excellent solar powered fridge supplied by UNICEF and we are able to supply polio vaccine to the most remote villages each year for the National Polio Vaccination Days. Due to the terrain it actually takes about a week to get around them all using the hospital ambulances. 

So with the current COVID-19 pandemic, we are fortunate that the necessary infrastructure is already in place, but where are the vaccines? So far 25 million doses have been given for the African population of 1.35 billion  whereas we in the UK have given 32 million doses for 68 million people, that is a 25 fold difference. This disparity represents  what the WHO has called a potential 'catastrophic moral failure' of inequality. We need to campaign for  our government and the World Trade Organisation to enable sharing the knowledge and technology so that a low cost vaccine  can be equitably and freely available throughout  the world. This is best done by a TRIPS (patents) waiver, which is supported by the majority of nations  but opposed by  pharmaceutical companies and rich western nations. If you want to show solidarity with your global neighbours click on  the BMS petition.

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VACCINES 1: ‘Could you patent the sun?’

                                                                                              A hospital ward with patients treated with iron lungs USA 1952

Patents: there is an impasse so far at the WTO talks on establishing a TRIPS (patents) waiver to enable an equitable and timely, production and distribution of COVID vaccines across the world. It seems that for the rich nations it is unthinkable that this should be proposed, it is apparently just not the way our world works. But it doesn’t have to be this way.

My mother would remind our family in the early seventies how fortunate we were that the swimming baths were open through the summer holidays. She spoke of how polio epidemics had forced them to be closed, along with cinemas before the vaccine was found.

Polio had been growing threat with seasonal epidemics throughout her life and by the early 1950’s was getting out of control with each summer bringing new localised but devastating epidemics. It is caused by a virus spread from one person to another through food or water contaminated with human waste. For the vast majority it passed as a mild gastroenteritis but for a small number fever and muscle pains were followed by varying patterns of temporary or permanent paralysis. In the UK several thousand were affected each year, about 700 died, and some required months of help to breathe with ingenious iron lungs. In 1950’s America only the thought of nuclear war caused more fear: It was a worldwide phenomena.

Despite President Roosevelt having launched a nationwide appeal in 1938 to fund research and support for the affected, there was no solution and the situation was getting worse. The 1952 epidemic in the USA was the worst ever with 57 000 cases, 21 000 with a permanent paralysis, and 3000 deaths.  In that same year, Jonas Salk, a virologist in Pittsburgh who had been working on polio for several years, announced that he had a candidate vaccine. In 1955, following a trial with over a million children, the injectable vaccine was declared both safe and efficacious. The following year mass vaccinations started in the UK and annual numbers of cases fell rapidly so that by the time I was born just 5 years later, in 1961 annual case number had fallen by over 90%, and shortly afterwards with the change to an oral vaccine, found by Albert Sabin, cases rapidly became vanishingly rare in the UK.

This is an amazing success story, but we have yet to mention the most surprising yet crucial part of it. On April 10^th 1955, the day that the vaccine was declared safe and effective, Jonas Salk spoke with CBS news,

                                  

                                     Interviewer : "Who owns this patent?"

                                     Jonas Salk: " Well the people I would say

                                                             There is no patent

                                                               Could you patent the sun?"

Remarkably Albert Sabin also chose not to patent his oral polio vaccine, so that it could be widely and quickly produced and used for the benefit of the whole world, he said

                                     "A scientist who is also a human being cannot rest

                                      while knowledge which might be 

                                      used to reduce suffering rests on the shelf"

The COVID-19 pandemic is far more deadly than polio ever was, so now that we have a vaccine surely exceptional circumstances demand exceptional measures once again. Let us join with the WHO, BMS World Mission and a majority of the worlds nations in petitioning the WTO and our leaders so that the necessary special approvals can be made and patents lifted so that COVID vaccines can be made worldwide by any company that has the capacity to manufacture them" 

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Towards a greener Sahara: Part 3

Away in a manger no crib for a bed. The little Lord Jesus laid down his sweet head.

It seems to me at Christmas we enjoy talking about how Jesus didn’t have a proper cot or crib and had to lie on straw, but we don’t often mention his other needs such as food and nappies. Why not?  After all they are also part of a babies basic needs.

Thinking about this an article in the BMJ caught our eye this week as we catch up on back issues whilst in the capital -Support breast feeding and the environment.

Most of the talk about breast milk vs bottle feeding concentrates on the value of breast milk and the risks of bottle feeding. WHO estimates around 800,000 children under 5 die world-wide per year as a result of bottle feeding. A few days ago I had a message from Bardai telling me that one of our cleaners at the hospital had lost her baby after it was initially admitted with diarrhoea and dehydration and the family decided to take it to Libya for care. Almost all Teda women bottle feed and we spend a lot of our time dealing with diarrhoea as a result of poor hygiene. The bottles have an offensive smell of sour cheese, they are so dirty. Breast feeding is so much easier than sterilising bottles and much cheaper.

But now it looks like we have another reason to encourage breast feeding. The environmental effect of breast feeding we can assume is small as it uses few resources and produces minimal waste. When it comes to formula feeding let’s start with the milk. The water footprint to make one kg of powdered milk is an incredible 4700l and we shouldn’t forget the methane produced by the cows giving the milk (methane of course trapping heat in the atmosphere 30 x more than C02). Cows milk alone is not nutritionally adequate, so palm oil, coconut oil, fish oils and minerals are added, only adding to the environmental costs of production. Interestingly only 40-50 processing plants exist worldwide, so imagine the food miles transporting the raw ingredients and then distributing the milk world-wide. Once the milk is finished we have to consider what to do with the 86,000 tonnes of metal and the 364,000 tonnes of paper left -land fill is the usual option. These figures are from 2009 and apparently use of formula has doubled since then. So it looks like formula milk is not a very eco-friendly option and that’s before we start thinking about buying and making bottles and sterilising them and heating water for the milk. In the UK alone estimates of the carbon emissions savings gained by breast feeding instead of bottle are the equivalent of taking 50 000 to 77 500 cars off the road per year.

We can safely assume that Jesus was breast fed and Mary and Joseph didn’t have to worry about such issues. Unlike the 78 million children who are not breast fed in the world, the 76% of children not being  exclusively breast fed at 6 weeks in the UK and of course our Teda friends.

What about the other end of the baby. There has been a lot of discussion about cloth versus disposable nappies and the fact that using both electricity and hot water to wash and dry cotton nappies makes them less eco-friendly than you would imagine. Washing at lower temperatures and line drying would clearly reduce their impact. However this is far from the only consideration, for a start nappies have to be transported around and obviously you need a lot more miles to transport disposable ones than cotton! Then they have to be disposed of; in the UK estimates are that they make 2-3% of land fill as they slowly disappear.

Things begin to look even less ecological when you start to consider production; it takes 3 times more energy, 20 more raw materials and 2 times more water to make a disposable nappy compared to a reusable one.

Sadly Bardai doesn’t do too well. Although where we live most clothes are washed by hand using no electricity and dried on the line ( easy when it doesn’t rain) all of which should make the cloth option even better. However most of our Teda friends use disposable nappies and they are disposed of just about anywhere, with no concern for hygiene and waiting for the next 500 years to pass before they disappear. All the other problems apply too , they have to be brought to Bardai in trucks across the desert and of course they have to be manufactured as well. It could be time for some interesting conversations.

Let’s get back to Christmas, I guess Mary didn’t have the luxury of nappies in any form and must have used some eco-friendly extra swaddling for Jesus and that’s not so uncommon in Chad either, it can be disconcerting to end up wet when giving a baby a cuddle!

So after all this cheerful information what next? May be this year as we celebrate the birth of this special baby it might be the moment to start thinking and working out what you can do to make a difference to protect this beautiful world we have been given.

Happy Christmas and many blessings for an environmentally friendly New Year

Towards a greener Sahara - Part 2

The hospital gates are open for a day.

The loud speaker on the small mosque on the far side of the wadi crackles into life at 4:30 am, awakening the faithful and calling them to prayer at dawn. It is the coolest time of day but not yet the cold season so the temperature is a respectable 15C. There is a slight chill in the air but  we are sleeping outside in our yard. Sometimes I say a short silent prayer from my bed, sometimes not, either way I am soon asleep again until 6am. I don’t hear it every day but a few nights ago I did and shortly afterwards there was the sound of the gates opening in the neighbours yard and a couple of petrol engines coughed into life. They sat there running for 10 minutes or more, to make sure the engine was warm, and then I heard the cabin doors  of the pick ups slamming shut, others passengers were no doubt  climbing on the back that is already piled high with luggage and with a cry they were off down the rocky hillside  on their adventure- to the gold fields. 

The Teda, it seems to me, are never happier than when they are travelling. I guess that in the past that the men spent time away from their villages in the mountains riding on camel trains, but now camels are rare and are used as a source of meat rather than transport. They have been replaced by Toyota pickips, be they the lighter slightly more economical Hi-Lux pickups or the more rugged and thirsty Land Cruisers preferred by the military and those that can afford them.

Energy efficiency label in Bardai.
Verdict poor. 

So what happened to the motorbikes that are so comparatively cheap to buy and economical to run? A fuel efficiency of  giving  80-100 mpg. There are two in Bardai and they are rarely seen in use. In the Tibesti the distances between towns are such that you need to travel with all your fuel and water plus sleeping equipment, and you wouldn’t ever travel alone.  Even driving around town for short trips would be difficult due to all the loose sand.  So unlike Ndjamena and the south of the country, where motorbikes outnumber cars 10:1, and saloon cars and taxis similarly outnumber SUV’s, in Bardai a small means of transport is a 4X4 petrol powered pickup giving about 26 mpg.

At the Drive Thru Pharmacy!

The young Teda men drive them around all the time, even f!or short trips of a kilometre or so around the town. Fuel economy is not a consideration with a price of 40p a litre from Libya as opposed to 80p in Ndjamena. Engines are left running not only to warm up (Is that really needed) but also whilst trying to fit in a quick consultation at the hospital and then drive straight on the 50 meters to the pharmacy to get the drugs. Actually as the hospital has got busier we have limited that by trying to keep the gates locked so as to diminish the risk of accident in what should be a pedestrian zone.

If the Teda lived in London perhaps some criticism of their choice of expensive 4X4, or indeed any personal vehicle could be justified. The effects of CO2 and other pollutants are significant both for the health of the planet and its human population. But what other choice could be practical for this isolated mountain dwelling people? Many of them live in homes that cost much less than their vehicles with no sanitation or running water. The long distances on sand and mountains, on unmade roads, means that it is either a camel train or 4X4. I know which I would choose. At least off road vehicles are used off road here, unlike in the UK where many are only off road when parked on the pavement of a congested city.

Gold mining equipment, sand sifters, for sale in Bardai

The sheer numbers of vehicles up here is amazing, where  did all the money come from. The cheapest new  pick ups  coming from Libya are £24 000 and another £8000 for Chadian import taxes ( the latter rarely paid in this remote province). In a country where nurses and teachers are paid $300 a month this is a colossal sum. Many of the men struck it rich with the early part of the gold rush when large nuggets were being readily found in the superficial sands using metal detectors. A vehicle cost about 500g of gold. It was all  a bit of a lottery you might find some  large nuggets, you might find nothing or you might be really unlucky and  find an antipersonnel mine. However prospecting for nuggets finds just a small  a fraction of the available gold, now the men are digging large quantities of auriferous sand and rocks and using air blowers they can sift it and get about half of the available gold. It is less efficient than traditional water washing but water is in short supply and there isn’t even enough for basic hygiene; diarrhoeal illness, typhoid  and viral  hepatitis have been frequent problems.

 Last week I heard of 2 new tragedies, one immediate and one long term. The first was of a mine collapse that killed 30 people up towards the Libyan frontier. Unsupported mine workings in rich seams of gold bearing dirt are dangerous. I saw a photo of a similar accident from September, a large group of men lined up around a large sunken linear crater in which another 30 men had lost their lives, there were no survivors.

The second and  long term problem is that of using mercury, a very dense liquid metal,  to improve the yield.  Reportedly using this technique  80g ($3500) of tiny flecks of gold can be found in a sack of 50KG of dirt. The process is simple using a small amount of water to make a suspension of the dirt mercury is added and all the gold that comes into contact with the mercury dissolves in it making an amalgam. The mercury is then gently heated  and it boils away leaving  grains of pure gold. The problem is that mercury which can be inhaled is toxic in many ways including neurological and psychiatric syndromes. In other gold mining sites  around the world mercury poisoning is a major problem as environmental contamination of fields and water supplies around villages leads to birth defects, mental retardation in the next generation. At least up in the remote wilderness only working men are found and so the risks are confined to them.

Gold, if it is well managed, is a potential blessing for the economy of the Tibesti. It could bring about major beneficial changes for the local and incoming populations and since 2012 there are some big changes in population and markets. The immediate  problems associated with infectious disease, accidents and insecurity are all to some extent acknowledged but so far the long term issues arising from environmental pollution, be that from vehicles or mercury, are not even on the radar. 

In a cloud of dust, showing off to the girls using the new 'camel'

Towards a greener Sahara: Part 1

A question : September 20^th 2019, where were you?  And what did you do?

The evening before, we were in London drinking coffee with Rebecca. When we compared plans for the following day, they couldn’t have been more different. 

Celebrating Mark's
birthday at 35,000 feet

She had made a difficult decision to skip lectures from her course at King’s College London and join with members of the university Students for Global Health Society and millions of young people around the world on the Global Climate Strike. 

We would have loved to join her too but instead we had to wake up at 3am, walk to Terminal 4 Heathrow and board an Air France flight to Paris then on to Abuja and finally Ndjamena, a journey of at least 3500 CO2 emitting air miles.

Could we have done the journey in a different way? Horse and cart, sailing boat and camel train would have made for an interesting blog, and would have been quite in the spirit of Greta Thunberg’s recent voyage to the Climate Change Action Summit at the UN. Alternatively we could have symbolically delayed our flight, but in doing so we would have missed the special MAF charter flight to get out team back to Bardai. In reality neither were practical possibilities, we needed to get back to work supporting and developing the health services in the Tibesti mountains- mid Sahara. However neither we, nor BMS World mission, are ignoring the impact of our travel on climate change. How could we? It is the poor and disadvantaged that we seek to serve who will suffer the most from its consequences. Accordingly all our miles travelled by air to and from Chad or on home assignment are logged and a financial carbon offset is set aside for the BMS Eco-Fund. In an imperfect world, this helps to reduce the unintended consequences of our travel.

 The Tibesti mountains are one of those places where a small change in temperature or rainfall could completely alter the character of the towns and the life of the people that live there. The Sahara is no stranger to climate change there have been previous profound natural changes on the flora, fauna and way of life as it becomes drier and drier. Five to ten thousand  years ago , during the last ice age,  the Sahara was green and the mountains and valleys were the habitat of elephants, giraffes, ostriches and other exotic animals.  

The evidence can be seen in the fossil record at the museum in Ndjamena and also carved on to rocks and cliffs some of which are at just a couple of km from our house.  When the Teda people migrated here, their tradition says from Egypt in about 600BC , the tropical animals had gone , perhaps it was them that introduced the camel ( strictly speaking dromedary) to the area. They may have seen however have seen some North African elephants on their way through modern day Libya. (Hannibal’s hometown Carthage was nearby on the Mediterranean coast).

Flooding in the wadi

They settled  in the mountains mid Sahara at various places where water could be found, sometimes at springs where water flow out of rocks and sometimes in places like Bardai beside a  wadi (a mostly dry seasonal river that floods after rains come in the mountains) . In Bardai they found a place where the water table would have been just below the surface of the sand  along with associated small lakes and  permanent wet lands.  Each year the rains came the wadi would flood and the life sustaining superficial underground water would be replenished. The date palms, which need to be able to get into a water table at most four metres from the surface flourished  and much of the local culture and calendar revolved around the dates, climbing and pollinating, harvesting, using the trunks for housing, the spines as pins, the fibres from the leaves to make ropes, the bases of the branches for firewood, the branches themselves as supports for the long reeds growing in the wetlands which are used for making partition walls and roofing.

An old well

Now the traditional way of life in this rocky oasis is under increasing threat. The palm trees are still there, producing plenty of dates, but the water levels are falling.  Forty years ago there were many gardens and fields throughout the valley, water was drawn from wells using the simple old technology of a counterbalance bucket and the water poured into open channels that irrigated the enclosed fields. Vegetables and amazingly enough wheat was grown to make the traditional Teda flatbreads. Water must have been plentiful. Now there are just one or two of these farms left growing lettuce, rocket  and okra, no one grows wheat.  The disused wells look dry, the wetlands have gone and the water table has fallen to between 2 and 3 metres. The local people say that it just doesn’t rain like it used to. Climate change is significant but hasn’t been the only impetus to change, the turn of the century rebellion that lasted about 8 years took a generation of men off the fields, joining the rebels, or fleeing to Libya or Ndjamena. The remaining villagers,  the elderly, women and children were obliged to live in the towns. Once peace came in 2008 the discovery of gold and the open frontier with Libya have lead to an influx of cheap flour and other foods, all this coupled with climate change there has been no incentive to return to the old way of life.

After the floods at the hospital

In the UK we are getting used to extreme weather events and flooding. The Teda have lived with the risk for thousands of years as a nice flat dry wadi can become a raging torrent. Presumably Jesus had experience of similar events in Palestine, the wise man built his house upon the rock, the foolish one built his house upon the sand ( The Bible Matt 7 24 onwards). Villages and markets were traditionally built on rocky hillsides beside wadis. Now in Bardai there are many buildings on the flat broad sandy areas at a reasonable distance from the main wadi as it is so much easier to build there.

This year heavy rains have come and wreaked damage, the walled hospital filled with muddy water and only avoided serious internal damage when the gates were opened and the water could flow out. Abdoulaye, the gatekeeper awoke to find his small tin shop flooded and lost a lot of stock. He has been here since 2008 and had never seen rain or flooding like it. The same flood waters shot through the town to get to the main wadi, destroying a number of shops. In a nearby village there was much more damage and loss of livestock.

The eco system here is finely balanced, at times hot and dry with temperatures of up to 45C in the shade in the hot months, at others overnight temperatures approaching freezing at night in the cold months. There is little local rainfall and the town is reliant on periodic flooding of the wadi from water that falls on the vast areas of bare rock on the surrounding mountains. Too little, irregular rain and the date palms will die, too much rain at one time and the destruction of property and life is serious. This balance could be jeopardised by even a small rise in global temperatures and accompanying changing weather patterns.

You can see that there have been some important ecological changes in Bardai, as in the rest of the world. Over the next 3 or 4 months we plan to look at how we and our neighbours live here and how that impacts the environment.