Semliki

Two days exploring the Albertine Rift Valley, part of a 1200m deep 40 km wide depression running down the eastern border of Uganda into Rwanda, Tanzania and Malawi, caused by the separation of two huge tectonic plates.

We drove down a dramatic cliff-hugging dirt road into the savannah grassland below. Two luxury nights in a remote safari lodge , with game drives ( kob, kob, warthogs, buffalow and more kob.) Game numbers are beginning to increase again after they were decimated (for food) in the war years. We didn't see the elephants - we'll save those for a visit to Murchison Falls. We had a long morning's walk through dense riverine forest tracking one of three groups of chimpazees who we watched for 20 minutes chewing on the sugary pulp of palm fronds.

Packing up tomorrow. New Years Eve away with friends and then a new job on Tuesday - a two month attachment as Medical Officers in the District Hospital at Ishaka.

Christmas hols on Mount Elgon

We treated ourselves to a hike on Mount Elgon after a weeks job hunting. Our plans are still unresolved but we're hoping to work as jobbing Medical Officers in a rural district hospital for a couple of months and then move up to Kampala. We were very impressed by Mbuya Reachout, a church sponsored HIV project, in one of Kampala's poorest parishes. They have worked extremely hard over the last 5 years to encourage HIV testing , starting people on ARVs and providing psychological, social and economic support for people with HIV and their families. There is impressive community support for the project with a lot of volunteering and the whole place had a buzz about it. I hope we can set something up with them - our placement Manager at VSO in Kampala, Sarah Kyobe, has been very supportive.

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........

Job crisis and indecision

Nearly 3 months in and it looks like we've run out of work here. We've submitted a proposal for an academic department of Family Medicine and are waiting for the University and Ministry of Health to respond. They need to make financial commitments to the training and employment of generalist Medical Officers who can provide medical and surgical care in the rural level 4 Health Centres. This is all actually ministry policy but Museveni promised everyone the earth before the elections in February and it is now clear that spending on health is frozen at least until the next election looms in 2011. As we've said before health spending is 3.5% of GDP and a fraction of what is necessary to run even a basic service.

We are also submitting a proposal to the Dean and Hospital Chief Executive on Thursday for a Clinical Department of Family Medicine to take managerial responsibility for the very busy Outpatient Department here. This one doesnt really need funding just a commitment to change in an organisation that is resistant to change. The outpatient department is a chaotic, anarchic and riotous mass of bodies in all stages of ill health. There is no overall manager below the hospital chief executive and the staff come and go pretty much as they please. Government wages are low (£30 pcm for a nurse aid, £100 for a registered nurse, £150 for a clinical officer (physicians assistant grade) and £200 for a Medical Officer. Nobody can run an average sized Ugandan family and pay school fees without moonlighting in at least one other job and all the medical officers and clinical officers have a substantial private practice that takes them away from their government commitments. Understandably they're not keen on a couple of muzungus waltzing in and expecting some commitment to timekeeping.

So, effectively we've done a needs assessment and feel like nothing else is likely to happen here for at least a few months. We've asked VSO to give us details of other job opportunities and will be touring around looking at the options over the next week or so. We have a comfy social life here so a move feels difficult but we need to get our teeth into something more substantial so we'll see.........

The outpatient department is the building on the right in this picture. The crowds have taken cover from the torrential downpour. It feels like the rainy season has just finished with no rain for several days now. The next one is March to May.

Proposal for a clinical department of Family Medicine

PROPOSAL FOR THE DEPARTMENT OF FAMILY MEDICINE TO TAKE OVER THE MANAGEMENT OF THE OUTPATIENT DEPARTMENT

CURRENT CHALLENGES
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.
Inadequate finances
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.

PROPOSAL
The Department of Family Medicine and Community Practice should assume managerial control of the Outpatient Department in order to;
Provide leadership
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

Rwanda

A fleeting weekend visit to Rwanda with our friend Sylvia. Down to Kigali first to visit the Genocide museum - a harrowing but well done presentation of the grim reality of 1994. Then a scenic drive north west to lake Kivu for a couple of days of sightseeing. The countryside is spectacular - the land of a thousand hills. Steep hilly country with densely cultivated terraces and in the distance the mountains and volcanoes on the border with the Congo and Uganda. As we explored the countryside we immersed ourselves in books about the history and the multitude explanations for how neighbours turned on neighbours in a frenzy of killing.

The church in Kibuye was the site of the massacre of nearly 12000 Tutsis who had taken refuge from the Hutu mobs. First they chucked in grenades then they went in with machetes. It took 4 hours to kill everybody..... Only 1000 out of the 50,000 Tutsis in this district survived.

It's amazing now that there is stability and a sense of progress though its still a desperately poor country with many challenges . We will visit again. We want to find out more about the reconciliation process and what mechanisms are in place to prevent a relapse into violence.

Interestingly, we had good tarmac to the border of Rwanda then hit appalling potholed dirt in Uganda. The customs officer had gone for lunch so all the cross border travellers congregated impatiently until the customs officer rolled back completely pissed an hour later. In the queue a Ugandan woman working in Rwanda said Rwanda is making rapid progress. We asked why? She said because unlike in Uganda there is no corruption. Tarmac has been promised on the Ugandan side since 1986........