Where we standWe believe that there is no substantive controversy.

Davey Smith and Egger agree with us that loweringserum cholesterol in Western populations is beneficialand safe, and we agree on the clinical and publichealth strategies needed to reduce mortality fromischaemic heart disease.

Patients with existing cardiovascular disease arecandidates for cholesterol lowering drugs, and peoplein the general population should adopt healthierdiets that would lower their serum cholesterol con-centrations.We also largely agree over the quantitative esti-

mates of the association between serum cholesterolconcentration and ischaemic heart disease and ofthe benefits that will accrue from lowering cholesterol

concentration. These issues should no longer beregarded as controversial.

1 Law MR, Wald NJ, Wu T, Hackshaw A, Bailey A. Systematic underestimationof association between serum cholesterol concentration and ischaemic heartdisease in observational studies: data from the BUPA study. BMJ 1994;308:363-6.

2 Law MR, Wald NJ, Thompson SG. By how much and how quickly doesreduction in serum cholesterol concentration lower risk of ischaemic heartdisease?BMJ 1994;30:367-72.

3 Law MR, Thompson SG, Wald NJ. Assessing possible hazards of reducingserum cholesterol. BM_ 1994;308:373-9.

4 Wald NJ, Law M, Watt HC, Wu T, Bailey A, Johnson AM, et al.Apolipoproteins and ischaemic heart disease: implications for screening.Lancet 1994;343:75-9.

5 MacMahon S, Peto R, Cuder J, Collins R, Sorlie P, Neaton J, et al. Bloodpressure, stroke, and coronary heart disease. I. Prolonged differences inblood pressure: prospective observational studies corrected for the regressiondilution bias. Lancet 1990;33S:765-74.

6 Davey Smith G, Song F, Sheldon TA. Cholesterol lowering and mortality: theimportance ofconsideringinitial level ofrisk BM_ 1993;306:1367-73.

County Hospital, HerefordHR1 2ERJohn B Wood, consultantphysician

Hospitaii Teule, Muheza,TanzaniaElizabeth Hills,formermedical superintendentFilemonJ K Keto, medicalsupenintendent

Correspondence to:Dr Wood.

BMJ 1994;308:1029-32

Hands across the equator: the Hereford-Muheza link eight years on

John B Wood, Elizabeth Hills, Filemon JK Keto

Short elective sabbatical visits have been arrangedbetween Herefordshire Health Authority in Englandand Muheza Health District in Tanzania over thepast eight years. Any employee can apply, andthe 64 who have participated include midwives,physiotherapists, engineers, and nurse tutors. Thepossibility ofbeing chosen adds to the attractivenessof working in both districts, and costs have beensmall. The visits are believed to have led to newideas and a willingness and confidence to considerchange.

After 64 visits between Hereford in England andMuheza in Tanzania by a wide variety of healthworkers, contacts and friendships have extended intoboth communities to form new school, college, church,and local authority links. The beginnings, eight yearsago, of this relationship between the HerefordshireHealth Authority and Muheza Health District havebeen described'; we now evaluate the link, its effects,and the changes which have occurred.

The two communitiesMuheza district is in northeastern Tanzania, just

south of the Kenyan border, 50 km from the Indian

Hospital Teule has 260 beds, an annualbudgetofD1000O0, and serves 250 000 people

Ocean; it is fertile and usually well watered. Droughthas not affected it as seriously as much of sub-SaharanAfrica. Recent rains have been satisfactory, and therehas been a gradual improvement in living standardsdespite very severe inflation. Almost everyone culti-vates a garden (shamba) to supplement wages. Malariaremains by far the most serious medical problem, butinfection with HIV is increasing. Hospitali Teule servesabout 250 000 people. It is a joint government-missionorganisation. There are 260 beds and often manymore inpatients than beds.

Herefordshire in the west of England is also fertile,beautiful, and well watered, but it is much lessdependent on a rural economy. The population ofabout 170 000 is increasing and growing older,and many people retire to the county. Diseases ofprosperity, degeneration, and old age are common.The main acute hospitals in the district have about 420beds.

Nature ofthe linkThis link has concentrated on educational visits in

the hope that staff visiting different cultures withdifferent diseases and facilities will take home newideas and perspectives which may lead to bettertechniques, better practices, and even better economy.Administration in Hereford is by the Link Society,many ofwhose members have been to Muheza.

SelectionIn Hereford we try to select staff who will be able to

cope with a hot climate, difficult travel, and simpleliving conditions. They must mix well, make goodambassadors, and be able to study and perhaps teach.We prefer candidates with planned projects, and acommittee containing previous visitors makes theselection. Interpreters are available in Muheza so theability to speak Swahili is not essential.

Selection in Muheza is by a panel comprising themedical superintendent, members of the managementcommittee, and a senior church member. Criteria forselection include duration of service, the relevance forthe hospital of the proposed programme, whether aprevious visit has had a similar programme, thecandidate's basic education and ability to communicate,and the expected duration of service after return to

BMJ VOLUME 308 16 ApIL1994 1029

Muheza. Candidates need to be able to express them-selves in English.The authorities in Tanzania have readily granted

study leave to visit Hereford, but some Hereford staffhave had to take unpaid leave or use their holidayallocation. Muheza has staff employed in differentways-as employees of the diocese, of central govern-ment, or ofthe district council. Government employeeshave obtained a clothes allowance and in some cases asubsistence allowance for the visit.

SKLLS OF VISITORS

The table shows the range and variety of professionsof visitors. From Hereford there have been almost thesame number of visits by men (17) and women (15),but most visitors from Muheza have been men (24 of32).Hereford staff have included nurses, a health visitor,

paramedical staff, and five consultants. In addition.engineers, a plumber, a secretary, and a healtheducation officer have been selected, as well as twochaplains. Two people have travelled to Muhezatwice-a plumber, who returned to lay new pipes inthe children's isolation ward, and an accounts assistant,who fed information into a computer which theCommonwealth Foundation has donated as a result ofthe link. Most visitors from Muheza have been nurses,medical assistants, or doctors, partly because goodEnglish is required.

Equipment is in shortsupply, and much care isgiven byfamily members

STUDY ANDWORK PROGRAMMES

Communications between Hereford and Muheza aredifficult so details of each programme are arranged onarrival. Good programmes include observing or learn-ing techniques which may be useful and relevant andexperiences which will stimulate ideas. The amount ofclinical experience that can be gained depends onTanzanian and British licensing regulations. Few ofthe visitors from Muheza have qualifications recognisedin Britain.

Hereford's hospitals provide a district service, likeMuheza's hospital, but with many more resources.Some visitors to Hereford have been able to visithospitals with more specialised services. For example,a haematology technician appreciated visiting theregional blood transfusion centre and the radiographicauxiliary attended a two week course in Coventry.Visitors to Muheza have had an oppportunity to visitregional and national centres and to go with "outreachteams" to take immunisation to the villages. Hereforddoctors and a dentist have obtained temporaryTanzanian registration and have been able to share inclinical work.

Visits arranged by the link

To Hereford To Muheza

Doctors 6 5Nurses 7 5Nurse tutors 3 1Medical assistants* 6Mdwives 3Laboratory workers 1 2Engineers 4Chaplains 2Accountants 1 2Physiotherapists 1 2Pharmacists 1 1Dentists 1 1Radiographers 1 1AIDS counsellors 1Operating department assistants 1Health visitors 1Occupational therapists 1SecretaryAlbrarians 1Health education officers 1Ambulance staff I

*Provide primary medical services; no British equivalent.

A report is required after each visit. Sometimes thesereports provide a novel view: "In England a dentalwaiting room is a silent class-it is also a comfortableplace for the mind" (T Gershon, dental assistant).Some observations have been published,23 and in 1987Central Television showed a prize winning film, AnAfrican Tale, which told the story of an ophthalmicsurgeon and an accounts clerk visiting Muheza.

HEALTH

Muheza is in part of Tanzania where malaria isholoendemic, with much drug resistant falciparummalaria. Prophylaxis, backup treatment, and a goodmosquito net are essential. Hepatitis B, tuberculosis,and HIV infection are common, and visitors musttake sensible precautions. A pack containing drugs,syringes, and drip set (box) is sent with each travellerfrom Hereford. This is partly to ensure that equipmentis sterile, and also to avoid adding to the severeshortage of drugs in the hospital if the visitor becomesil. The pack is left behind on return. Treatment inTan is free (the Tanzanian government intro-duced cost sharing in July 1993) so medical insuranceis unnecessary except for the possibility of repatri-ation. One link visitor returned from Muheza withhepatitis B.

Visitors from Muheza find Hereford cold even in thesummer, and respiratory tract infections occur. Asupply ofwarm clothes is kept.

BMJ VOLUM 308 16 APRIL19941030

accommodation and hospitalityVisitors to Hereford live in the district general

hospital (the county hospital). They usually haverooms which otherwise are used for staff on dutyovernight. There is a kitchen, and meals can be boughtin the hospital canteen. Members of the Link Societyand previous visitors to Muheza take visitors out in theevenings and at weekends. Most Tanzanian visitorsspend a weekend in London as the guests ofDr J Meadway and her husband, who are the mainadministrators for the charity Medicines for Muheza.There they meet fundraisers and see the Londonsights.Accommodation in the student quarters in Muheza

is very spartan, and it is enlivened by a wide variety oftropical insects, animals, and reptiles. There areshowers and lavatories and a small communal kitchen.Food can be bought in local shops or the market andcooked in the quarters, or bought in the hQspitalcanteen. Link visitors are warmly welcomed and enjoymuch hospitality. We once discussed trying to build a

guesthouse at Muhezas' hospital, but those who hadvisited strongly opposed the idea because living asstudents led to fellowships with the Tanzanian staff,which might be lost if visitors had better accom-

modation. Most travellers try to visit the NgorongoroCrater or one of the other major game reserves.

All staff visiting both centres receive a modestsubsistence allowance as well as free travel andexpenses-without these the lower paid staff fromHereford and most of the Muheza staff would not beable to take part in the link.

FINANCE

Tanzania has very severe financial problems. TheTanzanian shilling has depreciated more than 20-foldagainst the pound sterling since the link started in1985. The annual total budget for Hospital Teule, thedistrict general hospital at Muheza, is about £100 000.Funding for the link therefore has to be found outsideTanzania. The Commonwealth Foundation has playeda major part by paying for travel for the first six years,and the Lennox-Boyd Memorial Trust has supportedthe link throughout. The link treasurer uses a "pocket"of the charitable trust funds of the HerefordshireHealth Authority. The acute unit and the communitytrust make contributions, and members of the LinkSociety raise funds.The main expense is paying for visits, but some

money is raised for equipment or projects in Muheza.Equipment is usually sent with larger consignmentsfrom the London charity Medicines for Muheza. Airfreight sent through Equipment to Charity HospitalsOverseas costs about £1.50 a kilo.

ADMINISTRATION

The Link Society in Herefordshire appoints officersfor the necessary administration. Many have been toMuheza, and they all give their services free, oftensubsidising the link as well. A member of the healthauthority and a senior member of the finance depart-ment serve on the Link Society's committee. Thesociety's funds are held as part of the health authority'strust funds and the balance earns interest, againstwhich is set a standard administration charge. AtMuheza the medical superintendent provides adminis-trative services and helps arrange visas, passports, andpermits.

TRAVEEL

Travel is arranged from Hereford. The link benefitsfrom the Reachout scheme, which reduces many airfares, and sometimes airlines allow excess baggage tobe taken free.Over eight years, travel has become easier, but for

Tanzanians to obtain passports often requires a lengthyvisit to Dar es Salaam, and visas to visit Tanzaniashould be requested in good time.

Effects ofthe linkSix weeks are too brieffor much development ofnew

skills, but most staff insist that they have leamt atremendous amount about another culture, otherillnesses, and different approaches to medical care. Allthe benefits that medical students gain by studentelectives are now available to any employee of thehealth authority who is selected. Several visitors haverequested longer visits.Some staff have returned to Hereford saying that the

experience has changed their lives, and one visitornearly swept her husband and two children backto Africa immediately. Another is now working inZambia. In Hereford there has been a growing aware-ness about the way in which care can be given despitedesperate shortages of money and equipment. Know-ledge of tropical diseases has increased, and thehistopathologists have been particularly pleased toprovide a service to Muheza and learn more abouttropical specimens and diseases. Many friendshipshave been forged. We believe that the link encouragesHereford staff to be thrifty, economical, and resource-ful and that the possibility of being chosen adds to theattractiveness ofworking for the health services in bothHereford and Muheza.Changes in Muheza have included better use of

partograms in midwifery and increased use of andlower mortality in the special care baby unit. Paediatric

BMJ VOLUME 308 16APRm 1994

Contents ofthe medicine chest taken by stafftravelling to Muheza for six week visitsChlorquine phosphate tabs 250 mg-2 each weekstarting 1 week before and continuing for 4 weeks afterProguanil tabs 100 mg-2 daily for the same durationas chloroquineQuinine sulphate tabs 300 mgs-30Fansidar tabs-3Erythromycin stearate tabs 250 mg-56Betadine ointmentLoperamide caps 2 mg-40Chlorpheniramine tabs 4 mg-25Hydrocortisone creamAnthisan creamHaemaccel-1 unitGiving set, syringes, needles

anaesthesia and postoperative care have improvedtremendously. Management of the operating theatresand repair of equipment have improved, and thecasualty facilities have been restructured. There arenow more counselling skills for AIDS patients andterminally ill patients. Engineers, a plumber, and aqualified electrician from Hereford (who is also achaplain) have repaired equipment and encouragedlocal staff to undertake their own repairs and main-tenance. While some of these changes could un-doubtedly have happened without the link, we believethat the visits have led to new ideas and a willingnessand confidence to consider change. Although it isfrustrating for staff at Muheza to learn ways of helpingpatients-only to be unable to get the necessary drugsor equipment-increased knowledge should allow staffto make the best use oflimited resources.

SIDE EFFECTS

The main function of this link has been to provideeducational visits. From these have come new friend-ships and interests, and extra contacts betweenHereford and Muheza have developed. These include acouncil link, school links, college links, medicalelectives, medical trainees who have made their ownarrangements to work for several months at Muheza,and parish links.

Service clubs have provided equipment for Muheza,and Cheltenham Trust Hospital has started a linkwith Kambi in Sierra Leone partly modelled on theHereford-Muheza link.

PROBLEMS

The problems have been relatively small, and theworst ones so far have been difficulty in obtainingreports from the travellers, difficulty contacting staff atMuheza by telephone or letter, the near impossibilityof restricting visitors to Hereford to their return flightbaggage allowance, and disappointment at havingfailed to obtain funds for those visitors who wouldbenefit from a further professional training course inBritain or elsewhere. As well, one laboratory workercaught hepatitis B.

GIFTS AND EQUIPMENT FORMUHEZA

A London charity, Medicines for Muheza, and a

Bristol group provide drugs and equipment to Muhezato supplement the government supply; the Hereford-Muheza link has concentrated on visits and educationrather than gifts. However, equipment in Herefordwhich is due to be scrapped is salvaged if it can beuseful in Muheza. Some items work perfectly well buthave been superseded and have almost no value inBritain. Useful equipment is either given to the LinkSociety or purchased for a nominal sum and thenchecked, repaired if necessary, and carried to Muhezaby hand by visitors or sent with a Medicines forMuheza consignment. Other help has been givenby repairing equipment brought from Muheza, byobtaining advice and information, and by helping toobtain drugs in an emergency.

ConclusionsThis link has survived and prospered. The enthu-

siasm of visitors has continued, and the link seemssecure while there are good applicants. The primepurpose is education. We have all learnt from eachother, and in addition there has been growing friend-ship and the exchange of gifts and ideas. The financialcosts to the health districts have been very small. Wehave been particularly pleased and encouraged to seethe spontaneous growth of a network of other pro-ductive contacts between Hereford and Muheza.

We wish to thank the hundreds of individuals in Muheza,Hereford, and elsewhere whose interest, kindness, courtesy,hospitality, and generosity have made the link possible, andparticularly to thank the major initial donors-the Common-wealth Foundation and the Lennox Boyd Memorial Trust.

AddressesECHO (Equipment to Charity Hospitals Overseas), Joint

Mission Hospital Equipment Board Ltd, Ullswater Crescent,Coulsdon, Surrey CR5 2HR (tel 081 660 2220).Medicines for Muheza, 4 Glebe Avenue, Woodford Green,

Essex IG8 9HB (tel 081 504 1958).

1 Wood JB, Hills EA. Hands across the equator the Hereford-Muheza link. BMJ1988;297:604-7.

2 Moore B. Obstetrics in Subsaharan Africa. Lancet 1987;ii:33 1.3 Moore B, Kombe H. Climacteric symptoms in a Tanzanian community.

Matunrtas 1991;13:229-34.

A MEMORABLE PATIENT

A real miracleSometimes it is easy as a junior doctor to see life and deathas routine, especially through the haze of fatigue from longhours and the distractions of study for examinations. Oncein a while, however, something happens to change yourperspective and jolt you out ofthat routine.One afternoon I was called to an emergency caesarean

section on a woman with a severely growth retarded fetusof 31 weeks. All tests indicated that the fetus was in poorshape and would not survive much longer in utero. Thechances of survival after delivery were also consideredremote. In the theatre I scrubbed up to receive the babyfor resuscitation. The obstetrician made the incision asusual, but then, in a sudden swift movement, he lifted outthe whole amniotic sac and placed it in the green towel Iwas holding.For a moment, I held the fetus's whole world in my

hands. Through the sac in my left hand there was aminiature placenta, its blood vessels rippling over thesurface. The umbilical cord coiled off to the right and inmy right hand lay a tiny curled fetus, quiet and still,unaware of the momentous change that had happened.My mind went back to the specimen fetus in the pathologymuseum of student days and I was filled with a senseof hopelessness at the impending resuscitation. The

obstetrician took a pair of scissors and in one movementsplit the membrane down the middle. Almost before hehad finished the silence in the theatre was broken by a cry.The fetus became a baby-a wriggling, squirming, cryingbaby girl, less than 500 g-who vigorously fought off anyattempts to resuscitate her.A baby was born and I was privileged to have unwittingly

become part ofit. It was the start ofa new life in the outsideworld like thousands of others but, here, the whole essenceof humanity was concentrated into a tiny scrap no biggerthan my hand. It was a powerful mixture of emotions. Inan instant the unknown had become known, hopelessnesschanged to hope, apprehension turned to elation and oneblas6 senior house officer was jolted back into the reality ofthe wonder ofbirth.The baby did well. A year later she starred on the

front page of the local newspaper. The picture showeda chubby baby peering cautiously at the camera withher proud mother. The accompanying article toldof her trials and tribulations in the special care babyunit and read along the lines of "miracle baby amazesdocs." For once, they were absolutely right.-HELENGIBSON is a public health medicine trainee, currendy living inCanada

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