Final episode

Last week I returned to Uganda to hand over the TB project to Grania (far right, pictured with Ian Clarke CEO of International Hospital Kampala and Bosco Byekwaso microbiology lab technician).
The project is on track to market and supply a highly sensitive rapid culture test for TB by the end of this year. Grania will also be talking to local movers and shakers about upgrading Tb diagnostics in Uganda as a whole.
The work is being sponsored by the Suubi Trust (suubitrust.org.uk/) in England.
After some serious frustrations in June and July it was good to end the year in Uganda on a high note, leaving with lasting good memories of people, experiences and landscapes.

Home Again

The blog petered out as we got ready for coming home. So this posting is for completion's sake. Jan managed to persuade a bright young American volunteer called Craig to take over her managerial duties at the Hope Clinic from September. He and Philip now have a year to work on a longterm sustainable plan for the clinic.
On the Saturday we left (4th September) Bosco plated up his first cultures using the MODS technique in the new TB lab. Funding is in place to cover operation and development costs for the first year and I'm heading back out to Kampala at the end of September to hand over to Grania who will replace me as clinical lead on the project.
Its good to be back at Tremenheere and to wake up to this view every morning!!

simplicity 2

Simplicity 2

In Saturdays Monitor(national daily newspaper) there was a full page devoted to “Top 10 Time Saving Gadgets”, complete with pictures. I left the paper somewhere and can’t remember them all, but included in the list were;

Washing machine

Vacuum cleaner

Microwave oven

Blender

Egg whisk

And, my own particular favourite;

Long handled broom.

It is truly a wonderful privilege to have spent a year living in an environment where these items are seen as something other than basic necessities....

Florence

Florence

We’re leaving soon. On the whole I can’t wait. But there are a couple of people who’s future I’m worrying about.

One of them is Florence.

She’s a nurse who came to work at Hope just after my arrival. I thought her appointment was a mistake and didn’t take to her at first. During the ‘rationalisation process’ in May several members of staff were sacked. Florence survived by the skin of her teeth. She came to see me the following day, told me how much she needed her job and asked me what she needed to do to keep it.

“Make yourself indispensable” I replied. And she has.

Why does she need the job so badly? She’s twenty something, has two children of her own (aged 6 month and 2) plus two more that are her husbands by one of his other wives who ran away. When she married she was unaware that he already had two wives and a handful of children, and he’s married again since her. He hits her, and the kids, doesn’t give her any money and refuses to use condoms despite his multiple women.

So, recently she left him. She could only do this because of the £9 a week she earns working for the clinic. With this she has to pay rent, employ a house-girl for childcare, feed herself and four kids and pay for medicines when they get sick. I have absolutely no idea how she does it. She doesn’t know how she is going to manage to pay for their schooling but is determined. “I’ll manage, somehow.” She says if I ask.

Now she knows me she’s lost her reserve. She’s actually warm and clever and funny. I’ll miss her and I just hope she’ll be OK...

Shopping again

I went to get a SIM card for Fred and Sara who arrived from the UK yesterday.

The conversation went something like this:

Hello, how are you? I’m fine, how are you?

I’m fine. Do you have an MTN SIM card? Yes, 10,000 shillings.

No, I won’t pay 10. I know they cost 5. Oh, where are you from?

I’m from England, but I’ve been in Uganda for a year. Oh, do you like Uganda?

Yes, very much. When do you go home?

Next month. Can I come with you?

No, but you can sell me a SIM card for 5. Why can’t I come with you to England?

Because my husband and children wouldn’t like it. No, it’ll be OK. I like England too much. Take me with you.

What about this SIM card? Which premier team do you support?

Sheffield Wednesday, what about you? MANCHESTER UNITED! Sheffield aren’t a premier league side.

No, but they used to be good. Oh, are they historic?

Yes, one of the oldest. Can you give me your email address?

No, what about a SIM card for 5? Oh OK........Give me your phone number?

No, no phone number, but thanks for the SIM card.

Smiles and handshakes all round.

How can you not love it?

TB lab progress

Work has begun on converting the aviation office at International Hospital into a small microbiology lab specialising in TB. We’ve had promises of $26,000 for all the work and equipment necessary to get us to start up and should be able to set up our first culture on 25^th July.

The technique we’re using, called the MODS (Microscopic Observation Drug Susceptibility) test, allows us to offer a cheap and reliable test for TB for the first time in Africa.

The ambition of the International MODS Network is to make this tool a routine component of TB management in low resource settings. In practice this means we will diagnose and treat people with TB much more quickly. We can also identify those with drug resistant TB before we start treatment.

Gorillas - 29th June

We finally got round to seeing the gorillas when Ad arrived last week. I’d been ambivalent – its an expensive, luxury tourist trail affair. But they are remarkable. For an hour the 8 of us in our party stood in a tropical woodland glade while a family group of 10 got on with their lives around us. They’re huge and impressive and it’s easy to anthropomorphise as they have such familiar expressions and behaviours.
Their mountain rainforest habitat is protected now but not very big and under constant threat from the rapidly growing population all around.
There are less than four hundred mountain gorillas remaining in the world. I was left with a demoralising sense of humanity as a destructive plague....

Soweta - 23rd June

At 7am on Saturday morning we picked up Rachel and Gaye and headed for Jinja. This time, we weren’t there for the white water. Twenty five of us, including fourteen VSO volunteers from Kampala were heading for Soweta. It’s a displaced persons camp just outside Jinja. Hardly anyone knows it’s there and, it seems, even fewer want to know. Four thousand mainly women and children from Northern Uganda, displaced by the war, live there in unbelievable squalor. No latrines, a few standpipes, open sewers, mud huts crowded together, no place to grow food. An overpowering smell of home brewed banana spirit hangs over the place.
Mark and I had gone to visit the week before and had met the extraordinary Mary Kafuka and her daughter Grace. Mary is a social worker who volunteers there with some financial help from the Catholic church. Grace helps her mum “because she gets very tired”. Together they provide the only source of hope and assistance in the whole place.
“What can we do to help?” I asked.
“Anything” she replied.
So we went. With de-worming pills and vitamin A and cream for ringworm and sticky eyes and antibiotics and malaria tablets.
In the longest surgery ever we saw 720 people. They queued patiently in the sun, a number on one palm in marker pen and a cross on the other when they got their pills. We saw everyone who wanted to be seen, and some of the more enterprising ones twice.
And we “did a good thing”. And we left. Driving away in our four-wheel-drives to cold beer and hot showers and good food and a comfortable bed for the night…

Huw's blog - A tourist Awakes

We had a great time when Huw visited last week and asked him to write a blog for us:

Its not every day that this could happen and it must have been a great floor show for the children as they flocked to see the muzungus make fools of themselves. The road up the hill was really rather gentle, if quite long, but what had caused the matattu to come to a final slithering stop was the mud - the red clinging treacherous Ugandan country road mud. The mud was very slippery and the hill was very long and now the muzungus were pushing. The timing could not have been better - the school had just finished for the day. In seconds we were engulfed by bright chattering laughing faces and crisp clean purple cotton shirts and dresses. Hellohowareyouimfine, again and again and again. Hello man, how are you? I am Huw, who are you? We answered happily, and laughed at ourselves, ridiculous in swimming shorts and T-shirts, still wet from this morning’s White Nile rafting. Our exhilaration and euphoria persisted, the red mud would wash, the banter with the children felt sparkling and who would not be moved by such a sea of smiling laughter. Soon we would be in a nice warm shower, bathing in the glow of self congratulatory well being.

Then Jan, working here for a year now, the old hand, whispers urgently in my ear - Huw, do you see the boy with the huge spleen. That one with the big abdomen in the blue T-shirt. No. thats just malnutrition, the one next to him. See him, with the red shirt. See him. And I saw him. And I saw that not all the children wore the purple cotton and carried the school notebooks, and that although most had the happy smile a lot had stick thin limbs and swollen abdomens. And I saw the sunken eyes and tiredness of hardship and malnourishment in their faces. And behind them, on the fringes, were the quiet ones, reticent and watchful. And then those peering round rickety house fronts or through dark dark sacking covered doorways and window openings. What about them?

The hill was long. Too long for the children who slowly gave up the pursuit. The grinding poverty now all too obvious, the muzungus, quieter now, trudged on with sandals and feet choked with the cloying red mud, until kicking and scraping we tried in vain to clean our feet before struggling back into the comfort of the matattu. As we did so, the white MRC four wheel drive pick up eased comfortably by. Through the open window came the quiet sly mocking of its Ugandan driver, “Welcome to Africa”

This is entirely true. After all as Jan would say “In Uganda, all muzungus are millionaires”

Reasons

Reasons

Ten reasons I love Uganda

1. The climate – out at dinner last night someone recalled “getting into a cold bed” – we’d all completely forgotten
2. The variety – honestly, no two days are the same
3. The challenge – anyone who knows me knows how I love a challenge
4. Walking – always something amazing, interesting or funny to look at, always someone to talk to
5. Fruit – fantastic pineapples, mangoes, passion fruit, tomatoes, bananas, papaya.....
6. The work – it’s the work I was born to do
7. The smiles – Even if people look somehow serious they are usually grinning within a couple of seconds of greeting
8. The colours – green lush vegetation, red soil, blue skies, bright clothes
9. The money – at 3400UGX to the £ it’s the only way I’ll ever be a millionaire
10. The versatility – everything has value, everything can be mended, everything is reused

Ten reasons I hate Uganda

1. The corruption – see previous blogs. It’s everywhere
2. People die – poverty and ill health takes a massive toll, death is everywhere and often needless
3. Dust and diesel – I walk a lot. Dust and diesel fumes are my enemy
4. Not enough novels – ran out a while back
5. Power sharing and water cuts – part of daily life and a real pain
6. Bugs – despite discovering ‘repel’ at a magnificent 55% deet I’m still sporting a fine collection of mozzie bites
7. Internet speed – honestly, you can make a cuppa and go to the loo whilst waiting to connect
8. An undercurrent of violence – intimidating crowds can gather very quickly
9. Timekeeping – shocking and irritating lateness for a type A like me
10. The noise – dogs bark, babies cry, birds and frogs sing and people party ALL NIGHT
11. “Yes please” – why can’t people just say what they mean?

Yes, I know there are eleven. Can’t decide which one to leave out....time to go home?

Dr Dollar

Dr Dollar

For the last month or so Kampala has been decorated with billboards announcing the imminent arrival of Dr Dollar. He is an evangelical preacher from the US who will appear at Namboole Stadium in front of a full house of 80,000 later this month.

His message is the usual televangelist one. Unquestioning faith and espousal of rigidly conservative moral views will bring you wealth and happiness.

This stuff angers me.

The hypocrisy angers me. Preachers are often tainted individuals who persuade an impoverished flock to part with money and goods to enrich them. One famous one here drives around in a brand new pink $100,000 Humvee.

The blind and unthinking superstition angers me. Last month Billy Hinn captured the first 4 pages of the principal national daily paper. The headline: “MIRACLES!” Not one but eleven miracles took place whilst he preached to the masses. All eleven miracles (the lame walking, the blind seeing, the deaf hearing etc) were reported in uncritical detail. No comment or question.

American evangelists love it here. There is a large audience for the deeply conservative views propounded – no sex except within marriage, no condoms, no abortions, no homosexuality. This is dangerous and hypocritical rhetoric. Uganda is a very sexual society with an average age of 14. Having multiple partners is the norm. Even the preachers juggle more than one wife. HIV and STI prevalence is high. Young women are dying everyday from illegal abortions and unwanted pregnancies. Time for a liberal revolution....

Matatus

I love matatus. It’s a sure sign of my increasing Africanisation. At first sight they don’t seem ideal. Often ancient and rickety, they have cracked windscreens and hanging off bumpers. Inside there is an instantly recognisable smell of blended BO and wood smoke. The seat padding and suspension are definitely insufficient for the deeply rutted and potholed dirt roads of Uganda’s capital city. But I love them!

They’re the most efficient form of transport ever, and my favourite way of travelling (after flip flops of course). They pass along every major and minor road in the country, stop everywhere to drop off and pick up and cost pennies to go miles. They run every few minutes, not according to a timetable as they leave the taxi park only when they’re full. The music is good and the other passengers are friendly . There will be an occasional grumpy goat, but given they’re destined for the pot I can’t really blame them....

I admit I’ve been lucky so far. I’ve not been on one that has broken down or had a drunk driver. The closest I’ve come to a bad experience was driving around Kampala for 45 minutes looking for diesel in a fuel shortage. But, hey, I got to go the wrong way up a one way street in the rush hour (quite exciting) and saw parts of Kampala I didn’t know existed.

When I first arrived in Uganda I was intimidated by the taxi park, which seemed chaotic and dangerous. Now I understand the system, it’s an organised chaos that works. And there are hawkers selling everything from knickers to watches and biscuits to keep me entertained while I’m waiting for my matatu to fill up.

The other day I fell asleep on the way into Kampala and woke in the taxi park to find it was raining. The driver and conductor were both asleep too, and the only other passenger was a woman carefully arranging a carrier bag over her hairdo (rain plays havoc with braids). She knotted the handles together, tucked the ends in, checked herself in her make-up mirror and went off into the rain.

Global Fund Shenanigans

A manic and slightly surreal last week. In common with thousands of other organisations in Uganda we were working long last minute hours to submit grant applications to the Global Fund for Malaria, HIV and TB. These are to support some of our health promotion activities at Reachout. Two out of three were wonderfully politically insensitive. First a programme to work with 25,000 local teenagers on sexual health and STI (sexually transmitted infection) screening. Some of our Catholic board members will become apoplectic about that one. The second is a plea for improved TB diagnostics and preventative treatment for HIV positive people. This is against national policy and so in a very conservative bureaucratic environment beyond the pale again.

All of this frantic activity was going on at the same time as dawn raids on the homes of several of those named in the 2005 Global Fund corruption saga. Jim Muhwezi, thought to have stolen $1m, slipped off to London the night before the raid but has returned “to proclaim his innocence” and has hogged the front pages with multiple press statements ever since. He is playing an interesting game with an unpredictable outcome.....

Weighty matters

The biggest compliment you can be paid here is “You have become fat.” Actually, that’s not strictly true. As a woman, it would be “Your husband has become fat.”

Thinness in Uganda is associated with poverty and ill health. Especially with the severe wasting seen in people with advanced HIV, it is feared as a precursor to death. Women discuss how they can put on a few kilo’s, and particularly want to gain weight around their hips and buttocks. Our mzungu neighbour Dan marries his Ugandan girlfriend Alice next month. His future father in law, in accordance with tradition, wanted to confine Alice to a hut and feed her milk and meat for the next 30 days to make her suitably fat for the wedding. Dan has had quite a job persuading him (successfully) that it is not vital to their marital happiness.

None of this is surprising. Even people employed in relatively well paid jobs have no sense of food security. The bitterest arguments I’ve witnessed at work have been about food, for example allegations of ‘being greedy with milk’. I no longer take in biscuits because of the trouble it causes. Sugar and salt are taken to houses as presents in the same way I would take chocolates or flowers.

Exercise, particularly walking, is also regarded as a sign of poverty. If you have any money at all, you take a boda.

This can make giving health advice difficult. I do see people with high blood pressure or diabetes. Often they are overweight. My standard “Eat less and do more” advice is not only unwelcome (lets be honest; it often is in the UK too), but is sometimes insulting. I’ve had interpreters point blank refuse. “I can’t translate that. He is the big man in the village.”

Where is boss?

Life here for a middle aged feminist can occasionally be distinctly trying.

At the weekend I sometimes run the seven kilometres to my favourite pool for a swim. I needed to drop something off, so went via work. Kamoga, and excellent, earnest graduate nurse asked to speak with me ‘on an important matter’.

He started with “Do you mind me asking, how old are you?” I told him how old I was. “Oh! It’s even worse than I thought. You are older than my mother. You should not run. It is very dangerous. Do you not fear dying?”

I explained that where I come from I am not considered old. In fact, I am only half way, and it’s quite OK for people of my age to exercise. He looked doubtful. “I agree, you look strong. But you have become very old. It is time now for you to rest.”

As I set off to continue my run he waved me off, looking very sad.

On arrival at the pool I was greeted by the pool attendant. “Good morning Mrs Mark. How are you? Where is boss?”

Tuberculosis and poverty. Time for more donations please.

TB is one of the archetypal diseases of poverty. Malnutrition, poor and crowded housing and now of course the HIV pandemic increase the toll. 20% of the worlds population are infected. Half of Reachout’s HIV clients will at some point have active TB and half of the clients who die will die from TB. That’s approximately 50 deaths a year among our 2400 clients.

It’s also an archetypal disease of poverty because it is ignored by richer countries. Our primary diagnostic test is examination of sputum by microscopy invented in 1882 by Robert Koch. Our standard treatment regime requires 8 months of treatment with drugs that are now more than 50 years old.

Access to HIV treatment has leapfrogged care for TB. Half our clients are on antiretroviral agents (costing hundreds of dollars every year) that offer them the possibility of longterm control of HIV. Yet we don’t have the capacity to screen for TB or offer preventative treatment for it.

New culture techniques have been developed that dramatically improve our ability to diagnose TB at low cost (see MODS test at http://www.upch.edu.pe/facien/dbmbqf/mods/mods.htm). I want to help set up a TB lab at the International Hospital in Kampala that uses these new techniques and improves access to TB diagnosis, treatment and prevention. So if you have a centrifuge, an inverted light microscope, a vortex or just some cash please get in touch:

Mark299@gmail.com

The picture shows Mycobacterium Tuberculosis in culture using the MODS technique

Old men learning new skills

Another birthday and with it growing confirmation that things probably can't only get better. Learning to kayak constitutes this years refusal to relax the grip on youthfulness. The Nile is probably the most perfect place in the world to kayak. It's huge, beautiful, warm and studded with challenging rapids. Eight of the worlds top ten kayakers were training here in the weeks running up to the world championships. I'm struggling with it. I'm nervous and tense and so wobbly and easily flipped by the least demanding of waves. I just have to keep reminding myself why I'm doing it!!

Global Fund Fiasco

Yesterday’s Daily Monitor carried reports of an investigation by GAVI (The Global Alliance for Vaccines and Immunisation) detailing the misappropriation of Global Fund for Health money in Uganda in 2004/2005. Several requisitions for funding totalling about $500,000 came out of the President’s and his wife’s offices. This money was supposedly for immunisation and health promotion campaigns but hasn’t been accounted for.

There is a high tolerance of corrupt practices in Uganda (“It’s normal”), so it’s unlikely that there will be any consequences. Shame that the Queen is visiting and will shake his hand in October.......

VSO critique

My flight home is booked, so it's time to commit a few thoughts to paper before the resumption of normal life. First, I need to say that I have a longstanding admiration for VSO and the concept of facilitating skilled volunteers to work in low resource settings. My concern is that, for institutional reasons, VSO may be failing its volunteers and the development process.

Many VSO placements don't seem to work out. VSO tradition and predeparture training emphasise that this is often because the volunteer is insufficiently emotionally equipped for the rigor of working in a resource poor setting.

Our experience is more that many placements are problematic. The jobs are often poorly thought out and in organisations that have made little or no commitment to change and development.

VSO's attachment to the notion that volunteers should be "placed" rather than exercise choice over where they go, perpetuates this problem. I would change the system so that volunteers could choose their own placements from an advertised list. They would make their choice according to their own skills and experiences, their preparedness to engage with a challenge and feedback from previous volunteers. Good postings would be competed for by many applicants. Bad placements would fall rapidly by the wayside.

In-country offices seem to be overwhelmed by issues of policy development and planning. They have little time to attend to volunteer support and placement development. Strange for an old pinko to say but maybe its time to liberalise this particular market..........

Buying shoes

Mark needed new trainers. Playing tennis on a clay court wreaks havoc on your footwear, apparently. He hates shopping, anywhere. I find it quite entertaining in Uganda so volunteered to go. I headed for the ‘sportswear zone’ of central Kampala. My purchase went something like this;

Hello, how are you? I’m fine, how are you? I’m fine.

I’d like to buy some trainers in a size 43 for my husband.

These are a size 40, is that OK? No, they’ll be too small.

Then what about these, they are a size 46? No, they’ll be too big.

But not too too big? Yes, too too big.

Then what about these, they are size 43? No, they are pink and have ‘Fame’ in glitter on them, he won’t like them.

Yes, they are OK, they are size 43, you can buy these. No, he won’t wear them. Do you have any others in size 43?

Then what about these? Yes, these ones are good. Are they genuine or a Chinese copy?

No, (shocked) of course they are genuine, they are second hand! I don’t want second hand trainers.

But, madam, second hand is the best quality, genuine product, it’s best to buy second hand. I know, normally I agree with you, but not trainers. I want new ones.

I finally settled on a pair of black Nikes, size 43. Genuine (I think). New (ditto, although admittedly no box and only £18 - but they looked and smelled new).

Job done.

Financial crisis at Hope

Hope has hit the financial buffers. There won’t be enough money to pay salaries at the end of the month. Philip is quietly heartbroken. He started the clinic seven years ago with his wife and they have bankrolled it ever since. They have been in Kampala for eleven years and have reached that point where they go home soon, or stay here forever. So they go home next year. They want the clinic to be independent of them before they go. I have spent the last three months trying (gently and completely unsuccessfully) to explain why that won’t work. So this week I got tough. Laid out for Philip his choices, which are;

1. Continue to spend £12000 of his own money every year indefinitely. Plus much of his free time and emotional energy.

2. Sack two thirds of the staff, run a much more limited service and spend significantly less of his own money and time supporting the clinic.

3. Sell it to an entrepreneur, or give it to a big NGO (like MSF) and let them run it. If they’ll have it.

He (the accountant) keeps asking me how we can do the impossible and continue to provide an almost free service to people who need it and might die without it.

I (the doctor) keep showing him the figures and pointing out the awful reality he has to face up to. Bite the bullet or shut up shop.

He’s thinking about it over the weekend.

I’m wondering how NOT to spend the next three months rearranging the deckchairs on the Titanic....

Reachout Catchup

I’m now half way through my placement at Reachout and enjoying it. Its whole philosophy is heart-warming (laying aside the contradictions of our conservative catholic condom averse sponsors). A parish project borne out of the effort of a group of volunteers and now providing income to hundreds and care to thousands of HIV positive clients.

I also love many of the characters here. The noble and wise and gentle Father Joseph. Our dynamic,hotheaded director, Stella. The manic and highly skilled Dr Charles. And many others....It’s a busy, busy place with a constant stream of visitors, but it’s easy to impress them with what’s being done.

I’m learning lots about TB and HIV when I’m not reluctantly sidelined into organisational management stuff. This week we’ve been interviewing for all the senior management positions in the organisation. This is part of a broad restructuring process to better equip us now that we’ve grown so huge. It’s an uncompromising process. Existing postholders are having to compete for their own jobs. Many will be unsuccessful. I’m often impressed by the calibre of the people I’m meeting and my hopes for the future here brighten somewhat.

Father Joseph is understandably ambivalent. We are transforming ourselves. A very low cost community organisation that arose out of a spirit of volunteerism will become yet another professionalised NGO in the two tier economy of Uganda (NGOs vs the rest). Our senior financial officer currently earns $150 a month. The new financial manager will be offered 10x more.....

Translation

Says........................................... Means.....

You slope...................................Go downhill

Extend.......................................Move up

Branch (right)...........................Turn (right)

I am not picking you............... I can’t understand a thing you’re saying

You are welcome......................Not much

Yes please.................................No thank you

I love you..................................Please give me money

Hey, mzungu, we go?...............Would you like to get on the back of my motorbike, the brakes don’t work, there’s no helmet, I’m 15 years old and possibly drunk

It is my best price....................It’s probably twice what it should be but, hey, it’s still only 15p

You mean now now?...............You seriously expect me to do it this week?

It can work...............................Not a bad idea

It will work...............................Not a bad idea, are you going to do it?

Are you saved?........................Can I talk to you for the next 30 minutes about Jesus and abstinence?

I have malaria.........................I’ve been feeling slightly unwell for the last couple of hours, please give me some of your finest toxic drugs. No, I don’t need a blood test, I just know it’s malaria.

Extraordinary people

Last week Sarah showed me one of her babies. She had delivered her exactly a year ago in the clinic. Later, I asked Sarah if many of the children she had delivered were brought to see her. She answered yes, but that this one was special. Her mother had been young, alone and ‘disappointed’ to find herself pregnant. So Sarah helps. She visits 3-4 times a week, gives her money when she can, and acts as a second mother to the child. I told her she was amazing. “No! I am responsible for her. What else should I do?” I asked her how many other babies she supports like this and she smiled, shook her head at me and got on with her work.

Yesterday I bought a fridge. I got chatting to the Ugandan Asian businessman who sold it to me. He had fled Uganda as a teenager in the Amin years and settled in Manchester. He returned to Uganda for the first time in 1990. He found a terrible mess. Shocked and desperate to help he decided to help an orphanage. He bought beds, mattresses, sheets, doors, iron sheets for the roof and was happy with his success. When he returned to the orphanage four months later everything had been sold. So he decided he’d have to start his own orphanage, and he did. He fund raised, found some land and built it. The model he describes sounds like a good one. There is a ‘mother’ to every 8 children. She sleeps with them, feeds and dresses them and now takes them to school (also built by him). He gets legal guardianship of the children through the court otherwise when they reach 5 or so and can work someone turns up to claim them. He told me of one eight month old baby brought to him at 1am by two policemen who had heard her crying and had found her in a skip. She’s now a thriving seven year old. He called her Stella.

Mabira Forest and popular democracy

Mabira is a 21,000 hectare tropical forest reserve an hour outside Kampala on the way to Jinja.

In one of his frequent and increasingly out of touch acts of autocracy President Museveni has decided it would be good for the economy to give (yes give) a third of the forest to the Mehta family’s sugar corporation. The trees will be felled at a profit to the corporation of an estimated $500m and then sugar cane will be planted for sugar production.

The issue is a good barometer of the political times in Uganda. The opposition is disorganised and silent. Some of the press is encouragingly vocal in its opposition. Most impressively there is a shared discomfiture about the whole thing. Sms text and web based campaigns of opposition are attracting attention. There is a widely held conviction that Museveni is wrong, has completely lost his populist touch (and is thus time expired) and is profiting personally from the deal (at the very least in terms of campaign fund contributions).

Unfortunately last weeks demonstration against the give away degenerated into violence with some anti – Indian attacks (and some very racist sentiments harking back to Amin’s expulsion of the Asian community) and 3 deaths. There is a perennial fear that Museveni will use demonstrations of political opposition to sanction military and police violence against any form of opposition……

Simplicity

There are many dramatic contrasts between life here and life in England.
As a spoilt rich kid from the affluent North, I find the simplicity and lack of choice here refreshing. Abundant, seasonal, locally grown, organic fruit and vegetables are available from every street corner stall. No processed food (well, there’s tinned tuna…); One brand of margarine (blue band); three cleaning options (vim, omo and bleach). The ubiquitous solid, single geared bicycle, too heavy to ride uphill but very sturdy and with parts and someone who can fix it also on every street corner. Nothing is ever terminally broken. Our ten year old (utterly wonderful) Rav 4 is a Japanese import – presumably shipped here because no one there wants a ten year old car – and is regarded here as ‘new’. A dreadfully rickety chest of drawers at work, not nice when it was new I’m sure, and now with two and a half functioning drawers and a significant amount of termite damage, looked to me to be destined for firewood. Grace, the midwife beamed at me, delighted and disbelieving that she could actually have it for her delivery room. “I can keep all my things in it. Thank you. Are you sure?”

Mark at Reachout

Mbuya Reachout is an exciting and innovative community HIV programme providing medical and social support to 2400 HIV positive clients and their families in a suburb of Kampala. Reachout also runs a training programme for health workers working in the field of HIV.

Reachout’s work is rooted in the community and in particular in the community of people living with HIV / AIDS. The programme models principles of participation and the importance of providing social and psychological support as well as high quality health care. Continuing medical education, case discussions and positive attention to team working with the support of community volunteers are priorities.

The organisation has grown rapidly since start up in 2000 and now employs 230, many of whom are HIV positive. There is weakness in middle management and there is a lack of robustness in its accounting, procurement and stock keeping systems. Dr Stella is instituting a process of organisational review and restructuring over the coming months.

My work plan over the remaining few months will include:

1. Providing medical support to the outpatient clinic and liaising with Hope Ward, IHK which provides us with inpatient facilities.
2. Teaching the trainees on the HIV care programme.
3. Conducting a survey of Reachout clients. This will yield information about family and household structure, the spread of access to Reachout’s social care programme, the prevalence of use of mosquito nets and establish any history of recent household contact with TB.
4. Working with the pharmacy and stores to develop robust record keeping and ordering systems. to avoid out stocking and reduce vulnerability to theft.
5. Assisting Reachout in improving its tuberculosis diagnostic and treatment capabilities. Half our clients will have TB at some point. Half of those who die will die from TB. In particular we should; improve clinicians’ adherence to treatment algorithms, improve X-ray interpreting skills, increase the yield from microscopy, explore the use of sputum culture, consider isoniazid prophylaxis, determine the prevalence of MDR TB.
6. Assisting Reachout in improving its customer care. Attitudes to customers in Uganda as a whole are negative. Patients are expected to wait for many hours and to make unnecessary repeat visits because of system inefficiencies.

mark.russell@ciospct.cornwall.nhs.uk

Jan at Hope

I’m four weeks into my time at Hope Clinic. I’m very aware of not having written about it, but am struggling to know quite what to say. It’s ‘somehow OK’.

Hope is a not-for-profit primary care clinic in a poor suburb of Kampala. Health care mapping here is hopeless and as a result there’s no government provision at all in this valley. Primary care in Uganda is different from the UK. The clinic has an outpatient area (2 rooms), laboratory, dispensary, 10 beds for inpatients and two labour rooms. There are user fees, but they nowhere near cover the cost of running the clinic.

A UK accountant who has lived here for a decade set up the clinic a few years ago, and it moved to new premises last year. The clinic has grown faster than it has been able to cope with and they asked VSO for some medical and management input.

Enter the queen of the protocol.

It’s work I can do, and I know they need. It’s a worthy cause. It’s a perfect VSO placement and it’s exactly what ‘development’ is about.

My ambivalence, I’ve decided, is pure selfishness. I loved the buzz of Ishaka, the challenge I faced every day, not having a clue what I was doing most of the time. I was learning at a phenomenal rate. It too was exactly what development should be about.

I know which I’ll choose next time…

Lonely Hearts

Lonely hearts columns here are a hoot. They are in most of the daily papers and are abundant in the Sundays. My favourite was;

“Unemployed HIV positive taxi driver seeks white woman for love and financial assistance.”

Endearingly honest but I can’t imagine he was inundated with replies.

The reality here is that a relationship with a mzungu is a passport to wealth. Being middle aged (and therefore fairly obviously past providing anyone with the mzungu baby they so strongly desire) I’m relatively protected, except for the questions about whether I have a sister they might be able to marry. Most of my female friends here are much younger and are pestered terribly. Offers of marriage are plentiful, even for those already wed, “It’s OK, I can be your African husband”. Petra has clocked up the most proposals (and propositions) of anyone I’ve ever met. She has lost count, but literally dozens, and she tells me thirty good ones, including two brothers who told her they were happy to share. The best prospect offered 300 cows for her hand in marriage, although she never saw the colour of his money…..(Petra is in the picture... Murchison Falls in the background.)

Jack and Jill went up the what?

We are all a product of our personal and cultural histories and our education. Uganda has had a very troubled history and is still in considerable difficulty politically, (the judges are currently on strike after outrageous judicial interference by the President). A large chunk of the population has no access to clean water, education or health care and don’t know where the food or fuel to cook it will come from for today’s meal. So it’s really not surprising that it seems hard for Ugandans to think further than today.

The education system contributes to the problem, effectively stifling any initiative shown by pupils. Class sizes are huge, often over 100. Textbooks and materials are scarce so lessons are taught by rote. The teacher will as a question and the class will answer together. Jack and Jill went up the what? Jack and Jill went up the hill. To fetch a pail of what? To fetch a pail of water. And so on. This phrasing is almost universal in Ugandan language, with people asking and then answering their own questions. And then I went to the what? I went to the hospital. To have a what? To have a blood test….Confusing for the newcomer to the country and very stunting for the developing mind. A teacher friend here was sitting in on a class recently when a teacher asked a question. A child put his hand up to answer and started his answer with “I think…”. The teacher stopped him, saying “I don’t want to know what you think; I want you to repeat what I just told you.”

Last week at my clinic I requested a blood slide to see if the child had malaria. The lab technician is a bright, graduate lab technologist who seems full of ideas and enthusiasm. He told me he couldn’t do the test as the power was off so his microscope wouldn’t work. The clinic has an inverter and batteries to store electricity when it’s on for use when it’s off. I asked about the inverter. He said it didn’t seem to be working. I asked why not. He said he didn’t know, but the battery was flat. I asked if he’d called someone to fix it. He said he didn’t have their number. I asked him if he could get it. He said OK. I asked him if he’d moved the reagents into the gas fridge so they wouldn’t get spoilt. He said no.

I can’t see any of this changing here until there is genuine democracy, food security and an education system that values and rewards initiative and creativity….

Wangye

Wangye is the second most common word I hear after “Hey, muzungu!”. And after 6 months I’m still not entirely sure what it means. Literally, it translates as “my/mine”, as in “my child(omwana wangye)”. But it seems to be a multipurpose word, used as pardon? or hello?(answering a telephone) or yes or I accept(as in “I accept what you say, don’t necessarily agree with you, don’t have any intention of doing whatever it is you have suggested but am far too polite to tell you any of this.”) One little word. Wangye.

There is also the “Ugandan shrug”. No, it’s not a dance. It’s a barely perceptible lift of the eyebrows. At first I mistook it for a restrained version of the “UK shrug” (exaggerated exasperation and huff accompanied by a bilateral eyebrow lift). But it’s not. It’s “wangye”. After an intense period of bartering over 2 large plastic buckets and 2 even larger plastic bowls (for the clinic – don’t ask) we settled on 21,000Ush. I paid the money and staggered away with my wares, only then realising that I had sealed the deal with a Ugandan shrug.

These are a few of my favourite things….

Things I brought to Uganda and have never needed;
Seeds – we’ve moved so often they wouldn’t have a chance to germinate.
Drugs (one large carrier bag full) – there’s a drug shop on every street corner where you can buy anything you might possibly need without a prescription for less than 30p.
A years supply of tampons – you can buy them in Kampala (if not anywhere else)
3 warm jumpers and a pair of fleece gloves – what was I thinking?
VSO participatory methods handbook – ditto.
A sharp knife – obviously, these are available. This is Uganda home of the overused panga.
Things I wouldn’t be without;
The laptop - which provides hours of entertainment and information (and frustration when connection speeds are dire) for both of us.

My pillow – I’m a sad, middle aged woman and I love my pillow. I even took it up Mount Elgon (carried by a porter of course).
My tin opener – being a leftie I find it hard to get things like this to work and we like the occasional tuna mayo on toast.
My head torch – it’s an ‘off day’ (power sharing) so I’m writing this by torchlight.
Sara’s lovely flip flops – I wear them all day, every day, except when I’m in bed (Sara -thank you, thank you).
Gel roller ball pens – they write so well (forget computer held records here) and are useful currency when stuck. Most common compliment I receive – you have beautiful pens.
Medicine in Africa – weight 5kg, brought in as hand luggage, pretending it was light. Worth every gram.
Thing I wish I’d known I’d need;
Teabags – why did I think a tea producing nation would be able to make a decent cuppa?
More gel roller pens – see above (stock running low).
A second laptop – we fight. There’s not a lot to do in the evenings.
More than 2 CD’s – our car has a plug in CD player and if I hold it at the right angle we don't miss a beat as we negotiate the potholes.

Touchy Feely Nirvana

Finally after 20 years of searching I’m working somewhere that begins each day with a group singsong and some gentle stretches. Mbuya Reachout was the inspitation of the Italian catholic parish priest Father Joseph and a doctor Margrethe Juncker in 2001. Since then it has grown into a massive enterprise based entirely within the poor Kampala parish of Mbuya. It now employs 234 and looks after 2300 people living with HIV / AIDs and their families.
The remarkable thing about it is its community focus. Counsellors and support workers are recruited from the local area (and are often HIV positive themselves) and work on education programmes in local schools and community centres to encourage testing and to break down the stigma around HIV. Each worker provides moral and practical support to his / her HIV infected neighbours. Within the project there is a literacy programme, a school fees programme, a food programme, a tailoring workshop providing much needed work and income and a loan scheme for small business start ups. The medical programme is supplementary to all this and works on the premise that without food, financial support and hope, medical care alone is insufficient. The clinics are run by specialist nurses and nurses attached to Mbuya on a 6 month HIV training course. I will be one of 4 medical officers supporting the nursing team in the clinics (there are 3 clinics in the parish) and am already learning loads!!
M

Laura

We never knew Laura. Angela came into our lives on Sunday picked up from the road side by some of our friends. Her friend Laura was one of 4 passengers killed instantly when their bus was hit by a lorry on the way back to Kampala from seeing the gorillas in Bwindi. Both were medical students from UCH spending their electives at the mission hospital in Kisizi. These devastating accidents are everyday news here. Potholed roads, poorly serviced vehicles and dangerous driving contribute to a disproportionately high death toll on the roads.
We were glad to meet and get to know Angela and her mum Brida. They returned to the UK today. We hope Angela gets through the next few difficult months OK. Our thoughts are with Laura’s parents and friends.

VSO CONFERENCE

We have just had a very successful Uganda VSO conference weekend in the luxury of the Jinja Nile resort. It was a good opportunity to air all our whinges about VSO (poor VSO I do love them really!).

The local volunteer committee will continue to pressure for:

1. A protocol at VSO Uganda office for how to deal promptly with volunteer allegations of fraud in their placement organisation.

2. A protocol to act promptly and sensitively when a volunteer complains that their placement isn't working out (whether thats because of the volunteer or because its a crap placement cos there are many of those!).

3. Better communication and information systems within VSO to enhance volunteer support and experience.

We had delegates present who had attended conferences 1,2 and 7 years ago who said the same angry complaints are made every year and no progress made!!....

WE HAVE MOVED

Home now is this comfortable bungalow in a small compound of 4. It’s a little muzungu enclave so we’re surrounded by friendly young brits working in schools or with aid organisations. The compound is in a dirt road suburb in the south of the city a walk from Jan’s health centre and a car commute from mine. For comparison with previous accommodation (score out of 5)
Disco induced building shaking sleep disturbance Kampala 0 Ishaka 4 Mbarara 2
Truck noise sleep disturbance Kla 0 Ishaka 1 Mbarara 5
Howling dog sleep disturbance Kla 3. Ishaka 4 Mbarara 5 (there aint no escape from this one!)
Though we did have a bed shaking earthquake in the early hours of this morning….

Recommendations for development at Ishaka Hospital

Feedback to Ishaka Adventist Hospital

The hospital is a friendly and welcoming place to work. We have enjoyed our short time here enormously, have learned a great deal and are sad to be leaving. We hope this feedback will be useful.

Facilities
The hospital facilities are adequate and will improve when the new outpatient department opens. The wards are clean and tidy. Access to diagnostic tests and medicines is adequate.
Staffing levels with the exception of the female and paediatric ward also seem adequate. The calibre of staff is good.
The nurse training school and laboratory technicians school are a positive presence within the Hospital.

Vocational commitment and Morning Prayers
The principles of the Adventist Mission underpin a positive approach to healthcare work. Morning Prayers are an upbeat start to the day and provide a forum for announcements. They encourage punctuality and should run to time finishing at 8.30 prompt.

Clinical Officers
The clinical officers are bright, reliable and conscientious. The hospital suffers for lack of a generalist physician to provide leadership and guidance for them in the outpatient department and on the wards. Without that guidance their practice will become increasingly idiosyncratic.
The Clinical Officers do not adhere closely enough to the sound and sensible advice of the Uganda Clinical Guidelines. They perform many unnecessary investigations. They over-prescribe medication causing unnecessary cost to the patients and exposing them to unnecessary and potentially dangerous adverse drug reactions. They are not used to working to protocols and tend to ignore them even when they are present and very clear. They should be frequently reminded of and urged to follow protocols and the Uganda Clinical Guidelines.

The Clinical Officers should meet every week with one of the Medical Officers for Continuing Medical Education (CME) and to discuss best practice for common conditions. The Clinical Officers should be encouraged to write brief, relevant and legible notes. Patient care would be best served if one clinical officer was attached to the wards for a week at a time.
We are actively seeking a replacement for us and would suggest to the hospital that they make this a financial priority.

Wards
The wards are clean, and not overcrowded. The semi-private ward is the much less busy of the two wards, yet they seem to have similar staffing levels. The women’s and children’s ward is in reality two wards and is dangerously understaffed. Through no fault of the staff this results in children dying needlessly. This needs to be addressed as a priority.
The staff do a handover between shifts and there is a ward book in which decisions and orders from the ward round are written. However, these decisions are not always acted upon. This system needs to be reviewed and improved if possible.
There are no protocols in place. We suggest protocols are introduced and adhered to in at least the following areas
Routine weighing and measuring of children under 5 on accurate scales
Routine voluntary HIV counselling and testing on all admissions
The management of unconscious patients
The management of shock
Fluid balance charts, orders for BP checks
The management of anaphylaxis and transfusion reactions
Blood transfusion chart
Removal of cannulae after IV drugs administration has stopped
Nasogastric tube positioning needs to be checked on each occasion by listening for air in the stomach. At present the ward has no stethoscope to do this.
Although already very busy, we believe matron should prioritise participation in the rounds at least once a week.
There should be access to clean drinking water on the wards for patients. Mosquito nets should be provided, at least on all the children’s beds.

Outpatients
Outpatients runs efficiently and waiting times are reasonable. We have introduced some simple protocols for management of common conditions. These should be kept up to date and added to over time.
The scales are inaccurate and need to be replaced. The department needs scales for weighing children less than 10kg. There are height measures but they are broken and need to be repaired or replaced.
It is unavoidable that people are sometimes waiting for hours, for investigation results for example. There should be access to clean drinking water in the department.
The staff in outpatients need customer care training; they should see patients attending as valued customers who they want to encourage to return.

Laboratory
There are an unacceptably large number of problems with lost specimens, inaccurate labelling and samples being collected in the wrong containers. This causes friction between the wards and the laboratory and teamwork between the lab and the wards is poor. Turn round of the tests and communication of the results to the ward is slow, and this has resulted in at least one death whilst we have been here. There is no system in place for monitoring or ordering of stock, so the lab runs out of reagents and cannot offer testing. Whilst we have been here the lab has run out of reagents for TPHA, FBC, HIV testing (first determine and then unigold) and CD4.
Stock control and ordering procedures are clearly inadequate and need to be improved as a matter of priority. We are often without blood for at least 24 hours before the stock is refreshed. The protocol for blood transfusion does not adhere to the Uganda Clinical Guidelines and this may contribute to the problem of running out of blood.
The laboratory continues to perform tests which are outdated and clinically unhelpful, despite the knowledge that the test is pointless. An example is the Widal Test. The senior staff are aware that the test has no merit, yet continue to order and perform the test, leading to inaccurate diagnosis and treatment of typhoid. They should participate in the CME sessions and pass on their knowledge, to alter clinical practice.
We suggest that the lab staff attend the wards on a daily basis and draw the bloods for testing or train the ward staff on a regular basis. This will ensure correct labelling and container use and we believe will improve communication between these departments.
In our opinion Sunday should be a normal working day. The laboratory staff are reluctant to perform tests on Sundays.

HIV service
The HIV service is relatively new and has great potential. However, the standard of service currently being provided is unacceptably low. HIV testing is rarely available on Fridays and not at all on Saturdays and Sundays. This means that for nearly half the week there is no testing at all. On other days there have been no counsellors and out-stocking of testing kits has been a continual problem. We estimate that testing has actually been available for less than 25% of the time in the 6 weeks we have spent here. All permanent lab staff should perform HIV testing and CD4 counts. It is a mistake for this to remain the preserve of only Duncan and occasionally Vicent. The consequence of a delayed diagnosis of HIV is often fatal when many patients are reluctant to come back to test.
Duncan’s performance as the in charge of HIV testing needs to improve dramatically otherwise the job should be given to someone else. The CD4 machine is capable of giving CD4 percentages, vital in the management of children, but the machine has not been calibrated and the staff member responsible has not arranged for this to happen despite requests.
The service should be redesigned, with a system introduced for timely ordering of test kits and CD4 reagents. Different and more reliable staff should be allocated to this vital area if necessary and sensitisation work undertaken with all staff members and students.
The clinical department suffers for lack of protocols. Starting people on ARVs is often unnecessarily delayed. Liaison with the wards and monitoring of inpatients with HIV/AIDS does not happen, and inpatients are only rarely started on ARV’s.
There remains some uneasiness and stigma amongst ward and outpatient staff about talking to patients about HIV and testing. There is a need for some training for the entire staff here and the HIV department should take the lead on this.

Drugs
Drugs and supplies are generally available, and easily on hand. The pharmacy is efficient and works well. Outstocking should not be tolerated and can be avoided by the introduction of a weekly stock check and never allowing stock on any item to fall below one months maximum usage before reordering. A simple Excel spreadsheet would make this task straightforward. We have placed an example on the computer in the records office which you are welcome to amend and use. The drug stock list needs to be updated to include;
W1050 Salbutamol inhalers
T0014 Aciclovir tablets 200mg
I0138 Cloxacillin 500mg IV vials
W0078 Aqueous cream
R1497 Soft paraffin
W0281 Clotrimazole pessaries
Something for prostatic hypertrophy (doxazosin, prazosin)
W1080 Silver nitrate cautery sticks
W0940 Podophylline solution
T1260 Spironolactone 25mg tabs
W0775 Oramorph solution
R0677 Gentian violet 25g
W0848 Paracetamol 250mg suppositories

Charges
Staff and patients are unaware of the charges in operation in the hospital. The clinical officers need to know the cost of items they prescribe, and charges for supplies and other items. Patients are often anxious about the size of their bills and this affects their decisions to discharge, sometimes earlier than we would recommend. We suggest price lists are displayed prominently on wards and in outpatients and given to clinical officers. Over prescription of intravenous fluids and intravenous drugs can dramatically increase costs.
For as long as the hospital service is so dependent on user charges for income the poorest and sickest members of the community will be discriminated against. Witness the lack of a feeding programme for malnourished children.
The hospital must look elsewhere for income if it is to discharge its obligations to the most needy members of the community.

Continuing education
The presence of the nursing school and laboratory training school is a great asset for the hospital. There is a clear desire to learn from nearly all staff, both those in training and qualified staff members. Regular evening weekly training sessions which are open to all should be introduced and we believe would be popular.

Income generation and investment
The hospital should work closely with VSO and other organisations to explore creative ways to generate income. Presently the hospital operates financially on a hand to mouth basis. There is an atmosphere of continual crisis within management. The service to patients suffers through an unacceptable toleration of out-stocking and no flexibility with charging to the poorest and sickest patients (e.g. malnourished babies).
The danger of underinvestment is worsening of patient services and falling staff morale and commitment. This will threaten the viability of IAH when KIU Hospital is fully operational.
Serious attempts should be made to generate income. The local health insurance plan needs to be reviewed. The cost and quality of private care offered should be increased (whilst maintaining a cheap and efficient service to the majority). Vehicles and facilities should be hired out. More attention should be paid to fundraising in the local and wider community.
The hospital needs a full time fundraiser skilled at negotiating for funds with the District, NGOs and international charities. Such a person should be able to generate an additional income of $50,000 pa. VSO may be able to help with such an appointment.
The hospital and church should use its land holdings to build houses for rent in the booming local market. This would provide long term income.
The hospital could advertise more extensively for medical student and other health professionals to visit from affluent countries and impose higher charges for use of the guest house and transport from and to Entebbe.

Priority areas of review
Increase staffing level on the female and paediatric ward.
Explore innovative fundraising possibilities to create more financial security.
Canvas VSO and other organisations to provide key personnel to develop the clinical service and generate funds for investment in the service.
Provide some staff training on high quality customer care. IAH will need to provide an excellent service if it is to compete with KIU.
Overhaul the HIV service to guarantee good service on 6 days of every week.
Protocols and guidelines to be established and adhered to for all common conditions
Weekly staff education sessions
Stock checking and ordering system put in place to ensure that there are no stockouts of essential items. Outstocking should be regarded as a disciplinary offence.


Jan Power, Mark Russell
February 2007