Mobile phones, healthy mothers and healthy babies

The electronic click of a digital camera.

I am examining a 3 year old boy with malaria. I glance up to find myself in the sights of a smartphone camera, held by a tall, slim woman leaning on the next bed. She is from the Masai tribe. Her long purple robe has no pockets, so she strings her phone around her neck when she is not calling, texting, or taking photographs. I catch her eye and smile. She smiles back in embarrassment, caught in this minor invasion of my privacy.

Her daughter has cerebral palsy, caused by a prolonged labour and delay reaching medical help. She has difficult to control convulsions. I exchange numbers with the mother so that we can keep in touch, and I can give advice about epilepsy medication over the phone. Sometimes she can't get to hospital- long distances, bridges washed away by floods, no money for motorbike fuel. 

Its not the first time we have used mobile phones to help patients. When we run out of HIV tests we collect and store blood, perform the tests later and phone results through to patients at home.

Mobile phone ownership has exploded in Tanzania. Nearly 65% of households have one. In comparison, less than 1% read newspapers, have landlines, or internet access. I recently contributed to an article in the Guardian about huge breakthroughs in public health, and I wrote about a campaign using mobile phones. They represent an exciting opportunity to reach people who were otherwise unreachable before, to target people specifically, and also to set up a two way dialogue. Access to communication is a devolution of power.

The world has never known such liberal access to communication. The voiceless now have a voice. The potential benefit to health is huge.

To read the Guardian article in which I've written about using mobile phones to help mothers and babies in Tanzania please see:

http://www.theguardian.com/global-development-professionals-network/2014/jun/06/five-memorable-movements-in-public-health

Malnutrition in Tanzania: published in The Guardian

I'm humbled that my latest piece of writing has been published in The Guardian.

Please read and share if you feel appropriate. I hope that opening the debate is the first step on the long road to tackling this challenge.

http://www.theguardian.com/global-development-professionals-network/2014/may/12/nutrition-children-malnourished-tanzania

Weighing babies and tipping the balance on malnutrition: Under 5 mortality in rural Tanzania

Silent, screaming grief mixes with the hot stagnant air. I stand beside a rusting hospital bed holding a kitenge. These vividly coloured wax printed sheets adorn Tanzanian women everywhere, as skirts, headscarves, baby carriers. Today, the one in my hands is a shroud. A grandmother stands next to me. She cries as I pull it over the cold, motionless face of a three month old baby.

The day started badly. I am frantically busy as I round the hospital alone. All the doctors have been ordered to attend a government seminar. We were informed of this by text message last night. If I wasn’t here, I’m not sure who they would have expected to see the patients. I visit Elena, a 17 year old girl with typhoid. The disease is endemic here. People do not have well-dug toilets and raw sewage filters into rivers. They cannot spare firewood to boil river water to kill the bacteria before drinking it. Typhoid thrives. This young woman caught the bug, got sick, and her bowel burst open inside her. Last week we opened her abdomen to scoop out the infection and repair the hole. It was a mixed success. Her life was saved but several days later the infection came back and her wound burst open. She now leaks fluid from a small gap in the surgical incision site. I examine her and clean her wound. She is a shadow. She has the build of a skinny 10 year old girl, and the face of a much older woman. Her skin clings to her. Every vessel, bone and muscle is visible. She sits uncomfortably on her bed staring at the wall. I encourage her to eat and write some more antibiotics.

Her grandmother is speaking fervently in the local language, Kikaguru. She is clutching a bundle of blankets, and starts to cry. A student translates- Elena has a 3 month old daughter which she is unable to feed because she has stopped producing breast milk. Her family didn’t know what to do. They fed the baby with unpasteurised cow’s milk, leading to a diarrhoeal illness with fevers of 42 degrees. They have since been feeding with over-diluted formula milk. A tin designed to last three days is almost full, one week on. They can’t read the instructions and want to ration the expensive milk. I flick through the case notes and no one in the hospital seems to have offered them any other advice.

I carefully unwrap the child. She is unconscious, thin, floppy, has oedema from malnutrition, and cannot feed. Her lips are dry and cracked, covered by the white spots of oral thrush. I carry the fragile, limp bundle to the children’s ward where we give her glucose, antibiotics, and a small amount of fluid through a vein in her scalp, wrap her up warm, and cautiously drip formula milk through a tube in her nose. She carries on deteriorating, and despite resuscitation dies several hours later.

I inspect the body. It is unspeakably terrible to see a still, lifeless baby. Is she at peace? I close her eyelids. She almost looks serene. Her great-grandmother unwraps the kitenge from her shoulders and hands it to me to wrap the baby. I say sorry. “Pole, Bibi”. I’m sorry, for my failure, for the failure of the hospital, for the cruel workings of the world which have led to you wrapping a funeral veil around your great-granddaughter. Bibi you have been crying since yesterday, and you feel this is your fault for not caring for the baby well. I feel angry, sad, and nauseous all at once. It will take me a while to get over this one. I know that you will never really recover.

They say that two wrongs don’t make a right. Using the same perversion of moral algebra I guess you could also say that two rights don’t correct a wrong. But some days working in this hospital is like wading upstream. Sometimes you have to remind yourself of the successes just to keep your head above water. This week we are nursing two children back from malnutrition. Slowly they are improving. My resources are limited. I cannot afford the expensive malnutrition feeds the WHO recommends so I make up my own, using powdered milk, sugar, oil, cereals, and added vitamins and minerals. Children are living.

Malnutrition is the scourge of children worldwide, and contributes to a staggering 50% of deaths of under 5s. About once a month we see a case of the most severe type- a skeletally thin marasmic child, or one swollen and lethargic from kwashiorkor. Even with the best treatment, 1 in 3 of these will die. But collectively the biggest burden is from chronic rates of mild and moderate malnutrition. These children would otherwise survive an episode of diarrhoea or measles, but deprived of the building blocks for health- vitamins, minerals, and calories- the balance is tipped against them. The problem starts with a diet of carbohydrate rich and nutrient deficient staples like maize, and is worsened by drought and inefficient farming methods. A malnourished child is more likely to get an infection, which in turn worsens their malnutrition, leading to more diseases and a deadly downward spiral. The solution starts with prevention. This year’s G20 focussed on optimising agriculture in Africa as an essential and enabling step out of the poverty trap. The average modern African farm is less productive than an American farm 100 years ago. The continent is rich with agricultural heritage, land and willingness to improve. Something, soon, must tip the balance and unlock this potential. Maybe this will be do-gooders from abroad. I suspect the important change will more likely come from within.

I end the day covering the outpatient department. My last patient is a happy, drooling, chubby-legged 8-month old boy. I joke with his mother that he is very fat. She glows with pride. The child is in fact not overweight, but merely in the statistically permissible upper limit of what the WHO would call normal. But after my 4 months here, and weighing hundreds of sick children, this is one of an exclusive handful which have either achieved or mildly exceeded their expected weight. He has pneumonia, but no danger signs. Because he is well-nourished he will likely weather the illness well.  He escapes home with a bottle of antibiotics and a follow-up appointment. I wave goodbye to him, and he grins happily, tied snugly to his mother’s back by a colourful kitenge.

Maternal mortality in rural Tanzania

OK. So in these situations it's best to start with the bad news first. Today we had what is probably the first maternal death since I have arrived here. The story is a tragedy, one of a system so inadequate, of a world set up with such injustice. If it seems I'm being dramatic I will start at the end, where I face a problem which my 3 months working in rural Africa has not prepared me for. A nurse and I are discussing with the family how they will take the body home. The body is that of a 25 year old woman. The mother, aunt, and sister of the woman feel they have no alternative but to take it on the back of a motorbike.

This young woman started feeling unwell several days ago so she visited a local chemist and was treated for malaria. Despite treatment she developed abdominal pain which gradually worsened. By this morning the pain was excruciating, and the family meet to discuss what to do. They quickly realise she must go to hospital, but due to the fact they are subsistence farmers, have no money to pay. Twelve hours go by whilst they borrow and negotiate with neighbours and distant relatives to find money and transport to get from their isolated village to us. Finally, now semi-conscious, she is sandwiched on the back of a Chinese motorbike to drive the thirty-odd kilometres along bumpy dirt roads.

As her limp body jolts against the force of every stone in the dusty road she gets sicker and sicker. Her fallopian tube is leaking blood, split open days ago by a gradually enlarging ectopically implanted fetus. By the time I see her, a critical amount of blood has seeped out of her blood vessels into her rapidly expanding abdomen. Her heart is racing, she has no blood pressure. I pull down her eyelid- it is as white as paper. I touch her hand- cold as stone. She has no blood left.

I plunge two huge needles into her arms and squeeze in two litres of fluid in an attempt to keep her blood pressure up. I know that two things can save her- rapid blood transfusion, and an immediate operation to remove the bleeding fallopian tube.

We have a beautiful blood fridge, donated by the US government. It sits, unplugged and empty, in the corner of the lab. We have no electricity to power it. A New York Times article came out about maternity surgery in our hospital several years ago, discussing the challenges of working without power. Some truly great soul read this and provided funding to bring the national grid to Berega. A few weeks ago a pole was erected outside the entrance to the hospital. This single act will one day save countless lives. But for now, we still have no electricity. At the same time several shops and houses around the hospital have all the electricity they desire. Every day I ask why and receive a different answer each time- someone says they are waiting for a special wire to connect it which must be imported from South Africa, someone else says that a politician is waiting to be paid off. The truth is that you can buy a refrigerated coke from the shack opposite the hospital, but still we can't run a refrigerator to store blood.

So, minutes after I start squeezing fluid into this woman's vessels and long before we go through the process of finding compatible donors to rapidly replace her leaking blood and long before we assemble the anaesthetist, theatre nurse, call the guard to switch on the emergency generator and wheel the woman to theatre to triumphantly stem the bleeding, she stops breathing, under torchlight in the corner of the female ward, surrounded by a team of medical professionals powerless to do anything but look. We start to resuscitate and after discussion we take the hard decision that without blood on standby our efforts are futile. We look, at each other, at the woman, at our feet, someone holds their head, another wrings their hands, and others' hands rest on colleagues' shoulders. My adrenaline is still high, but suddenly there are no tasks to be completed, or orders to bark. I take a nurse and explain our failure to the family. The kind nurse translates, explains and comforts. I've never heard a sound as disturbing as a mother's anguished wail. I'm not sure what to do in the face of such grief so I look at my feet again. It feels like a horrible film, but the scene won't cut, and we have to go on living it.

And now we come full circle, back to the beginning of my story, and the end of this one, the end for this woman, with her aunt, pulling me aside, asking me to hurry the writing of the death certificate because it is late in the night, they have very little money, and they must get the body home. The motorbike which brought them here is waiting outside, and they don’t want to miss it. I urge them to leave the body here in the mortuary, to be picked up in the morning. I almost give them the money to hire a car, but stop myself- my funds are already limited, and there will be other people, living people, on whom I can spend money to transport to the local referral hospital.

The cycle will repeat itself, day in, day out, in Tanzania’s rural areas, in which 80% of people live. The tribe I live amongst- the Kaguru people- are a wonderfully warm community, whose culture centres on the utmost care of the extended family, and the proud welcome of strangers, like me. Hospitality is in their DNA. They are rewarded with a callous and corrupt government, poor roads, appalling public transport, ill-equipped hospitals, and a creaking education system. People want change. Not necessarily the Coca-Cola, satellite television type of change which is the inevitable first wave of development, but some sort of infrastructure which helps you make it past your fifth birthday, and stops pregnancy being a dice with death. For every 100,000 pregnancies here, 460 end in the death of the mother, giving Tanzania the dubious honour of having the 20^th highest maternal mortality ratio in the world.

Ruptured ectopic pregnancy accounts for 1 in 20 maternal deaths in Africa. Perhaps because they are not as easily boxed or understood as infectious diseases like HIV and malaria they receive relatively little attention. The facts are that in countries like Chad and Afghanistan the current maternal mortality rates are about the same as medieval Europe. The majority of causes are from bleeding around the time of delivery, infections after delivery, disorders of blood pressure related to pregnancy, and obstructed labour, often requiring a caesarean section. The consensus of the WHO is that these can all be prevented, or picked up early enough to be treated, by having a trained health practitioner (midwife, nurse, or doctor) present at the time of delivery. This of course requires well-trained healthcare staff, the money to pay them, and the infrastructure to allow them to work. The solution is comprehensible, but the challenges in delivering it are vast.

I said that I would start with the bad news first. The good news is that this week I treated two women with septic miscarriages, who both arrived very sick, and getting worse, who turned the corner, recovered and have gone home. They are two people who will not be added to the maternal mortality statistic. As a doctor, when you see the scale of the problem, it is easy to think that what you are doing is so insignificant as to not be worth it. But I'm learning that the solution to the big problem of maternal mortality is not about big ideas. It starts with lots of people doing small things, helping the patient in front of them, and improving small parts of the system which they have the power to do. This is what we are trying to do here at our little hospital, nestled into the mountainside in Berega, working hard to break the cycle.

I sit on the steps to the hospital entrance sipping a warm Pepsi. People amble around me, chatting, laughing, and singing. Three old men are perched on a tree trunk, smartly dressed in suits, clutching bamboo canes and swinging their bare-feet in the dust. Two girls walk past with huge golden papayas balanced skilfully on their heads. A Masai tribesman draped in deep red robes paces under an acacia tree talking fervently into a mobile phone. Welcome to Berega.

I reflect on this week’s highlights. Unexpectedly I have found myself overseeing the paediatric ward. Two children were admitted over the weekend with soaring temperatures, bright yellow, and in deep deep comas. Every year, 18 million Tanzanians get malaria, and of these 60,000 die. Nearly all deaths are children aged under 5. The environment is just the right (or wrong) combination of warm climate and poor housing, leading to maximum biting from parasite filled mosquitoes. Children suffer the most as they have not had the years of exposure to the disease and ultimate resistance which that brings. The children we admitted had the most severe form possible, cerebral malaria, with involvement of the brain. Without treatment it almost always results in death. The team treated them diligently, we crossed our fingers, and watched anxiously on the first, second, and third days as they slowly improved but failed to revive from their comas. Then miraculously on the fourth day they were eating breakfast, and on the fifth day they both walked home.

Not all has gone well. I saw a two year old girl last week with Kwashiorkor, the most extreme form of malnutrition, whose parents refused to allow her to be treated in hospital. This is a life-threatening condition where the whole body starts to shut down, the most obvious manifestation being generalised body swelling, thin brittle hair, and a lethargic demeanour. This poor, tiny girl was so weak she was unable to cry, managing only a few muffled sobs. The mother, without an extended family to care for her remaining children, found it impossible to remain in hospital and fled overnight with her little girl. She has not returned and there is no way to trace her. The mortality of Kwashiorkor is high, and without specialist treatment and intensive feeding it is difficult to be optimistic. As a team we are deeply upset. We struggle to find some meaning or lesson to take from this. We muse on the huge social and economic pressure that illness puts on society, and especially on women. Mothers, daughters and aunts are relied upon not only to provide the most basic elements necessary for life (water, firewood, maize from the farms), but also to remain in hospital providing the majority of nursing care for sick relatives. This mother was forced to choose between the health of her daughter, and the feeding, warmth and security of her entire family. Perhaps without her presence at home another child, deprived a few bowls of maize porridge, would drop a few calories closer to malnutrition. Akin to Sophie’s choice, no one can hold her responsible for her disappearance from hospital. Unfortunately, the problem is not as simple as sending money, or food. Something, somewhere in the great antiquated systems driving economic and gender inequality is to blame. We must strive to fix this. We must think. We must learn. And in the meantime, we must do our best with the remaining patients.

I spend the evenings attempting to learn Swahili. On the whole my speaking is unintelligible, with occasional flashes of fluent idiocy. Thankfully, instead of demanding my immediate resignation, the patients have the grace to laugh. A ward round begins as I ask a giggling mother whether her baby has been doing much cooking the past few days. At the next bed the impeccably polite nursing staff cannot hide their grins as I enquire how beautiful a boy’s stools have been. Finally, as I leave the bedside of particularly terrified looking six year old girl I’m informed that I’ve just told her that a goat will be along to weigh her.

So as the sun sets over the dusty, green valley, my solar powered computer battery slowly dies. I hope to write again soon. Even during the past few days I’ve accrued a year’s worth of stories- hope, sadness and futility thrive here. Thank you for reading.