Last blog from Bangladesh ??

This may well be the last blog from Bangladesh. Sorry that there has been no news for a while. We have just come to the end of the high season. We were treating well over 1000 patients a week. Sometimes each doctor will have more than 100 consultations a day. This clearly is not ideal, and is only achievable by putting in some long days. I take my hat off to the clinic staff for dealing so well. Now that the situation has calmed down a little, staff are taking a little leave, and settling into a more “normal” routine. I have been getting ready for handing over. My replacement is in the country, and we will collecting her soon. I did not get much of a handover, as there was no expat Log to pass on the information. I hope to make Megan’s entrance to the job a little smoother than mine. There has been a lot to prepare. It has been announced that we will wind down our operation in Khagrachari. The timeframe is not yet fixed, but still means that there will be a shift in the way that things are given priority. We will not be expanding our work with therapeutic feeding, HIV, TB or any of the other possibilities that have been discussed. We are trying hard to find another actor in the region to take on the clinics, rather than close them. The health system here is woeful, and it is a hard decision to pull out. It is the right decision though. There are now many more NGOs than 2 – 3 years ago. It is hoped that they can continue the work that MSF started. MSF works in emergency situations, this is their strength. We have more than 50 expats, and a lot more national staff, in Lebanon, already. The work in Khagrachari is now a more developmental role. Other actors are better suited to this job. The medical need here is still great, but the presence of MSF, or another NGO, taking care of these needs, allows the government health system to leave it to us. Sometimes, we can improve the situation by leaving, and sparking a little life onto the existing setup. I so hope that it works.
No matter how bad things are here, they pale when I hear from colleagues around the World. My friends, Arnold & Akke are in Africa. The messages I receive from them, and others, can be mind-blowing. It can be depressing to think that human beings can behave like this. What can we do? We have to let one group try to find a solution to the problem, while others mop up the mess. The scale of suffering is beyond me to describe. I am only seeing a tiny sample, but it stuns me. I will not use this medium to retell stories from other people, they can be found on many websites.
I really wish the best for Bangladesh. There is no future though, unless the country can get rid of the greedy and selfish minority that sucks all the potential from the place. I may get into some trouble for expressing these views, this is not the official view of MSF, just me. I did add some other opinions here, but just deleted them. I think that my views are sometimes a little less than diplomatic.
I take this opportunity to wish all the good people, in all the organisations, who are helping around the World. Keep it going!! Without someone caring, there is little hope for the millions who rely on this aid. I know that we are only applying a dressing to a huge wound, but it is a dressing that is saving thousands of lives every day.
SALUT

Light at the end of the tunnel?

The end is in sight. I will be sad to leave in so many ways. I have found the mission very fulfilling and satisfying in a number of ways. I have also found it screamingly frustrating. I have missed the girls at home too much to say.
I look forward to having a cup of tea without ants in it. I will like eating food not being shared with ants. I won’t need to get the dried spaghetti from the freezer. Muesli and bread will not need to be kept in a bug-proof tin. I will not need to carry a torch after dark, indoors. Weekends will be days off. I hope to get fewer calls late at night and at weekends. My movements will not have to be submitted in triplicate a week in advance. Road travel will not be a spine-jarring ordeal every time. I will not have to sound the horn at every bend, pedestrian, cow, goat, pig, chicken and dog. Bus drivers will not try to run me off the road, hopefully. Restaurants should have menus, and have the items on the menu available to eat. Tea will not be thick and sweet. There will be no permanent background noise of ceiling fans, when the electricity supply is on. The electricity supply will be on all the time. Mosquitoes are not a constant irritation/hazard. My shoes and hat will not go mouldy. The TV will be in English. The TV will have a picture (the transmitter is on the same power supply as us). Sinks have both cold and hot taps, that work. We can drink the water from the tap. Drinking-water bottles contain water, and are not disguising rice-wine. I won’t be popping doxycycline every day. I can listen to a radio, which is not the clinics calling with problems, but is Terry Wogan having a laugh. I can wear shorts, and a vest in hot weather. Hot weather is a brief season, not every day for month after month. Soon I can walk on a street and not have people staring so hard that they risk twisting their necks, or crashing their rickshaws. Pavements won’t have huge holes dropping into stinking sewers. Public toilets. Shops might sell things that we want to buy, and not crappy junk. At least not all of them anyway. The goods in the shops will not be 90% fake. Telephones that can make telephone calls will be a nice change. Today we have had no telephones at all, this could last another day. Internet connections that actually connect and stay connected until you have finished. A connection speed above 24 Kbps will seem amazing after this. (Try 7.2 Kbps!! See how long that takes to browse !!) It will be good to find plumbing that works. Men and women can hold hands in public, and not just men. Men should address women in a group, rather than act as if they are not there. Men ought to carry any bags, and not walk five paces ahead, while “their” woman carries the load behind him.
I could go on, but I won’t.
Yeah, I am really going to miss all of this. I will be glad to be back.
See you all soon.

A quiet week this time. Our boss, Gabi is still away, but due back tomorrow. Stefan returned from Thailand and tells us how great the country is. Maybe I should nip over for a few days. My replacement is sorted. She is Megan, from Wales. Hi Megan, if you’re looking at this. I hope that she arrives in good time so that we can do a proper handover. It is not crucial, I did not get one at all. It would be helpful though. We have some of the usual problems here. We recruited a pharmacist in one of the clinics, then the day that she started, three men visited the clinic. They said that if we did not kick her out, then “something would happen”. They have sour grapes as one of their relatives will have applied and been unsuccessful. This is the way here, and it is quite normal. We will not tolerate it though. We have a meeting very soon, and if the threats are not lifted, then the clinic will close. Everyone loses, but that does not matter. A VSO volunteer had the same happen to her, but from her colleagues !! The NGO was in trouble, and they accused her of causing it, and even threatened her. She left, but has now returned. This may be the way to do business here, and I have seen it a few times, and experienced it myself, but it really hacks me off. This mentality is worse than children. If I can’t have it, then no-one can, a real ‘dog in a manger’ attitude. At least with children there is the excuse of their age, but we here are supposed to be dealing with adults. Very little evidence of that sometimes.
I will show a few pictures here. One is the cook at Kalendra, busy making our lunch. Spoon in one hand, and the dabba(bamboo pipe) in the other. The pipe has just tobacco in a little bowl, with a piece of charcoal. The smoke passes through a little water in the body of the dabba. Quite mild, but hard work.
The other is a bit blurry, as it from a distance. There are trees nearby that are full of bats hanging onto nearly every branch. These bats are huge, but are just fruit bats. Early evening is a good time to watch them set off. The big ones and the much smaller ones fly together. The small ones are still bigger than the bats seen in UK, while their larger cousins are more like flying cats than mice. I will get closer and get a better picture, hopefully.
Last week I said that the rain was here at last….well it stopped. No-one here can remember the weather being so mixed up. The seasons used to be as regular as clockwork. Not so any more. More to come next week.

Tired of commuting?

It seems that all the false starts to the rainy season have finished. Khagrachari is flooded at times. The soil is loaded with clay, and does not retain much rainfall. When it rains, the rivers rise dramatically. We watched a ½ metre rise in a ½ hour period. My usual running route was under 2 feet of water, but a few hours later was dry again. We expect the office to flood, like most years. I could be wrong about the season starting, as we have had many false starts, but it is much later in coming than in previous years. This rain has one major advantage. The roads are impassable in places, so we use boats to commute. See the picture of the view. Two hours spent on the boat is the alternative to two hours trekking through the forest. No complaints here!! Lovely views, nice and relaxing, even time for a nap if you were up late the night before watching a World Cup game. It beats squeezing onto a tube!!

Our patient numbers are climbing to record levels every month. We treated over 14,000 patients last month. I try to forecast the requirements of the project, but it is difficult. We are often a step behind rather than ahead, reactive, not proactive, to use board-room parlance. We only place major drug orders every six months. This means that if figures change by only a few percent, we will run out of some stock. We don’t over order as then we may have stock expire, and be binned. It is a balance, which is tricky to keep right. There will always be problems, but that is why we are here.

I put a picture on this blog a month ago, and am surprised that no comments have been made. The grey squirrel was snapped in Sherwood Forest. I don’t think there are any here. There is plenty of other wildlife to interest us. Last week our midwife was walking through the forest to reach a remote village. On her return journey the team stopped to see what was causing such interest at the side of the road. They saw that someone had found a snake, over 2 metres long, and thick as my leg. It makes you tread a little more carefully, and walk more noisily than usual. This rain brings them out. They need to find new shelter as their holes are full of water. I have posted a couple of pictures (Sarah will post a couple of pictures. Thanks again, sis!) See an example of Bangla plumbing. This joint was made by a plumber!! We cannot buy the correct connectors. Someone here makes the pipe, but no way of joining it. So the plumber heats the plastic and bangs in a piece of metal pipe. Simply add about a metre of gaffer tape…voila…connection. All is well if you do not mind the water leaking - a lot. The other reassuring picture is from a mineral water label…”Free from arsenic”. You might assume that all mineral water is free of this poison…not so. At least, not in Bangladesh, where arsenic in ground water is a common, local problem. Nice to know that. I keep checking my finger-nails, just in case.

Football crazy

It has been too long again. Even my daily diary has not been opened for a week now. This is not good, as then I have to try and remember what I have done for the past week. So much happens, that it all becomes a blur. We still have power cuts regularly, but they seem to be timed to avoid most of the football. If the people of the Chittagong Hill Tracts are to change the way they are treated, it will take a concerted effort. The World Cup may just be the catalyst needed to unite them. The whole region is football mad. In every town & village there are flags of most nations flying, although not many UJs, I noted. Some complain that this is not patriotic, but I cannot see what there is to complain about. Most of the support seems to be for Brazil & Argentina, with quite a few German flags flying too. I have even seen a handful of Japanese flags. A dearth of UJs, and a complete absence of Stars & Stripes !!
Temperature sits around 33 in the daytime, but often feels a lot more. Even with the humidity, the sweat, sorry…perspiration, runs freely a lot of the time. Think of living in a steam room. Luckily we have fans in every room, and the communal room has an air-con unit. Now all we need is some electricity to run them.
Conflicting reports say whether or not we are in the rainy season. I don’t know. Sometimes it rains torrentially, like now. Then it stops for a few days, leaving increased humidity and a lot of mud. At least the place smells better after the rain. The rise & fall of the rivers is truly remarkable. I will make an effort to get some before & after pictures.
Our patient numbers are up 45% on last year. I may have said that in a previous post. It keeps us busy. Dr. Stefan is in Thailand on holiday. I hope he is having a good time. Dr. Gabi, project co-ordinator, is in Amsterdam on the MSF management course. I doubt she is having a good time, although I hope she can enjoy the change. Two of us are running the show. Not quite single-handed, as we have 130 staff, but we are trying to do the jobs of four expats, two of whom are doctors. Coping fine, but I will definitely take a few days off when the other two are back. I might go back to Cox’s Bazaar, the Bangladesh version of Brighton. Not too much taste, but plenty of cheep hotels, and places to eat. Just have to remember to stay dressed for swimming in the ocean.
My replacement has been approached, and should be lined up to continue my work here. I just hope the chloroform lasts the flight. He should arrive by 18th Aug, so I can spend a week handing over. Then I start to make my slow return from about 25th Aug. There will be stops and debriefs in Dhaka & Berlin, which will add a few days to the journey. I’ll keep you posted on that.

It's a mad, mad World

So much for good intentions, eh? Again the workload has increased. Stefan prepared a bimonthly report, and our patient numbers are up 45% this year, on the same period last year. No wonder we are tired. Malaria is rising despite our best efforts. It is not disheartening though, as we are treating many more cases. Maybe it is just that our recording and reporting is improving. I visit the clinics to check on logistical needs, and also to get a BIG reminder of why we are all working the hours we do. Malnutrition is increasing too. We are soon to start therapeutic feeding programmes, mainly using a product called Plumpy-Nut. Sounds like a strange affliction for men!! It is a French made paste, a bit like sweet peanut butter. Sounds bad to me, but the good thing about it is that kids love it. It is packed with calories, and will add weight quickly. We will limit the time that patients are on the programme to five weeks, as there are many recorded cases where parents stop feeding the malnourished child, to keep the child’s weight below the release threshold. This means that we continue giving them the food supplements. Obviously this not the idea, and is bad for the child. If this is made clear at the beginning then we hope that parents are not tempted to try it.
The fatigue has caused some disagreements in the team. The bad feeling we got after I had to sack someone caused a rift. We have cleared it up now, thankfully, and accept that we have different management styles. Last weekend I went to Chittagong and booked into a hotel. By Bangladesh standards it is 4 stars, but is really a bit like a Travel-Lodge. It was so good to stay in a room with a bath, air-con, a supply of electricity that works and all the usual stuff. I had a mobile, but left it switched off, took no radio or computer, and just dropped off the face for two days. It was very much needed. I had a book to read, but did not open it. There was a swimming pool on the roof, I did use that ! I was even happy to see a Pizza-Hut near the building….never thought I would say that. Only went once, that was enough. Just wanted a change from rice. Got back to work straight away. The driver who collected me stopped in the city to buy two big batteries. They are like car batteries, but more like six joined together in one box. We have six of these as backup for essential things, and two are for the radios. On the Friday, one of the staff blew one apart trying to disconnect the leads. He arced the terminals with a spanner. There was acid all over, but amazingly, no one got harmed. See the photo when it goes on, I have included my foot in the snap for a size comparison, not lousy photography…honest. So out of the car, quick shower and a cuppa, then to work. Weekends can be like that. I really do not mind the work, or the problems…we are here to try and solve problems after all. It gets wearisome when people make problems though. We asked a local leader if we could use a derelict building for training traditional birth attendants (TBAs). It is a bamboo room, which we were repairing in return for the use of it one day per month. Not much to ask for, in my mind, as we were paying for all the work to be done, and he would get back the use of his building. He sucked his teeth, and said that he could not confirm that we would be allowed to use it, for just one day a month. This training is to provide the nearest thing to midwives, for villages where it is believe that prolonged labour is relieved by sprinkling fresh chicken blood on the poor women. I kept calm, shook hands, and paid off the carpenters. No more work will be done for him. I just cannot understand things here.
The rain stopped! The wet season started well, we had a week of nearly constant downpours. Travel to half of the clinics was by boat, as the roads and bridges get washed away. Now it has stopped, the rivers have dropped again, so we are back on the roads. Only now the roads are worse than before! Road repair is temporary as so many corners are cut through corruption, that where tarmac is used, it is like cling-film. A contractor will be paid an agreed amount for the job, but then has to pay so much to different groups and official bodies to be allowed to work, that he ends up with about 30% of the budget left. How is this country supposed to sort itself out when this system prevails? This method of dealing applies to ALL organisations. If you want a government job, you need to pay the government body so much of a bribe to get the job, that you may have a loan for ten years or more.
Enough for now, it is nine at night and I must sleep.

I am determined to write at least once a week, so now my lunch break is a useful time to get this written down. I should have worked on it last night, but was busy until late writing a letter terminating a contract. Now I have to recruit a new guard. All just some of the problems here. It takes a long time for messages to be accepted. I told a guard that sleeping on duty and arriving late for work were not going to be accepted. Yet he did those things four times in one month. The third warning was extra, as I do feel sympathy for his situation, but the other guards are tired of doing extra half hour shifts, and why should they? So he is fired.

Anyway, the weather, our British interest in this subject needs to be satisfied. The storms we had, though violent and fatal in a few cases (deaths by lightning strike), were a false start. On Thursday it started to rain, and has hardly stopped since. The volume of rain varies from light to heavy to torrential, with light rain being in the minority. I have seen a lot of rain before, but this takes some beating. No one here is concerned, yet, as it has only just started. This worries me a little. I looked at a huge lake, the one I was swimming in, and tried to imagine how much rain was needed to raise such a mass of water by 15 – 20 metres……mind-boggling. Now I am starting to get an idea of how it will happen. It is cooler, thankfully, and the rivers should cool down, but the humidity is 100%. Everything feels damp to the touch…bed sheets, paper, clothes, skin etc. Sweat has nowhere to go, so it doesn’t. I have heard that clothes and shoes will grow a furry coat if not worn regularly. How are we to dry clothes? I have not seen a tumble drier anywhere in Bangladesh.

With the rain we have frogs. I heard noises that sounded like a cross between a cow and a donkey. They were neither. These frogs make such an odd, and loud, noise which does not change or stop. Even a frog must get bored of the same sound after 2 or 3 days. They don’t seem to. The roads are alive in places with frogs confused by where the river stops and the road starts. The paddy fields were mostly dried up and brown last week, now they are lots of small, regularly shaped pools. They are joining into larger pools by the hour. Our vehicle shed tried to take off in the wind, and is now tied down. Some cables were pulled loose and need resecuring, but I am not going near them with all this water around. Bangladesh wiring does not quite meet 16th edition !!

We have a journalist/author with us at the moment. He is visiting ten MSF missions for a book. As soon as I find out the title (not decided yet) I will let you all know. That is all for now. I am finishing late at night as my lunch break was cut short. I will squeeze in an extra post in the week.