Making Bad Decisions

Photo of the week

Highlight of the week: Mating leopards. 6 hyenas. 10 lions. An outstanding day in the park

Lowlight of the week: The bat-phone drowns in the sink. 24 hours of resuscitation is needed.

Maximum temperature: 42 degrees Celsius

Rainfall: Not here

I remember distinctly being told that I had made a bad decision. So I sat…… And I sat….. And I thought about what I had done. On the naughty step. For what seemed like an age. At least I was spared the strap. The cat of nine tails. The birch. Sometimes punished. Sometimes rewarded. I was being manipulated for sure. But it was for my own good. I needed to understand how the world works. My parents knew best.

Fast forward 55 years. I still have choices. I still make decisions. Some rational. Some subconscious. Some better. Some worse. I either reap the rewards, or live with the consequences. And so fate is decided. By the apparent roll of a dice.

Many in our Valley accept their fate. As if their tombstones are already carved. Yet there are good decisions, and bad decisions. Do you opt for delayed gratification, and make good life choices? Or do you fly too close to the sun? Burn out quickly, in a blaze of glory. Two possible extremes.

But, life is not black versus white. Instead we have shades of grey. The possibilities are infinite. If only it was possible for people to know the consequences of each decision. If only it was possible to know where each possible path would end up. Could we all then make the choices that are right for each one of us?

Imagine that we know what is good for our Valley population. A premise that, in itself, is a huge leap of faith. In that Utopia, we would guide people to health, and away from despair. We would know when to nudge people towards the light.

How do we change a person’s behaviour? A community’s behaviour? Encourage people to do things differently? Is it better to reward good behaviour? Or to punish bad? In child psychology, it is suggested that encouraging good is better than punishing bad. That assumes that the child knows the rules. Some people struggle with the concept of rewarding good behaviour. Even the bible focuses on what we shouldn’t do. Not what we should do. It’s a tricky one. Library shelves heave with learned tomes on how to raise children. How should we mould the perfectly balanced new person? My way is best. Choose mine. There are so many ways to skin a cat. But at least the authors of all of these learned tomes agree on one thing. There have to be rules.

But with rules come either inducements or penalties. Carrots or sticks if you like.

There are rules in our Valley. Our maternity department for example, has a few rules. Rules that we have only just unearthed. Rules designed to reduce risk. Rules to make pregnancy safe. Healthier mothers. Healthier babies. Neonatal mortality is very high in Zambia. There are 27 neonatal deaths for every 1000 live births ^{(compared to 2.9 in the UK).} A big improvement compared to 37 deaths, twenty years ago. Infections and prematurity take the biggest toll. Rules can help. Rules for staff. Rules for patients. Known and followed.

Our health centre looks after 20,000 people. The population is booming. We register over 40 new pregnancies per month. For most women, pregnancy and delivery are safe. Low risk mothers can safely have their pregnancies near to home. And deliver in our clinic. 4 well-trained able midwives tend their flock. But when they get to the sharp end of their job, things can get tricky. In a labour ward without night time illumination - our solar power system is currently out of action. And until last week, smart phones were the only option, to light up where the sun don’t shine. Phone battery lives are finite. And night shifts seem to stretch on forever. But out of darkness there is now light. Our Virtual Doctor team from the UK have saved the night and turned it into day. Solar power again captures day light and saves it for later. Virtual Doctors¹ have kindly donated 10 solar lanterns to our clinic. Peri-partum care comes out of the dark ages. Let there be light.

Our clinic runs a midwife led pregnancy service. Unlike in the UK, there are no obstetricians on site to deal with a more tricky situation. To escalate care, our patients have to be transported, in an ambulance, an hour up the road. Kamoto Hospital has the knives and the gas. But the ambulance lives in Kamoto. That makes a transfer take a full 2 hours. On a good day. Not good news when minutes cost lives. In pairs. So we need rules.

Delivery in Kamoto is not optional for high risk pregnancies. Rules dictate their birthing plan. Breech. Twins. Previous caesarean section. These women are all told to go to Kamoto at 38 weeks’. To sit out the last 2-3 weeks of their pregnancies. Camp out and wait for labour. Break the rules and wait for the wrath of God. Our tales of obstetric woes in Zambia and Tanzania could easily fill another blog. For now we will spare you.

So far the rules make sense. Kamoto has its own special community. Waiting for Mr Braxton and Mr Hicks to show their faces².  A support network for mums. Accommodation. Nourishment. Laundry. Childcare. Meanwhile dad stays away. Their nebs kept comprehensively out of it. Conception begins the whole shooting party. But dad really only has a token role in the creation of a new baby.

So here are the 3 main rules:

1. A woman MUST book her pregnancy before 12 weeks gestation. No mean feat when you need a positive pregnancy test to book. Pregnancy tests are found in the same place as the hens’ teeth.
2. Home deliveries are banned. Choice is not an option. And if your labour is precipitous, you can whistle all you like to hail a lift. Transport is rather thin on the ground. Shank’s pony is standard. A bike or a motorbike is a luxury. A woman’s uterus does not know the rules. Hair triggered or slow burning. Unpredictable and quirky.
3. Each mother is told where their delivery will be. Kakumbi or Kamoto. They are sorted according to risk.

This Tuesday, at a tree clinic, things got heated. Tempers frayed. Raised voices. Some laughter. All over 200 Kwacha. That’s about £8 or $10 in your money.  Zambians use English numbers. So, 200 Kwacha is pronounced two hundred Kwacha. Easy for us to pick out, from the jabbering and cursing. Again, and again. We quizzed our colleagues to figure out the cause of the rumpus. The tree clinic is way down South. Towards the airport. A place where mangos grow. At the right time of year, nirvana to me and Keith. We love mangos.

200 Kwacha is the stick. A fine. For not following the rules. The clinic staff explain the new Kakumbi rules at our tree clinic. Well intentioned rules. Intended to avoid harm, to mum or babe. Home delivery is hazardous. The clinic cuts the risks. Knowing hands and knowing eyes are on hand, to deal with things, when things go South. This kind of expertise can’t be on tap everywhere. And in maternity, things can go South very quickly.

The new rules are well meant, but in my humble opinion, totally misjudged. A recipe to disenfranchise the vulnerable, the isolated and the disorganised. Those with no money to get to clinic, or those with an overbearing husband. Long trips to clinic mean that no one is home to cook, to clean, to fetch water, to sell their wares, to watch the kids.

And how to enforce the fines? The next part of this plan involves a trip to see the chief. Chief Kakumbi lives just up the road from us³. Each tour of duty as a Valley doctor includes a visit to the chief. Buy in from the traditional leadership is critical. We observe ritual and tradition. But this year’s first visit to see the chief is different. The staff ask me for a lift, to the see the chief. They need him to sign the papers. To ratify the rules. I provide a taxi service.

We get to the chief’s palace, but do not have an appointment. By luck the chief is available. We only wait for one hour. The maternity staff then go in to plead their case. They make a persuasive argument. But the chief is swayed by our team’s main beef: All of the other chiefdoms already fine their patients. We can’t cope if mothers see us as a soft option. Birth rates are high and health tourism is becoming popular. We need to follow the trend. No choose and book here. 

The chief agrees the fine system. If the rules are broken, the first punishment is 5 days of community service. Just what a vulnerable pregnant lady needs. This will involve sweeping up litter. Or any other job the community needs done. In the event of a failure to serve duty, then there is a 200 Kwacha fine. If the fine is not paid, the Chief steps in. Meting out whatever punishment he feels is appropriate.

So we have chosen a Stick out here. A crazy punishment for vulnerable women. Dreamt up by mostly female midwives. Nothing we say can persuade them this is a bad idea. Obviously, we have the same dilemma in the UK. When there is a service which is free at the point of delivery, not turning up is de rigueur. Missed appointments in the UK waste thousands of pounds. A system for fining people has never been implemented. Deemed too expensive to run. The sages also acknowledge that it would disproportionately affect the poor and less able in society.

It remains to be seen how these rules will affect maternity care in Kakumbi. But If it does indeed lead to better outcomes, I will eat my hat. A nice chocolate flavoured one. The decision is made. The die is cast. Badly.

1 Virtual Doctors is a charity that gives medical support to rural Zambian and Malawian clinicians. Through a unique app volunteer doctors in the UK support remote clinicians to care for their poor patients.

2 Braxton Hicks contractions are practice contractions that do not suggest that labour is on its way.

3 Standard practice for all Valley doctors is to visit the chief. To pay our respects. It’s a well-worn path for us now. We take him some pasta. Put some money in an envelope. Go to his palace at the allotted time. We are kept waiting, at his pleasure, for as long as he likes. Be ushered in to see him. We kneel and clap. Each time we meet him, he tells us he has 2 clinics. Why do we just work at Kakumbi? Why don’t you work at my other clinic too? We nod in sympathy. But we only have one car. It is not Zambian to say no. So we say that we will try to get to the other clinic. But we haven’t yet found the time. We are too busy at the Kakumbi clinic. 

The lion's bollocks

Come and get it

We meet up with  Joseph. 15 months on from his crocodile encounter. He still has 2 arms. Some nasty scars. And a residual deformity. Follow this link to read his story https://keithandginnybirre.wixsite.com/intoafrica/post/the-most-fearsome-creature-in-the-valley