longer boats

And so the long boats left, this time with a new helmsman as the usual and trusty driver, Kume has had enough of the dusty Addis road and has turned his hand to house building for a few weeks, and the representatives of MWW.DK return to inhabit the land of Hans Christian Anderson.
There is, if my readings of their deliberations are correct, now a completely new approach to the provision of financial support for those needing help with paying for intra-partum care (delivery). Previously (see blogs passim) vouchers paid for intra-partum care for those in need and this had been rapidly accelerated to those who asked and care was delivered in a mission hospital at a cost. Now the maternity worldwide voucher now pays for medication, if required in a government hospital for those in a rural community, provided they are seen to be in need by a committee of their peers. Means testing comes to West Wollega. Medicines here are remarkably cheap by western standards, some chloramphenicol eye drops and paracetamol syrup cost me 16 birr yesterday. Private travel is however not and some poor wretch with a ruptured uterus was required to pay 2000 birr (£80) for a lift on a lorry surrounded by eucalyptus logs for emergency surgery that was to cost her 1600 birr (£60) at this now private facility, having initially, despite being moribund been turned away either as a result of poor assessment or having no money as it had been spent on transport. The former being less morally reprehensible. For someone who has been brought up in what the Americans would describe as ‘socialised medicine’ it is a rude shock to realise that I am to spend my last few months here working in the American commercial sector. The parallels sadly run deeper as the Adventist Hospital boasts two obstetricians, by local standards adequate resources, much provided by western benefactors not least our own supplies and access to emergency surgery more quickly than is available in many U.K. hospitals (no nonsense about CEPOD lists in this neck of the woods). The government hospital meanwhile is under bedded and under resourced but with a keen and competent obstetrician who has trained one of his general doctors to do the caesarean sections when he is not around, though with the more complex surgery who knows, though it might explain 2 ruptured uteri in one day here. There is however only one operating theatre and if in use by others, tough. Another NHS parallel here as there is usually only one emergency theatre and surgeons wrangle over access to it. Transport as ever remains an issue and there has been much discussion over the deployment of e ranger motorcycles currently children’s play things with ever flattening batteries (they have discovered that it is fun to turn the lights on and off) ensconced in the hospital foyer but soon to be deployed in two rural areas and will with shoulders of strong villagers, a single health centre car and local buses become the transport at either cost or means tested subsidy for those on their way to the government facility whether or not they bear vouchers offering them free antibiotics to help offset the incipient sepsis from their obstructed labours as they await skilled help and access to an operating theatre - we live in interesting times.
The new watch words are of course sustainability and training and much training is to be offered to those in health centres, though little is delivered on site as trainees like to gather in centres to be instructed as this carries transport and the ever important per deum. (these are a day rate for attending courses and are an important income stream for health officials and explains why they are regularly at these courses at every possible opportunity). Hopefully they will learn useful skills like recognising when labour has become obstructed (it has been going on for more than 12 hours and no end is in sight) and make provision for transfer to somewhere that can do something about it before it is too late. Sadly restrictions on what is permissible in health centres, basically an outpatients with a labour ward, means that oxytocin, a uterine muscle stimulant, is available for third stage problems but not intra-partum, so the prima-gravid with uterine inertia are condemned to a long ride to hospital and a caesarean section to protect their multi-gravid fellows from possible overstimulation and uterine rupture. Storing up trouble for the future me thinks and the training will never be subtle enough to make this distinction.
Although the management of first stage uterine inertia may require more skill and judgement than is available in health centres the management of eclampsia does not and is much needed given that the maternal death and other acutely nearly dead people I have seen could have been rescued by earlier and very straightforward intervention and with this in mind I have on my trips to various health centre offered some in situ but per deum less scenario training around patient stabilisation prior to transfer. Treatment is by magnesium sulphate, cheap but actually apparently available free and safe, effective and easy to administer (painful injection in the bum) and probably does not matter if you have the diagnosis wrong (cerebral malaria is about in these parts) and might actually save a few lives. Problem – well yes, though apparently free not yet available in health centre or indeed a couple of local hospitals which may go some way to explaining why some women have come a long way, apparently passing various treatment centres to be here. A strange and topsy turvey world we live in. What is on offer, curiously is large amounts of free methyl dopa, useful if carefully judged in the chronic situation, but requiring frequent monitoring, which is non existent and to be given in appropriate doses, which by enlarge it is not, effective emergency treatment is just locked away. Sustainability is about training and retraining to understand and react to the problems we encounter in an appropriate and in this case diagnostic or therapeutic way, but in order to do this one requires the tools. The training is shaky but the tools which that training should equip you to use are yet to be put in place.

Those of you who are reading this will realise that you are now on a restricted reading list as the forces of, well I am not sure what, are so upset that what I have said, which has actually gone, and now probably more important what I might say that I am strictured only to allow it to the select few. I am told that I need to reflect on what I say as it is deeply hurtful, which indeed it may be. The hurt equally should probably reflect on why they are hurt as however distorted there is always a grain of truth, but if I have been too negative and hurtful I am of course sorry, but those to whom it has happened will probably no longer get to read this. I am too incompetent to get a link but listen to the words of longer boats cat stephens on you tube!