For those who have worked in this area before, they will understand the mix of English, French and Portuguese and if they are curious enough to want to know what any specific term means, please refer to Google Translate.
*****
Dear Ann (and Christian),Many thanks for your e-mail, and regrets that I haven’t responded earlier. Mary and I had only just got back from Florence where we spent a magical four days and we have only now just returned to our ordinary senses. If you and Christian have not visited Florence together, it is time that you did before the responsibility of family life makes it almost impossible. For us, the high point was the Caravaggio of The Beheading of John the Baptist which was on display in the church at Carmine. It had just been restored for Valetta Cathedral in Malta and was being displayed for a few weeks before being returned to Valetta for ever.
What happened after you left ? Well, it is a long story !
I was told that there was absolutely no need to look for new cases of cholera since the data showed that it was generally on the decline. I regret that I declined to accept this on the basis that we had an Explo Team and it is as important to know that you DO NOT have cholera cases as it is to know that you DO have cholera cases. So, Mama and Jean-Yves were duly despatched to the north (Angonia). Quite apart from being in a car which caught fire not once, but twice, on the same journey; and the fact that they found really severe malnutrition; and that they had to enter Malawi to visit some of the areas in Mozambique (now there is a contradiction for you !); and the fact that they came across a hospital set up by MSF a couple of years ago which used none of the wonderful equipment available; and the fact that Mama nearly assaulted a nurse in charge because he was letting cases go untreated for no other reason than he was just too lazy – then apart from that, nothing happened. Oh yes; and we did find cholera not too far from Angonia Sede at a place called Lefidze where they had 5 deaths in one week due not to their incompetence but to the remoteness and the fact that ‘entradas’ were arriving when it was already too late. Actually, the health authorities in Angonia were exceptionally good – naturally because the DDS was a woman. . . . . . . Need I say more ?
Jozefien was as excitable as ever. Because Jozefien is what she is, she wanted to train all the world and his wife, and set about it, too ! Sadly, she met her match in the enfermeiro at Chitima. Nevertheless, she did a wonderful job and we had great fun working together. My only concern is that she may burn herself out if she carries on as she is doing at present. Sharing a house with her and her four bottles of shampoo was a real education for me. Her analysis of the epidemic when we closed down, was excellent.
I think that while Jozefien protested every time I opened a door for her, or pulled out a chair for her to sit on, secretly she rather enjoyed it. When we left, she produced malaria and between Jacob and myself, she was cosseted and didn’t protest once. She must have been quite ill, poor girl. But she got her posting to Angola despite all the fuss and changes of heart which are Jozefien. I last saw her in Brussels when I was de-briefing with Murray Biedler (the water man whom I have known for some years now), and she was debriefing a bit late after recovering from malaria. I think she was sad to say goodbye finally.
How did we close down ? I like to think that we did a text-book closure, thanks to my ability to work with Jacob; and his ability to ask the right questions. Undoubtedly, AnaMaria Bulatovic played a major role in it all. Going back to the sequence of events:
- AnaMaria came to Tete to discuss the epidemic, and she started the thinking about what to do for the next season. Because she is so good at explaining herself, and because she is simple in her presentation of even a complex subject, she was able to show us how to estimate how many cases we were likely to see in the next season (Attack Rate this season = ±3.5/1,000; next season slightly higher at ±5/1,000, and why this should be);
- Of those ‘attacked’, what percentage would we see in the CTCs (CTC = Cholera Treatment Centre) (basically all since attack rate only looks at those cases which we ‘see’);
- Of those in the CTCs, how many would require Ringer (75%), and how many Ringers each (she said 5, but MSF policy is 8); and how many would require ORS sachets, and how many (10 per case – all cases in the CTC, 5 for the time in the CTC, and 5 for home use);
- Then she suggested that we only keep in stock those consumables required for the first 4 weeks of the epidemic since this would give time to re-order – the question being what percentage of the total will we see in the first four weeks ? (This is where I played with the figures and I estimated 35% to 37%; and we used 35%);
- Then came the details of where to store the supplies. I have this (possibly mistaken ?) belief that if MSF is there to ‘train’ government to do the work themselves without MSF, then the only way we will get them to do it without us, is to give them the responsibility; and they should store everything. I proposed this, Jacob accepted – as did the DPS (Provincial Director of Health) herself – with the proviso that MSF keeps one kit-cholera in reserve just in case (625 cases).
You may have seen her as a bit of a dragon. Yes, she is a dragon but she is also very, very good at her job. Another woman. . . . . as Jozefien would say ! Jacob and she got on like a house on fire, and when he came up to Tete to help in the final closure, we had two very productive meetings with her over a long weekend; the first at the disco with music throbbing at 120 decibels and Jacob, Jozefien and I shouting at the tops of our voices about attack rates and storage locations. Luckily, the beer was good. The second meeting was at her request, the following morning at our offices. When she came, the electricity was off, the temperature at ±40ºC, and we had 3 hours of one of the best NGO-Govt meetings I think I have ever had the privilege to attend. Thanks to Jacob and Dona Esmeralda.
Being a good bureaucrat that I am, and being really quite fed up that we had had a team in Tete before us and had virtually nothing from their time left for us to use, I felt we should leave very obvious tracks behind us. I thus told Jacob that I wanted to leave two files behind (both identical) in which all relevant information would be available. One of the files for Tete and the other for Dr Luuc in Maputo in case Marcos stole the first one ! Jacob agreed.
It took me long nights for ten days before departure to prepare the files but Jacob was so impressed that he ordered an identical copy to be made so he could take it to Brussels to show them a model of how we should close down at the end of an epidemic. My file, by the way, also had a stiffy disk (3.5”) with all necessary relevant files.
Being a good bureaucrat that I am, and being really quite fed up that we had had a team in Tete before us and had virtually nothing from their time left for us to use, I felt we should leave very obvious tracks behind us. I thus told Jacob that I wanted to leave two files behind (both identical) in which all relevant information would be available. One of the files for Tete and the other for Dr Luuc in Maputo in case Marcos stole the first one ! Jacob agreed.
It took me long nights for ten days before departure to prepare the files but Jacob was so impressed that he ordered an identical copy to be made so he could take it to Brussels to show them a model of how we should close down at the end of an epidemic. My file, by the way, also had a stiffy disk (3.5”) with all necessary relevant files.
We had refined the reporting format so that all the spreadsheets were linked. Jozefien had found that the data were so badly handled that in Cangara Sede, for instance, there was an arithmetic error of 100 (183 + 3 = 286); and many others as well (courtesy Sr Tiago). If spreadsheets were linked and the data were entered correctly, the computer does the rest for you eliminating most of these sort of errors. Isabel couldn’t fault us on this. So the file had our refined format which included the necessary graphics of Cases+Obitos and Case Fatality Rate etc.
Attached to this letter is the listing of those files on computer that we left on the stiffy disk. For your next cholera programme. . . . Brussels has the actual files as well (just ask Murray Biedler).
On balance, we were very lucky that Tete suffered least of the four provinces where the epidemic occurred; and it gave me time to prepare for the next epidemic. Whoever goes in to Tete for the next epidemic will have everything he/she needs, down to phone numbers, addresses, stock lists, maps and end of mission reports. Lucky people.
I am still trying to get maps for MSF. Despite many phone calls, requests, threats and so on, I never did get any mapping of Malawi or Zimbabwe. I got a photocopy of a corner of Zambia around Zumbo (top end of the lake on the north side) after I went and made eyes at the second secretary of the Zambian embassy called Faith who not only filled her position, she overflowed it ! She must have weighed 120kgs; but she had a winning smile and was very willing to help. So, to get the right maps, I am having to travel to London (for yet another debriefing with MSF (Tete, Maputo, Geneva, Brussels and now London. . . .)) and visit a shop called Stanfords which I believe has maps of every square metre of the globe at whatever scale you need. Crazy, isn’t it ? You can’t get a map of Malawi in Blantyre, but you can get about five or six different ones from a little shop in London !
And then I was asked of I would like to go on to Zambia for MSF ? Possibly next year when I have earned enough to afford to work for MSF, I said. So, see you next year or the year after. . . .
By the way, thanks for all your support, it made the programme much easier to handle. It really is good to work with well motivated professionals even if some of them are a bit off-the-wall like Joz !
When Jacob decided to come to Tete to help in the closure, I decided to go and meet him at the airport but, not having met him before (he was just leaving on holiday when I came), I wanted to know how to recognise him. What does he look like I asked Jozefien and Mama. ‘Well’, I was told, ‘he is black’. A hell of a lot of use that is, in Tete ! ‘Is he tall ?’, I asked. No, he isn’t. Is he short, then ? No, he isn’t. Is he fat ? No, he isn’t. Is he thin ? No, he isn’t. Your Mr Average all round. Does he have a moustache ? One said yes, the other, no. Does he wear spectacles ? Same answer. Just the sort of man who stands out in a crowd ! Eventually, I waved an MSF sticker and he waved back. Problem solved.
I so enjoyed working with him that I hope I work with him again at some stage. A good thinker; enthusiastic; professional; good sense of humour; and supportive of his staff. What more can you ask for in a Coordinator ? He even has the same ghastly taste as I have in garlic clams (amêijoas) ! And, needless to say, beer.
You asked if I knew anywhere in Zanzibar for your honeymoon. I don’t. But have you ever thought to go to Lamu ? I am told that it is paradise on earth. It is an island a bit to the north and has a lot of history with it. Or, how about Ilha de Moçambique ???????? They might even still have some cholera cases for you. Seriously, if ever you get back to Moçambique, put Magaruque (just off the coast near Vilanculos) on your itinerary. When I win the UK lottery, this is the place I am going to visit for at least a week, with my boat. The sea is blue, blue, blue. The flamingos are a delicate shade of pink. The fish think you are one of them; and the sand is white, white, white.
I must end.
All the very best to you both (three yet ?); and have a happy wedding on 7th June.
Ken
Layout of computer disk for Tete:
Essential info on radio operation
(frequencies, radio alphabet etc);
1998/99
CTC results on a daily and weekly basis + graphics;
Materials
given to CTCs in 98/99;
Materials
required for emergency preparedness 99/2000;
Materials
for opening one CTC; and
A
listing of CTC staff and their salaries in 98/99;
Recommendations
and issues;
Plans,
proposals or discussion documents;
Organisation
charts (includes names, phone numbers etc); and
Contact
with the Zimbabwean Health Authorities
SitReps;
and
WatSan
reports.
*****
Ken Gibbs can be contacted via kengibbs1941@gmail.com
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