Friday, December 29, 2006
Tuesday, December 26, 2006
Mount Elgon on Uganda’s eastern border with Kenya is one of Africas free standing volcanoes ( like Kilimanjaro and Mount Kenya), covers the largest surface area of any such volcano, and rises to 4321m. It’s a national park and we took a four day tour, with guides (Rogers and Abel)and porters (Fred and Bosco). The landscape is beautiful and unspoilt, the vegetation changing as you increase in altitude from bamboo and mountain forest to alpine moorland. The latter reminded us strongly of the peaks (on steroids) and walks on Derwent edge though of course everything - the hills, the heathers and the flowers are bigger and more exotic. The first nights campsite is shown in the picture - a huge bat filled cavern with a waterfall streaming down over its entrance. The walking was steady and not overly demanding though we both suffered the effects of altitude when we got to the top - feeling very sick and headachey. This got suddenly and dramatically better as soon as we descended to 3000m.
For Christmas we went back to the Haven, the beautiful campsite overlooking the Nile just north of lake Victoria at Jinja. Wonderfully relaxing and a welcome opportunity to lose ourselves in some novels. We’re still waiting to find out about jobs and have yet to compose our letter of resignation to the University of Mbarara........
Tuesday, December 12, 2006
The outpatient department has 19 clinical staff members and performs a vital function in administering care to approximately 100,000 attenders each year. Its efficiency is impaired by a number of factors:
Lack of leadership
There is an identified senior management team but no leadership. There are no departmental or management meetings and as a consequence the department does not work as a team. Some of the staff members’ attendance and time keeping is poor.
Lack of systems
There are no protocols or guidelines for patient management.
There is no drug formulary.
There is no system for the ordering of stock.
Lack of training
There is no attention to service development.
There is no regular in-house staff training.
Prescribing knowledge is largely driven by the pharmaceutical industry.
There is no discrete budget for the department.
Pharmacy stock is inadequate for the demand.
Poor relationships with other departments
Not all outpatient attenders are seen each day and the overflow arrives directly at the wards.
Referrals to other departments are perceived as being too high.
There is no coordination or planning with other departments.
There is no coordination or planning with the wider community
Many staff members seem opposed to change.
On the positive side:
There is adequate infrastructure.
Many staff members are very experienced and capable.
Some staff members would welcome attention to organisational development.
The Department of Family Medicine and Community Practice should assume managerial control of the Outpatient Department in order to;
Monitor the service, campaign for budget increases and explore limited cost sharing schemes
Introduce a drug formulary for outpatients and improve drug ordering systems and supply
Contribute to the clinical workforce (minimum 2 lecturers)
Provide an organisational development role with regular team meetings and in-service training
Develop protocols and guidelines with particular attention to rational prescribing and appropriate referral
Introduce audit as a routine tool for the development and improvement of the service
Create an environment for clinical research
Provide a teaching environment for undergraduate and postgraduate students of all disciplines
Liaise with other departments and specialties
Liaise with community health facilities to improve patient flow and management
Jan Power and Mark Russell. December 2006
Sunday, December 10, 2006
Thursday, November 30, 2006
Kitwe HC4 is an hour down a dirt road, off the main road from Ntungamo. It has a good range of buildings, staff accommodation even a fully equipped operating theatre. But with no medical officer and no anaesthetist the theatre has been unused since it was built 5 years ago. Even when there was a medical officer in post a couple of years ago they are often new graduates and don't have the confidence to keep up a surgical practice. With no electricity, no running water and not much to do in the evenings it's hard to keep doctors there for any length of time. The team seemed bright and capable and were really trying to provide a good service. It's hard to see how they can stay optimistic in the face of their difficulties though. They had 2 clinical officers, 4 midwives 4 nurses , 3 nurse aides and a bunch of support staff.
Ruhama HC2 is a tiny enterprise started by a Ugandan in his old family house. Again, a good team, poor facilities but big ideas. Unfortunately it is less than 2 miles from a government health centre and the two seem to be in competition rather than collaborating to improve health outcomes. Why the NGOs and missionary outfits don't ever get involved in running and improving existing services I really don't understand. The Ruhama enterprise was interesting in its efforts to generate income locally to help fund the service. The running costs of $750 pcm which provided a nurse, 2 nurse aides, a lab technician , a finance officer and support staff were met 1/3 from user fees for medicines, 1/3 from the parent NGO and 1/3 from a variety of local projects. These included eucalyptus plantations to provide firewood for sale, a stone quarry and beekeeping enterprise as well as a savings and credit scheme. Addressing income in impoverished rural areas is vital.
Our third visit of the day was to a HC2 run by brazilian nuns. The 20 minutes down a very rough dirt road gave no hint of the splendour of the unit. From being almost impassable the road gave out to a wrought iron gate in a crafted stone wall worthy of a Hollywood mansion. The concrete driveway flanked by luscious palms led through a manicured but productive garden to a gleamingly clean and welcoming purpose built health centre. The quietly spoken and determined nun seemed to have sorted the ideal arrangement. She had persuaded the district to give the centre its own budget which amounted to $500 pcm, which they spent on drugs. They then sell the drugs and lab tests at cost and use that money to pay staff wages (the nuns come free, they employ an additional nurse, a clerk, a lab technician and household support staff). Oh and she keeps a firm grip on all the keys so none of the stock disappears. The place was beautifully kept with plenty of welcoming posters and messages on the walls and doors. Enough to make you believe in God (or nuns at least).
Our final visit was to Rugarama HC4 in Kabale. Another splendid example of a mission based health unit, operating semi independently of the district but with a government budget. Well staffed and efficiently run, it was clearly delivering a high standard of care compared with the government hospital up the road, but again was charging user fees and there seemed to be no communication between the two units. The Ministry of Health Grant of $4000 pcm paid the wages of almost 80 staff. There were consultation fees inpatient charges and drugs and lab tests were charged at cost. Capital costs are met by donations usually from the International Lions organisation. They are hoping to start obstetric surgery soon and want to build a paediatric unit to allow the maternity unit to expand. They need to build more staff accommodation as providing accommodation is the only way to make their salaries competitive with government ones. Nurses are on $150 pcm, clinical officers on $250 and docs on $500.
We've done with visiting! It's been great to see so many examples of good and not so good practice, the challenges faced by overwhelmed government units and the contrast with better resourced private ones.
We're both left unsure about the whole business of user fees. Coming from the UK it goes against the grain to charge people at all for health care, let alone the really poor for treatment of diseases of poverty. But at least with the brazilian set up the charges were as low as they could be and were posted on the wall so people knew what was being charged for. We heard stories in government centres of parents having to go to a drug shop to buy the syringe and needle for their child to get the injection of antimalarials they desperately needed because the hospital had run out, and that isn't right either.
Sunday, November 26, 2006
It turned out to be the most eventful sponsored walk I've ever been on. We marched around the small town of Ntungamo led by the 'chief walker' and in formation 3 abreast behind the banner and childrens band. People carrying home made posters in English and Runyankore with messages urging immunisation, safe sex and regular deworming. My favourite was the child walking along proudly holding aloft his poster reading 'participants register here'.
After 2 or 3 km Francis, the NGO director and event organiser fell heavily whilst running to catch up with the leading group and had an obvious fracture of his left arm. He was sweaty and in pain but after a makeshift sling and a couple of ibuprofen got up and hurried on. When I caught up with him near the end of the walk he told me they had a very good traditional healer at the health centre who would sort him out when he got there. He continued to lead from the front and finished the walk before coming over a bit queasy again and agreeing to come with us back into town for an xray and plaster of paris. The xray confirmed the fracture, and the POP, bought in a local pharmacy and applied by a Belgian medical student (with my inexpert help) looked a bit scruffy but seemed to do the trick.
We retired for barbecued maize, chapati, beer and aftersun....J
Wednesday, November 22, 2006
Monday, November 20, 2006
Shopping involves a 20 minute walk past George the stork, along a murrum road, across a golf course, then murrum road into town. On the way I greet and am greeted by literally dozens of people, schoolchildren in their smart uniforms, women carrying improbably bulky loads on their heads, boda boys trying to persuade me I want a life on the back of their motorbike (interlude here – it seems incomprehensible that I would want to walk, I must have money as I’m muzungu, so why don’t I get a lift? When I’m out running I can see people watching mystified, then turning to the person next to them and saying “Oh, she’s taking exercise!”).
Some days I go to the dairy. This is about a further 10 minutes out of town, basically in a house. It’s a family business, making yoghurt and cheese (‘feta’, ‘gouda’, ‘cheddar’ and ‘mozzarella’ all tasting roughly the same). Then to the market where I cause great amusement trying to buy using only runyankore.
The availability of food is directly seasonal. The first mangoes are appearing on stalls, and the grasshoppers have just hatched(?). There are clouds of them flying around, and piles of them in the market. Some fresh and green and still with legs and wings, and others without (I think although I’m too squeamish to get close enough to know for sure) and fried brown.
And I usually end up buying a basket or two. They’re just great. And very cheap, ranging from 10p to 70p depending on size and shape. Irresistible.
ASSESSMENT OF THE CONTINUING POTENTIAL FOR A DEPARTMENT OF FAMILY MEDICINE AND COMMUNITY PRACTICE AT MBARARA UNIVERSITY OF SCIENCE AND TECHNOLOGY – NOVEMBER 2006
Uganda faces considerable health challenges;
50% of the population do not have access to clean water
Average life expectancy is 45
320 people (mostly children) die every day from malaria
One and a half million people are known to be living with HIV/AIDS
51% of the population are more than 5km from any health facility
1 in 200 women who get pregnant will die from a pregnancy related complication
Infant mortality is 87/1000
There is less than 1 doctor per 10,000 of the population
80% of the population live on less than $1 a day, 96% on less than $2.
The Health Sector Strategic Plan (2000-2005) envisaged a strengthening of Primary Care with most care delivered by Health Centres 1-4 (each level with more sophisticated infrastructure and staffing) rather than by District or Regional Hospitals. This is a sound plan. Part of the development of this strategy requires strengthening the medical presence in Health Centre 4s, to provide comprehensive primary care as well as effective intrapartum care and some emergency surgical services. It was to meet the demand for these Health Centre 4 Medical Officers that the Ministry of Health supported the creation of the two Ugandan Masters Courses in Family Medicine and Community Practice (one at Makerere and one in Mbarara).
There are many significant blocks to the successful delivery of effective Primary Care;
The Health Sector as a whole is under-resourced. Government spending on health is 8% of an already small Gross Domestic Product (GDP). A Save the Children Fund report recommends 12-15% of GDP funding to meet already stated objectives
Undergraduate medical training is still largely specialty hospital focussed, although Makerere has had a more community orientated programme since 2003
Most medical students are from Kampala and prefer to follow careers in Kampala
There are too few medical graduates. The three major teaching hospitals are struggling to fill their own intern posts. Only 33% of rural medical posts are filled
Well funded NGOs offer higher salaries and draw doctors away from the public sector
Collaboration between NGO and Government facilities is poor with many NGO programmes concentrating on the delivery of disease specific services for HIV/AIDS or TB. In practice, there is no concept of comprehensive primary care.
In the public sector the level of commitment among doctors is low. Many public sector doctors spend much of their working time in the private sector to boost their income
Doctors are reluctant to work in remote settings under difficult physical conditions many hours distant from their families
Poor remuneration at medical officer level makes recruitment difficult
Lack of career progression and career opportunities is de-motivating
There are no opportunities for continuing medical education or support
Accommodation and facilities in remote settings are poor
There are often inadequate levels of support staff
Supply of drugs and equipment are outside the control of the individual doctor and are at best sporadic
Lack of infrastructure for performing operations e.g. caesarian sections leads to deskilling of the doctor and thus a total loss of the service at HC4 level
Widespread corruption and theft of supplies further impedes service delivery and damages morale.
We have been recruited by Mbarara University of Science and Technology (MUST) to help consolidate the Department of Family Medicine and Community Practice. This Department currently exists only on paper. Dr Vincent Batwala has managed the Masters Programme in Community Practice and Family Medicine under the auspices of the Community Health Department for several years.
Current issues facing the Programme in Family Medicine:
There is no Clinical Department. This is a vital pre-requisite for teaching postgraduate and undergraduate students in a clinical discipline
There is no office space
There are currently no members of staff in the department and no-one associated with the University has a background in Family Medicine
There is no budget
The curriculum needs to be rewritten to prioritise the learning needs of the students and the Health Sector’s demand for generalist practitioners
At present the students are regarded by their placement departments as an extra pair of hands – the educational component of their attachments is poor
Student assessment is burdensome and not tailored to the practice of Family Medicine
There are currently no students in the first two years of the course.
Minimum requirements for a successful department to be established;
A secure funding stream must be established
At least one and preferably two Ugandan lecturers with a Masters in Family Medicine should be appointed as soon as possible
A follow on VSO volunteer lecturer in Family Medicine should be appointed to begin before September 2007
The department will need an office, a library, IT equipment and furniture
There needs to be a clinical teaching base for students of Family Medicine. In the successful South African model, the Department of Family Medicine runs a generalist triage service for the emergency room and the outpatient department
Lecturers in Family Medicine should have a clinical service commitment of at least 2 days each week
The Course Curriculum needs to be rewritten to reflect the objectives of Comprehensive Primary Care Delivery in Uganda with an emphasis on the management of HIV/AIDS, TB and malaria as well as on the delivery of effective child and maternal health programmes
Traditional courses are unsuitable for this Masters programme. Students come from backgrounds with very different work experiences. The course should be flexible enough to meet individual learning needs. Course assessments should reflect this
A programme of continuing medical education (CME). This requires a commitment to resource and support graduates in order that they can undertake an annual minimum level of CME
Institutions that deliver excellent Primary Care and individuals who practice Primary Care to a high standard need to be identified and supported. Students will be placed at these sites in apprenticeship roles with a comprehensive programme of mentoring and supervision. This system will require funding of the supervisors and supervising institutions
3-5 students need to be recruited into each academic year.
In order to meet these targets the ongoing support and sponsorship of the Faculty of Medicine, MUST and the Ministry of Health (MoH) is essential.
The Faculty of Medicine and MUST will need to provide;
funding for the Lecturer posts and
support for the establishment of a clinical department of Family Medicine.
The MoH will need to commit to the funding of;
Government salaries whilst students are on the Masters Programme
Travel and subsistence grants for community placements
Special Medical Officer status with a salary enhancement for Masters graduates
Grants for continuing medical education for Level 4 Health Centre Medical Officers
A salary structure which reflects training, experience and length of service.
Jan Power and Mark Russell. November 2006
Sunday, November 19, 2006
Foreign aid constitutes the largest sector in the Ugandan economy, with more than 50% of government income coming from donors. This is big business. Ambitious and greedy people go into politics and use their connections to set up or get involved in NGOs. They have access to salaries, cars and, via various scams, a criminal income. There are now 6000 NGOs working on HIV alone in Uganda. They compete, sometimes aggressively, for scarce resources. Because they are in direct competition with each other there is a disincentive to work collaboratively. There is no effective control over their policies and practices, so they rarely work with the same aims, and it seems even more rarely in line with overall government strategy. Result; ineffectiveness, chaos and duplication. This is just one area. The country is full of NGOs. There’s a part of me that thinks all the money should be directed through central government so that they can work effectively to a sensible strategy, and part of me that knows that would be even more hopeless as the money would simply disappear.
This form of entrepreneurialism is effectively modelled by president Museveni, his family, friends and political colleagues. Museveni and his family have stolen hundreds of millions of dollars from the Ugandan people. This is corrosive stuff. When his health minister Jim Muhwezi was found after a commission of enquiry to have stolen millions of dollars from the global fund (destined to help Uganda fight HIV, TB and malaria), Museveni protected him, refusing to sack him. Largely, it was suspected, because Muheza knew too much about Museveni’s dodgy dealings. His own corrupt and some say murderous habits mean Museveni has a strong incentive to stay in power for life to evade investigation and accountability for his record - what democracy there is here may be no more than a sham. The Global Fund (worth $100m to Uganda) has been suspended since July 2005, and has just been suspended again until next year at the earliest.
Nearly everybody steals or expects things to be stolen. Corrupt practices hamper sensible business development and investment because the playing field is biased and unpredictable. Funds don’t reach their targets so infrastructure is poorly developed; the roads are bad, electricity unreliable (the national electricity company is run by Museveni’s daughter).
On Thursday we met Paddy and Mike Martin from Marazion. They’ve been coming to Uganda for 5 years and have invested heavily in the construction and supplying of a primary school north of Kampala. They are now switching their energies elsewhere after a catalogue of abuses, with building supplies stolen, school equipment stolen, and teachers barely turning up for work.
Our dilemma then, is, do you engage with or disengage from corrupt organisations? VSO’s view seems to be one of constructive engagement. The ‘muzungu’ sticks the course, models a European work ethic, insists on transparent practices, is appalled by any hint of corruption and thereby educates people about good governance. Our experience is that this is a fairly ineffective approach. The corruption becomes more covert or the muzungu is unwelcome. Judith, who was posted to the corrupt pharmacy department at Mbarara hospital, was ignored and not spoken to for her first 3 months here until she decided she should get a job elsewhere. I favour a process which sets high standards for the partner organisations, maybe even aiding them with short term placements at start up to regularise issues of accounting and governance. VSO’s ‘bums on seats’ approach to maximising placement numbers seems to us to be counterproductive in this situation.
Ugandans love to talk politics and most are fed up with Museveni. However, alongside that discontent many still have vivid memories of 20 years of mayhem, brutality and bloodshed from a few years after independence in 1962 to Museveni’s overthrow of Obote in 1986. During those years most administrators and civil servants were murdered, expelled from or fled the country. Museveni has brought relative stability though little in the way of economic development or the regeneration of civil society. Uganda is a fertile country with plentiful food and some valuable natural resources, equatorial sunshine, plenty of rain, the Nile for energy and now apparently some oil reserves but there seems to be no way out of the present predicament short of another bloody revolution at some point down the line.
We enjoyed the thought advertised in the press recently of a prize for the African president who voluntarily stands down after no longer than 2 terms, having left the country in a better state than when he arrived. The prize was a pension of $5m pa for life. Local people quipped that that’s probably as much as Museveni steals in an average day!!!...........
We spent the weekend with Frouke and Petra exploring the source of the Nile where it leaves Lake Victoria at Jinja. Saturday night’s idyllic campsite was at The Haven, a small encampment 10 miles north of the busy colonial town of Jinja. The Haven sits high on the bank of the Nile, above a set of its famous grade 5 rapids, as the river courses through lush green countryside. There are yet more goat shed style buildings here, beautifully decorated and finished, so they provided plenty of inspiration for our next venture.
There is no hint of development in the surrounding area. Small hamlets of brick and mud huts melt into the matoke and sugar cane plantations – the land is heavily cultivated but not in a manner we would recognise. From a distance it appears like an open woodland. Up close the trees are a mix of productive trees including many laden with impossibly large Jack fruits.
We’ll be going back and we are also definitely going to go over the rapids in a raft!
In order to keep morale up, we both skived off several of the sessions as the ones we attended, though interesting, tended to be of a Ugandan style lecture based format and could easily hit 2 hours long without a break. My attention span is a maximum 20 minutes in that kind of setting. Instead we hit the shopping centres, finding ourselves wandering dazed and drooling through the huge and shiny shopping malls of downtown Kampala. We’ve bought loads of books to satisfy Jan’s thirst for reading.
Kampala is a medium sized, grotty, smog choked traffic jam of a city so it was good to discover some of its nicer aspects. We ate really well! First with Mya and Alastair, then at the Café Roma, Le Petit Bistro and finally at the Speke resort. We also spent a comfortable afternoon (and then most of Jan’s birthday) lounging in the luxurious environs of the Speke resort. This is a deluxe hotel complex on the shore of Lake Victoria with possibly the nicest 50 metre swimming pool ever built.They also had 2 storey goat sheds in their grounds!!
Wednesday, November 15, 2006
Bwindi Community Health Centre was established by American Missionaries Scott and Carol Kellerman in 2002, to bring healthcare to the Batwa Pigmy Community. The Batwas are traditional hunter gatherers displaced from their natural forest home by the incursion of agriculturalists and by the creation of the national parks. These people now live in extreme poverty with no culture of food growing and no means of earning an income. Childhood mortality is 60%. Scott has created a charitable foundation that works with the Batwa people to provide housing, sanitation, water and schooling as well as providing health services.
The health centre has in patient facilities for adults and children, a busy outpatient department, an antenatal clinic as well as an immunisation programme. In-patients are mainly children with severe malaria or with malnutrition.
Paul and Vicky are two VSO volunteers who have been working at the centre since Easter this year. They have worked hard to introduce professional standards of care with clear protocols for the management of the common conditions. There are regular teaching sessions and staff meetings. The service is currently run by a medical officer, 2 clinical officers (nurse practitioner equivalent) and 5 nurses. There are basic laboratory, Xray and ultrasound facilities and hopes to open a surgical unit next year. Proactive HIV screening starts on December 1st (world AIDS day) and access to ARVs will come soon.
The annual running cost is currently about $200,000 of which half comes from charging the non Batwa users of the service and half comes from funds raised by Scott mainly in the USA. (Currently TB treatment, feeding of malnourished children and HIV testing are free. The Batwa community have a completely free service).
Scott is now spending half the year in Bwindi and half the year raising funds in America.
Compared to the other services we have had experience of since we’ve been in Uganda this service is excellent. (Remember it is common for there to be no drugs, no IV fluids, routine laboratory tests unavailable, poor medical care, non-existent nursing care).
We spent our week either on the ward or in the outpatient department. On Friday we joined Vicky and Paul at an outreach clinic in a Batwa village, 40 minutes from Bwindi. King, the manager of one of the local tourist camps brought a few of his staff for crowd control and to act as interpreters and we rattled through 80 people with an assortment of problems including coughs, colds and fevers.
We were well looked after in the guest house at the centre and had the good company not only of Paul and Vicky and the permanent staff at the centre but also of a couple of Danish medical students and Steve from Lake Tahoe who has been working as a general handyman here for the last 3 months.
Paul and Vicky are facing many challenges. Good timekeeping, regular ward rounds and teaching sessions and good record keeping depend on their continued presence and tend to slip when they leave Bwindi.
BCHC has up to now had a hand to mouth existence. It is very dependent on funds raised by Scott. When Scott isn’t around cash-flow can be problematic. Paul has taken to schmoozing with tourists visiting the national park to raise funds for important new projects (very successfully). A VSO volunteer is coming for 3 months in the new year to establish a formal accounting and budgeting system. Paul is also setting up a ‘Friends of Bwindi’ group, who he hopes will make regular financial contributions and provide regular income. One of the financial challenges is the extent to which the centre develops as a mini hospital. The current limited x-ray and ultrasound facilities are expensive to run and of dubious priority given the low immunisation rate, poor access to antenatal care and high incidence of the big killers – malnutrition, malaria, TB and HIV.
The establishment of a surgical unit will impose further financial strain on the centre. Whilst it makes sense to offer caesarian sections when maternal mortality is currently so high and the transfer time to the nearest surgical facility is 2 hours it will involve large revenue costs with surgical, anaesthetic and nursing staff as well as equipment and supplies. Paul worries that high cost interventions that help the few will limit the organisations capacity to make low cost interventions that help many more people such as community education, vaccination, antenatal care and family planning (a familiar tension in all health systems).
We were enormously impressed by the health centre and by the work Paul and Vicky are doing. This is a well organised, corruption free project. Within the confines of a low resource setting the health centre is providing extremely high quality care. Paul has identified improvements in maternal and child healthcare, and reducing the very high mortality rates as one of their most important priorities. In order to achieve this they have appointed a midwife, Evelyn, to provide antenatal and intrapartum care. She is great. Competent and kind, she is proving very successsful at persuading women to attend for antenatal care where several simple interventions can be made to dramatically reduce maternal and child mortality. Specifically, the treatment and prophylaxis of malaria and worms reduces anaemia and the likelihood of death from Post Partum Haemorrhage. Screening and treatment for HIV and syphilis (both probably with around 10% prevalence) reduces congenital transmission, and tetanus vaccination prevents neonatal tetanus. She and Paul are developing protocols for identifying women who are at higher risk of running into problems in pregnancy or labour to target them for more intensive antenatal care and to try to persuade them to attend the centre for delivery. She is seeing about twenty new women a week in a weekly antenatal clinic.
Large family sizes are the norm. This is entirely understandable. Women expect that at least half of their children will die before the age of five and the role of children in the family is to collect water, herd goats and look after younger siblings. Access to family planning is poor. Prolonged and obstructed labours in isolated homes are very common and cause large numbers of stillbirths and maternal deaths.
It has previously been a struggle to encourage women to attend the centre for delivery but Evelyn’s popularity is changing this. As word is spreading amongst the local women, her workload is increasing rapidly. Evelyn is on call 24hrs per day for 25 days then has 5 days off, when labour ward and antenatal clinic are covered by the only other nurse with any obstetric experience. In the week we were there she was up most of the night every night, and looked completely exhausted. There is an urgent need for a second midwife. It would cost approximately £150 per month to cover her salary and other costs. Before we left the UK some of our friends asked us to identify a small project that they could contribute to directly. This could well be a good one. Check out Bwindi’s website at http://www.bchc.ug/ or mail us for more information.
PS I had my first Ugandan snake encounter in the bathroom in Bwindi. Just turned and noticed the snake sitting on a ledge a foot away from where I was brushing my teeth. Made me jump and I had to be rescued by the security guard who whacked it with a very long stick!
Thursday, November 02, 2006
Fortunately for us the external examiner, Atai, came from the departmentof Family Medicine in Kampala. She's a bright and dynamic Ugandan woman who has been the Head of Department there for 3 years. Now, finally, after several long conversations with her, we've begun to understand what's expected of us and can start to make plans.
These revolve around establishing a proper department of Family Medicine, with office space and lecturing staff and some form of clinical component to it's activity. Initially we'll be looking at creating a presence in the outpatient department of the University Hospital here. Many of the patients self refer to outpatients even though they have problems that can be dealt with easily in Primary Care (chest infections, hypertension, malaria). Given that Primary Care isn't well established some form of Primary Care clinic as a first stop seems sensible and works elsewhere... Needless to say it'll have to go through a lot of committees.....
Sunday, October 29, 2006
Over the next 2 months we are going to visit as many and varied health facilities as possible. From the new year we will work with the Family Medicine Department in Kampala to revamp the curriculum at Mbarara University for training physicians to work in and run level 4 health centres. As part of that process we want to see if we can establish a Clinical Department of Family Medicine and identify someone (some people) to keep it going when we leave. We'll see.......
Thursday, October 26, 2006
As we arrived on the ward there was a young woman on a mattress on the floor who looked like she was about to die from blood loss (at one point we thought she had died). We managed to galvanise the nurse into going to at least look for some fluid and blood for her. After 2 litres of fluid and a bag of blood poured into her in less than an hour she looked a little better. Two hours later she was able to smile and shake my hand! Not out of the woods by any means, but it’s amazing how resilient people can be.
My pidgin medical Runyankore is improving and I’m getting more confident about having a go. I can ask quite a lot of questions. The problem is that I can’t really understand the answers! Quite understandably people assume that if I’m asking I must be able to understand so they gabble away in answer and I just stand there looking baffled.
Two days in the HIV clinic this week. It really is a different world. It’s well funded because of involvement from multiple NGOs. There are loads of them. MJAP, TREAT, FTF, PAPFER. There seems to be a real hierarchy of care. If you are ‘lucky’ enough to qualify for help from one of the NGOs funded to provide HIV care, you get everything paid for. TREAT seems to be ‘the best’. It covers all blood tests, drugs and any investigations that are needed. But you have to be HIV positive, female, widowed or with dependent children etc. It feels great to be able to do at least basic investigations without a major discussion about whether or not patients or relatives can afford it. I’m not sure if it’s an unusual week this week as everyone seems to be preoccupied with med student exams, but by the afternoon of my first day in clinic I was seeing patients on my own, and by day 2 Mark and I made up over 50% of the workforce. We keep frantically looking things up in books to try to keep on top of what we’re seeing. It’s a great way to learn, both African medicine and Runyankore but I’m not sure its right. Again taken aback by the tolerance and good humour people show.
Yesterday there was 1 doctor, a nurse practitioner, an HIV expert from the US, Mark and I in clinic. Over 200 patients. One died whilst being seen. Several were very sick. Everyone turns up first thing and gets a scrap of paper with their number on. The last person was seen at 5.15, still smiling and saying thank you. No apologies for waiting times, no explanation when we stopped to eat or drink. People everywhere, on the floor and lying on benches. Some had travelled 80 miles to be seen. By mid afternoon the lab had stopped doing CD4 counts so people had to stay overnight to get it done the following day. Amazing!
Day 2. Expert from US poorly in bed. Nurse Practitioner not feeling great but there. 2 doctors plus Mark and I so we were put to work. Mark was lucky enough to have an interpreter AND a BNF AND a pocket textbook of tropical medicine! I had to rely on pidgin runyankore, bits of english, a medical student who spoke runyankore but buggered off when she got bored, a very unenthusiastic pharmacist who helped out when I was really stuck, and nipping in to look things up in Marks BNF or textbook when I needed to.
But the striking thing is that many people are completely well and functioning normally on their ARVs. It's an indication of what can be done when the commitment to healthcare exists and the resources and infrastructure are provided to at least partly meet the need. More of the same with the care broadened from its focus on HIV would achieve so much....
Saturday, October 21, 2006
This week Samples of blood, sputum, CSF etc could be looked at under a microscope but are not sent for culture. There is a shortage of most drugs. There are cannulae but a shortage of giving sets and IV fluids. There are no scales on the ward. No thermometers. One sphygmomanometer carefully locked in a cupboard. The surgical theatre has been closed since last week as the anaesthetists refused to work in it until it was redecorated and the equipment was repaired. It’s likely to be closed for at least a month.
Nursing care is practically non existent. The 2 nurses administer what medication there is ( though most of the patients have to buy their own or go without if they can't afford it). The patients are fed and watered by their relatives. Noone does routine observations on the patients. The nursing and medical management in the hospial is completely ineffectual.
We keep wondering how this can be a regional referral hospital, and one of two university teaching hospitals in Uganda. It’s interesting watching the reactions of other expat doctors to our obvious distress at conditions on the ward. Having been here more than a few months they have become acclimatised. To stepping over patients and sleeping babies on mattresses on the floor, to the lack of privacy, the poor quality of care, the limited diagnostics and the limited treatment options. I’m sure we’ll get used to it to0, although I’m almost more worried about that than continuing to be horrified.
Most of the patients on the ward are desperately ill. Two young women are paraplegic with spinal cord lesions (one probably from TB in her lower cervical spine, the other of unknown aetiology, she’s 18), one with tetanus. More than half the patients on the ward have an AIDS related illness and many of them have pulmonary TB. There's also malaria, although severe malaria usually only affects children and I’m building up to doing paeds next month! Rheumatic fever is still very common in childhood so I’ve seen more people with terrible rheumatic heart disease here than I have for 20 years in the UK. And they’re really young, in their teens and twenties with awful heart failure, strokes from AF etc. Their only treatment option is to go abroad (to India) for valve surgery, which the ones we’re seeing can’t afford.
Every patient consultation involved a negotiation with the carers about how much money they have available. Can they pay for blood tests and Xrays from the private clinics in town (presumably beneficiaries in more ways than one from the lack of facilities in the hospital). The 22 year old with crashing heart failure and atrial fibrillation from her rheumatic valve disease couldn't afford the few pounds necessary for the frusemide or amiodarone that would give her a few more months of active life. This week there's been no oral frusemide so the patients have been given it intravenously.....
In medical outpatients there are two large tables pushed together in the middle of the room with two couches at the sides. At these tables sit 4 doctors, 4 patients, possibly patients carers/relatives, medical students, a nurse taking blood for HIV testing. These consultations also revolve around whether patients can afford medication and investigations. I saw one woman in her 20’s with the biggest spleen I’ve ever seen. She was wasted with an enormous swollen abdomen, all spleen. Probably postmalarial but no real possibility of finding out why.
On the plus side, once diagnosed, HIV and TB treatments are really good, available and free (funded by NGOs). The diagnosis is usually easy on clinical grounds and HIV testing is routine on all patients who attend hospital as out or inpatients. To preserve some confidentiality patients are described as NYN if negative or NYY if positive. The HIV clinic operates from a newly constructed building which has consulting rooms, chairs and desks. AND only one consultation per room! I’m spending next week in the HIV clinic to cheer myself up…….
Sunday, October 15, 2006
Friday, October 13, 2006
This week was spent with Robert learning the basics of the Runyankore language. One of the Bantu languages (similar to Swahili) it is a dialect spoken by the Ankore tribe of South west Uganda.
Robert is an interesting mix of professional linguist, business consultant, entrepreneur and farmer. The pictures were taken at his family farm about 40 minutes west of Mbarara. He has planted a couple of acres of plantain bananas (Matoke) which are the staple carbohydrate in Uganda. These have been grown in this area for 2000 years though the plants originated in southeast asia. The bananas are interspersed with passion fruit vines, avocado trees, lime trees, jack fruit and coffee bushes. No self respecting Ankore tribesman can get away without cows so he has 20 roaming over about 10 acres of pasture.
Wednesday, October 11, 2006
There has been mass grazing of the hillsides in the south west by Ankole cattle. They are magnificent beasts with the most dramatic horns. They have had quite an impact on the environment though and there are bare hillsides all around. There's a big lemongrass project, growing masses of it as its very good for soil stabilisation and then production of essential oils as a byproduct. A friend of ours is working on the project as a volunteer and has found out in her first week that the UN development grant has been stolen (eaten as they say around here) and that the project faces bankruptcy. Corruption is commonplace.
What do we eat and drink? There are several local beers which are OK. All a light lager. We tend to drink Nile Special but there's also Bell, Club and Tusker that I've tried. They work out at about 30p a bottle. Food wise you can get pretty much anything you want at the supermarkets, at a price. The main problems are storage and cooking facilities. We're lucky 'cos we have a fridge and more importantly electricity. Most people don't bother with a fridge as the electricity is so unreliable. I have an electric cooker but only one ring works and the oven doesn't work either! Again most people have a double gas burner. It does mean that shopping and cooking take much longer than they would in the UK. Theres a very good market that sells seasonal fruit and veg (tomatoes, peppers aubergines, beans of all descriptions, onions, garlic, potatoes (called Irish), yam, cassava, sweet potato, matoke(green banana), huge avocados(the size of a small melon) passion fruit, pineapple various bananas rice, maize flour, eggs, meat and fish. You buy by the pile, a pile is 500 shillings (15p). For that you get 4 green peppers, 6 eggs, a huge bunch of bananas, 10-15 passion fruit etc.
I haven't bought meat or fish as its hanging around in the heat and is covered in flies, although i'm told its fine after a wash. Oh and theres also grasshoppers(cooked). Can't say I fancy them either. Ugandan food is very carbohdrate heavy, usually matoke(green bananas) cooked and mashed or posho(maize flour porridge) and/or rice and/or Irish with a bean stew. The Indian influence is obvious too. Eating out theres Ugandan, English or Indian food. At around £1.50-£2.50 a head.
It's the rainy season but i'm not sure what that means. Its sunny about half the time and occasionally it buckets down, but only for a few minutes and not every day. Its like a good English Summer all the time.
We're having an intensive Runyankore language week this week. Its very hard. it has nothing in common with European languages and has a complex (to me) structure where you have to know which of 6 or 7 classes a noun falls into before you can use a verb, adjective etc. Even of is 7 different words. Eg a different of for bananas, table and water. And different for singular and pleural. Even numbers! Numbers 1 to 5 change depending on what you're counting!! Oh and the time is different too. One o'clock is 7am. The rationale is that the sun rises and sets at 6, so 1 hour after sunrise is 1am, midday is 6am etc. Theres no description for the hours between 6pm and 6am, its night time.
Thursday, October 05, 2006
Two days on from my last blog. Yesterday we drove 2 hours towards the democratic republic of the Congo through some beautiful countryside and past this crater lake. We were visiting some 4th year medical students on their 4 week community health placement in a remote level 4 health centre. (Level 4 is one level of sophistication lower than a district hospital and is run by a medic supported by a clinical officer -like a nurse practitioner- and a nursing team).
We're beginning to learn what our job might entail.
We’ve met most of the people in the department at the university. The theme is “You are welcome” followed by slight mystification at what a family doctor/GP is. We seem to have been recruited to re-energise the masters course in community health and family medicine. This course is meant to be a kind of 3 year vocational training scheme for generalist doctors to run remote health centres. The curriculum for these doctors is daunting. They need to be general surgeons, obstetricians, anaesthetists, registrar grade paediatricians and general physicians as well as having training in ENT, ophthalmology, psychiatry...there is no money for training and if they were to take up the posts they would be paid appalling wages (less than £200 per month) to live in a remote spot doing a 1 in 1 with iffy power and water supply etc etc. Many qualified docs prefer the higher wages of private practice in Kampala or abroad. Mark and I keep looking at each other helplessly wondering what on earth we can do that might be of any use!
There is pressure (but no resources) from the Ministry of Health to introduce family medicine/community care and decentralise health services. This clearly needs doing. The health stats are still appalling.
One in 200 women die in and around childbirth. Infant mortality is 87/1000.
320 people a day (mostly children) die from malaria.
In 2001 1.05 million people were known to be living with HIV/AIDS.
80% of the population live on less than $1 a day (96% live on less than $2 a day).
Only 50% of the population have access to clean water.
Only 49% live within 5km of any health facility.
There is less than one doctor per 10,000 of the population.
But I HAVE found the most wonderful aerobics class! Its hard work and fun. Its run by a lovely Ugandan man with a big pot belly. Most of the class are Ugandan men, very serious and totally anarchic, rarely doing what the teacher is, but dancing around and seemingly having a ball. Much needed light relief every Monday Wednesday and Friday at 7.30pm.
We have our first Runyankore lesson tomorrow with an 80 year old retired bishop and have bought some primary 1 level reading books to try to crack it.
We’re planning to get away this weekend to Lake Bunyoni. Its about a two hour drive. We’re told its very beautiful and the good news is that it’s OK for swimming in without risk of bilharzia, crocs or hippos because its very steep sided. I’m taking a novel and a swimsuit and I’m going to be a tourist for the weekend.
Quote of the day yesterday from the Health Minister. “Be careful about being encouraged to use condoms, those are selling gimmicks. Condoms have quite a significant failure rate, they are not completely effective. Let nobody tell you young people about condoms and AIDS. Don’t be victims of marketing.”
Tuesday, October 03, 2006
Jan listening to the archers on BBC online and checking emails in our new home. behind the laptop you can see a telephone with an antenna. Mobile phone technology has leapfrogged landlines or cabling here, so these phones which are connected to a mobile network are everywhere. For £100 and £30 a month you can have reasonable intenet access from pretty much anywhere near a town here. Out of the price range of nearly all Ugandans, but on every street corner is a man with a wooden box sometimes a makeshift kiosk with one of these phones offering its use for a fee. Most consumer goods are freely available in Mbarara which is probably the third largest town in Uganda. Prices are the same as in the uk with chinese imports dominating (as in the UK...) Petrol is 75p/litre. Food is cheap and labour is cheap.
Our home is a dark and pokey 2 room cell adjacent to the panafrican highway (Uganda to Tanzania and Rwanda) so noisy and dusty to boot. Added entertainment is provided by 2 enormous sleeping policemen, which slow the 10 ton trucks and trailers to a crawl as they bounce and crash over them ( though 2am - 5am is reasonably quiet).
We're moving to a larger flat in december so have decided to make do, clean decorate and equip our half goatshed size abode. We had thought about renting a house up the road, but all the house rentals are completely unfurnished - no cooker no nothing so it didnt seem worthwhile. We may yet change our minds.
Our home is in a small residential compound for foreign workers so we're surrounded by a warm and friendly and eclectic bunch of english, dutch and cubans working in the hospital / university. We've been made very welcome, hence our reluctance to move to alternative accommodation.
Tomorrow is our first day in our working roles visiting a rural health centre with our community health department boss, Vincent.
Monday, October 02, 2006
How are you?
I'm fine. How are you?
I'm good. How is your day?
Its good. How is your day?
Its OK. How is life?
Life is good. How is life?
Life is good.
Then you can get down to the business of buying a loaf of bread, tomatoes or whatever.
The Uganda version of 'Dreckly' is 'now'. If its going to happen soon its 'now now'.
Its expected of us that we'll employ people to clean and do our laundry, and others will employ house boys/girls, gardeners, security guards etc. We're told we should as it will provide local employment but it seems weird to me at the moment. Its very untouristy, and there are very few bazungu (plural) mostly working for NGOs. It seems Uganda is full of NGOs.
The roads are dreadful, mostly dirt track, heavily rutted, even in Kampala, with a few tarmac roads around the place. There are 3 or 4 sets of traffic lights in Kampala and I haven't seen one since. As the electricity is at most alternate days on/off and on the on days is sometimes off the traffic lights are largely ignored anyway, as are roundabouts, junctions etc. The rule is the largest vehicle has priority, with motorbikes and bikes and pedestrians getting out of the way of cars etc.
Already we hear terrible stuff about HIV/AIDS. It seems everyone you speak to has lost most of their family to it and there are a large number of child headed households and elderly headed households. It seems everyone in hospital has HIV and TB and something else. The University hospital, a regional referral centre, has no ECG machine, the ultrasound machine is broken, the chemical analysis machine is broken, so they can do CD4 counts but not sodium levels, and has no insulin. The drugs in the pharmacy are sold on the black market because wages are so poor etc. Not sure what we can achieve in our year here medically...
On the plus side! The light is amazing! The landscape is awesome. There's a feeling of horizon and grandeur in the landscape I've never experienced before. And the noise!! Birds, bats, grasshoppers, all making as much noise as they can. There are these amazing enourmous ugly storks, the equivalent of St Ives seagulls that scavenge around the place. The trees, the flowers, the pineapples, watermelon, pawpaw, passion fruit (1p each). I've so far come across five different words for bananas, green bananas, plantain, sweet bananas generally, long finger sweet bananas and short finger sweet bananas, oh and a different word for cooked green banana! There are also red bananas but I don't know the Runyankore word for them yet.
Thursday, September 28, 2006
He and his 69 cabinet ministers have just been on a well publicised 3 day retreat in Entebbe. Museveni is known as a blunt speaker and accused his ministers of sleeping and being lazy and inefficient. Museveni is keen to attract foreign investment and expand business growth. The current political motto is of developing a first world eceonomy in Uganda. Museveni criticises the main university for wasting its time training environmentalists and psychologists rather than businessmen and says Ugandans are a nation of hairdressers who need to learn how to work hard in order to get rich.
In the meantime power is on alternate days in the capital. The hydro generator at the start of the nile river on lake victoria has been half closed because lake levels have dropped over recent years.
Needless to say MPs have just each voted themselves a bonus of a brand new $40,000 4 wheel drive car......
A UK oil consortium has just bought exploration rights in Uganda. There may be large untapped reserves. One positive outcome of this is that there now is a huge incentive to resolve the ongoing war with the Lords resistance army in the north and for the first time in years people are optimistic that the peace talks in Sudan may be successful.......
Monday, September 25, 2006
The compound is protected as are most shops in town by an armed guard and at night by some mythical but very noisy dogs (please don't go out between midnight and 6am because the dogs are loose!!)
We've done our patriotic duty - walked 2 hours down to the lake and back yesterday in the middle of the day with no protection and now have distinctly red faces and arms. Hundreds of children everywhere shouting hey muzungu at the party of white folk out for their midday stroll.
Everywhere (apart from the roads which are mayhem) is friendly and safe.
Runyankore language training starts tomorrow.....