This summer I was invited by two British doctors, Noj and Mary Northway working at Berega Anglican Mission Hospital near Morogoro in central eastern Tanzania, to teach their staff some practical paediatric skills. After several quite unsettled years at the hospital, they felt that the staff were now ready to receive some further clinical training. This assignment involved taking two weeks out from my consultant paediatric job in Newcastle-upon-Tyne. One week of the two was generously given to me by my Trust as paid special leave.
There has been a recent outbreak of resuscitation courses in the UK, where they have greatly improved the skill of paediatric staff to cope with events that are relatively rare and demanding. How challenging it seemed to adapt one for use in poorer settings where children present in extremis everyday. If effective, it could be something that many doctors in the UK could go out and run, and a way to help in a working environment where longer periods of service leave are hard to take. Running such courses is perhaps the ultimate 'short-termism' in medical missionary work!
However, as I approached this project I did so with a number of reservations. Resuscitation is not uppermost in the minds of health staff in Tanzania at the moment. This is a country that is beginning to feel the pain and loss of HIV infection. In the area around the hospital, about 25% of adults of child-rearing age are infected. There is no sign that this situation has changed people's sexual behaviour and this rate is likely to rise further. Sadly this is partly because there is little public recognition of the disease and the education programme is in its infancy. What publicity is given seems too little and too late. Orphanages, which used to be full of children whose mothers have died in child birth, are now increasingly stretched with those whose mothers have died of AIDS.
With so much chronic and incurable illness I sensed an understandable despair amongst staff about how much they could do for the sickest children. Every day they see children arrive beyond any medical help after a long journey carried in their mother's arms. Moreover, when resuscitation is given there were limited back-up resources. There was no oxygen in the hospital, let alone any facility to ventilate. Realistically, resuscitation was only going to help the newborn who needed gentle lung inflation to get going and a few older children with respiratory arrest secondary to reversible causes such as hypoglycaemia and anticonvulsants. As well as resuscitation, I wanted the teaching sessions to cover triage of sick children by the relatively untrained staff who receive children at outpatients. Recent valuable research by Professor Elizabeth Molyneux and others in Malawi has shown how effective a few simple clinical signs can be in picking out the sickest children in the queue, hopefully before they require emergency resuscitation. In our teaching we focussed on four of these - alertness, cold hands, respiratory rate and skin pinch.
In addition to the disease context and the lack of follow-up facilities, I had concerns about how appropriate the short course method was going to be in this setting. This paratrooper approach to teaching only works in the UK in highly motivated students who have done some preparation, can learn from accompanying written material and can apply what they have learnt afterwards with appropriate supervision. That didn't obviously apply to where I was going.
I was fortunate to be accompanied by a registrar colleague. He was a great help in bouncing ideas off, discussing how things were going and sharing the teaching in both the theory and practical sessions. Our schedule was tight! We arrived on the Sunday to discover our first teaching session on basic resuscitation was on Tuesday. Monday was spent quickly acclimatising ourselves to the hospital and its staff. There was little time to adapt any material. Fortunately, regular e-mail contact with the director and two students from our medical school, who were already out there on elective, had prepared us for the strikingly basic conditions and needs.
We were warmly received and the various sessions were much enjoyed not least as a change for the staff from the hot and demanding wards and outpatient queues. As with clinical teaching in the UK, I was aware of how easy it is for patients to become a problem (especially in resuscitation) or an intellectual issue and not an inestimably special individual made uniquely in the image of God. So we started the day by sharing this perspective with the staff.
Homespun drama is a prominent part of Tanzanian life and the scenarios using mannequins stole the show. They were so much more effective at getting the point over than a series of flipchart diagrams. We also showed some WHO videos of clinical features of sick children. These were popular since televisions were rare even in the houses of health workers. However, there is nothing like a real patient and we invited in a number of mothers with their children so that the staff could practise the routine of assessing the key triage features. The linguistic and academic background of those we taught was variable. The trained staff spoke English and the untrained staff sessions were ably translated by one of the expatriate midwives. No day was complete without a break for 'mandazis' (a sort of local doughnut) and sodas.
Our most ambitious day was aimed at teaching community midwives how to look after the newborn and where necessary how to give mouth-to-mask resuscitation. The latter is a highly effective alternative to bag-and-mask for saving newborns in terminal apnoea without the need for oxygen. The kit costs about £10 and can be carried in a pocket.
The community midwives were elected by their village committee who considered age to be akin to skill in childbirth. Before this day most seemed to have given very little thought to how they should look after the baby. The care of the mother seemed paramount. Even the emphasis on drying the infant and then replacing the wet cloth with another dry one took time to sink in. For some, the perhaps five-mile walk to the hospital had seemed all too much and they found themselves asleep at the back. Others seemed to have received little education. We thought that all were literate until to our dismay some had trouble putting their name badges on the right way up because they couldn't read their own name. However, most did seem to master the routine on the mannequins. The jury is still out on how much they will use the mouth-to-mask kit. It was designed so that the midwife's face was a little way from that of the infant and all secretions could be gathered in a filter. Nevertheless, the technique will, I expect, succeed or fail on their concerns about catching HIV through its use.
The time passed fast and all too soon our visit was over. It has been encouraging to hear that some of the senior clinical staff have been repeating the teaching material and I am sure that this is key to the skills sticking. I would very much like to return there next year to see how much of the teaching is being used and if not why not.
If the approach were tested in terms of the usual mission criteria, I think it would be found wanting. We had little time to relate the material to the educational and cultural background of the staff, few opportunities to discuss with them what they thought of the feasibility and appropriateness of resuscitation and triage, and got to know only a limited number of the staff whom we taught. However, from our side it was refreshing to spend time in a place where needs and resources were so different from home and a blessing to meet brothers and sisters wrestling in this context on behalf of the poor. Whether the care of children has improved by our visit, I do not know. However, I do know that the Lord can and does use the most unpromising things in surprising ways to his glory and it is in this that I find hope.
28 September 2001
There has been a recent outbreak of resuscitation courses in the UK, where they have greatly improved the skill of paediatric staff to cope with events that are relatively rare and demanding. How challenging it seemed to adapt one for use in poorer settings where children present in extremis everyday. If effective, it could be something that many doctors in the UK could go out and run, and a way to help in a working environment where longer periods of service leave are hard to take. Running such courses is perhaps the ultimate 'short-termism' in medical missionary work!
However, as I approached this project I did so with a number of reservations. Resuscitation is not uppermost in the minds of health staff in Tanzania at the moment. This is a country that is beginning to feel the pain and loss of HIV infection. In the area around the hospital, about 25% of adults of child-rearing age are infected. There is no sign that this situation has changed people's sexual behaviour and this rate is likely to rise further. Sadly this is partly because there is little public recognition of the disease and the education programme is in its infancy. What publicity is given seems too little and too late. Orphanages, which used to be full of children whose mothers have died in child birth, are now increasingly stretched with those whose mothers have died of AIDS.
With so much chronic and incurable illness I sensed an understandable despair amongst staff about how much they could do for the sickest children. Every day they see children arrive beyond any medical help after a long journey carried in their mother's arms. Moreover, when resuscitation is given there were limited back-up resources. There was no oxygen in the hospital, let alone any facility to ventilate. Realistically, resuscitation was only going to help the newborn who needed gentle lung inflation to get going and a few older children with respiratory arrest secondary to reversible causes such as hypoglycaemia and anticonvulsants. As well as resuscitation, I wanted the teaching sessions to cover triage of sick children by the relatively untrained staff who receive children at outpatients. Recent valuable research by Professor Elizabeth Molyneux and others in Malawi has shown how effective a few simple clinical signs can be in picking out the sickest children in the queue, hopefully before they require emergency resuscitation. In our teaching we focussed on four of these - alertness, cold hands, respiratory rate and skin pinch.
In addition to the disease context and the lack of follow-up facilities, I had concerns about how appropriate the short course method was going to be in this setting. This paratrooper approach to teaching only works in the UK in highly motivated students who have done some preparation, can learn from accompanying written material and can apply what they have learnt afterwards with appropriate supervision. That didn't obviously apply to where I was going.
I was fortunate to be accompanied by a registrar colleague. He was a great help in bouncing ideas off, discussing how things were going and sharing the teaching in both the theory and practical sessions. Our schedule was tight! We arrived on the Sunday to discover our first teaching session on basic resuscitation was on Tuesday. Monday was spent quickly acclimatising ourselves to the hospital and its staff. There was little time to adapt any material. Fortunately, regular e-mail contact with the director and two students from our medical school, who were already out there on elective, had prepared us for the strikingly basic conditions and needs.
We were warmly received and the various sessions were much enjoyed not least as a change for the staff from the hot and demanding wards and outpatient queues. As with clinical teaching in the UK, I was aware of how easy it is for patients to become a problem (especially in resuscitation) or an intellectual issue and not an inestimably special individual made uniquely in the image of God. So we started the day by sharing this perspective with the staff.
Homespun drama is a prominent part of Tanzanian life and the scenarios using mannequins stole the show. They were so much more effective at getting the point over than a series of flipchart diagrams. We also showed some WHO videos of clinical features of sick children. These were popular since televisions were rare even in the houses of health workers. However, there is nothing like a real patient and we invited in a number of mothers with their children so that the staff could practise the routine of assessing the key triage features. The linguistic and academic background of those we taught was variable. The trained staff spoke English and the untrained staff sessions were ably translated by one of the expatriate midwives. No day was complete without a break for 'mandazis' (a sort of local doughnut) and sodas.
Our most ambitious day was aimed at teaching community midwives how to look after the newborn and where necessary how to give mouth-to-mask resuscitation. The latter is a highly effective alternative to bag-and-mask for saving newborns in terminal apnoea without the need for oxygen. The kit costs about £10 and can be carried in a pocket.
The community midwives were elected by their village committee who considered age to be akin to skill in childbirth. Before this day most seemed to have given very little thought to how they should look after the baby. The care of the mother seemed paramount. Even the emphasis on drying the infant and then replacing the wet cloth with another dry one took time to sink in. For some, the perhaps five-mile walk to the hospital had seemed all too much and they found themselves asleep at the back. Others seemed to have received little education. We thought that all were literate until to our dismay some had trouble putting their name badges on the right way up because they couldn't read their own name. However, most did seem to master the routine on the mannequins. The jury is still out on how much they will use the mouth-to-mask kit. It was designed so that the midwife's face was a little way from that of the infant and all secretions could be gathered in a filter. Nevertheless, the technique will, I expect, succeed or fail on their concerns about catching HIV through its use.
The time passed fast and all too soon our visit was over. It has been encouraging to hear that some of the senior clinical staff have been repeating the teaching material and I am sure that this is key to the skills sticking. I would very much like to return there next year to see how much of the teaching is being used and if not why not.
If the approach were tested in terms of the usual mission criteria, I think it would be found wanting. We had little time to relate the material to the educational and cultural background of the staff, few opportunities to discuss with them what they thought of the feasibility and appropriateness of resuscitation and triage, and got to know only a limited number of the staff whom we taught. However, from our side it was refreshing to spend time in a place where needs and resources were so different from home and a blessing to meet brothers and sisters wrestling in this context on behalf of the poor. Whether the care of children has improved by our visit, I do not know. However, I do know that the Lord can and does use the most unpromising things in surprising ways to his glory and it is in this that I find hope.
28 September 2001
