Sunday, October 29, 2006

Constructive engagement

We've been trying to come to terms with our sense of culture shock. The medical wards are crowded with sick and dying people most of whom are the victims of the HIV and Tb epidemic. The government spends 8% of a small GDP on healthcare - so there just isnt much to go around in terms of facilities, staff, medicines. There is a different work ethic and years (centuries) of war, brutality and exploitation mean that there is still an overriding survival / preservation instinct which means you take what you can, however you can, cos you don't know what tomorrow will bring.
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

Much better now. Had a lovely weekend reading and sleeping and eating and going for little jogs. Its Eid so officially a public holiday today so there was no HIV Clinic. I decided to go to the medical ward instead. I was amazed to find that 2 patients who I’d given up on the previous week and had expected to die over the weekend were looking, well not exactly healthy, but alive and better that they had on Friday. One had bad malaria and a horrible secondary pneumonia after being unconscious for 12 hours prior to admission. The other had SJS with loss of all her skin (from septrin) and came in with septic shock.
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

On the medical ward.

We've just spent our first real week working in Mbarara Regional Referral Hospital. Not a good week from a healthcare perspective. There was no functioning xray (no films). No access to routine lab tests like haemoglobins or creatinine ( a problem because the highest haemoglobin we'd seen on the ward from the week before was 9g/dl and levels of 4-6 are common as a result of HIV, hookworm and poor nutrition - the test reagents had been stolen). Medicating the patients is a lottery according to what stocks are available (it is widely known that the pharmacy staff steal the drugs and the requisitioning process is nightmarishly inefficient). We still don't really understand how there is so much tolerance of the lack of leadership and managerial inefficiency and the downright crookedness of key personnel ( though alleged death threats to the curious and inquisitive probably aren't exagerated).
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

Our new home!

Third floor right hand side. Great view across town to the cultivated hillsides beyond. All mod cons - hot water and reliable electricity! These flats provide staff accommodation at the University.

You can see some small speed bumps on the road in front - these are the ones the petrol tankers pulling trailers bounce up and down over on their way to Rwanda and DCR.

Mbarara needs a bypass!! Let's tarmac over Africa...

Lake Nburo National Park

An hour east of Mbarara back towards Kampala, this 400km2 Park is centred on a large upland lake. The lake has plenty of hippos, crocs, fish eagles and other birdlife and the surrounding savannah is home to Impala, Zebra, water buffalo and warthogs in large numbers.
The water buffalo have a particular reputation for bad temperedness and will charge you if they feel you're getting too close ( Hippos likewise).

Friday, October 13, 2006

Robert Kagwa intensive Runyankore language training

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

Lake bunyoni

We had a fab weekend at the lake. I suspect it may become a regular weekend spot. It's at about 2000m so is lovely and cool and has the only lake thats OK for swimming (no hippos, crocs or schistosomiasis). We stayed on an island about 800m long and 200m wide with an ecotourism resort (5 tents and a couple of bungalows) mainly eucalyptus forest, yards from the lake edge, kept awake by birdsong. Also very sound, operating as a co-op between a canadian NGo, the church of Uganda and the community, supporting workers, orphans and widows, teaching the children to swim, a tree nursery for reforestation to prevent soil erosion etc. All for £12 a night. And lots of crayfish on the menu.
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

What exactly are we meant to be doing?

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.”
Hey ho.

Tuesday, October 03, 2006

Home for the moment

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

George the stork does the business

George the stork sits patiently on our rubbish skip at the gate to the student accommodation waiting to sort organic material from nonorganic material. Penwith district Council is still in the dark ages!!
Really amazing, difficult first 10 days. Rich experiences, well out of my comfort zone, which I keep reminding myself is exactly what I wanted. We spent a week just outside Kampala staying at a Church of Uganda training centre, and then came down to Mbarara a few days ago. Its so very different here, so UNpolitically correct in a strange way. People shout MUZUNGU (white person) at us all day, in a very friendly way, kids wave all the time and want to talk to us. Greeting is big in Uganda and goes something like -
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.
J 2/10/06