INSECT REPELLENTS

We’re running low on insect repellent. This is a problem. I’ve waxed lyrical about Uganda having the perfect climate. And, believe me, it does. It’s also perfect for mosquito’s, safari ants and, more worryingly, tsetse flies. All of which pack a powerful punch. Tsetse can even get you through jeans. We’ve used up the supply of insect repellent we brought from the UK and have only, so far, found more in muzungu supermarkets in Kampala. My particular favourite is OFF!, which is fragrance free and repels absolutely everything. It stings a bit when you put it on, mind, but with 15% deet what else can you expect? Sadly, we finished that last week after a particularly savage attack in Queen Elizabeth National Park, which left us both with over 100 bites and itching like mad all night even after taking piriton. So now we’re down to Citronella. It smells nice and smarts when you put it on but, frankly, it isn’t up to the job. Mark bought some insect spray (DOOM!) which he uses to keep the ants out of the house. And we’ve got mosquito coils (TOX!). After some intensive research on the internet M concluded that they were only ‘a bit OK’ (aside – local vernacular – things or people can be described, in descending order as – fine, somehow OK, a bit OK, fair, somehow fair, a bit fair, not fair).
So now we only use them when we’re not in the room. I’m not sure there’s a scientific basis for this strategy. We move to Kampala in three weeks. I know what my first purchase will be…..

Begging letter

To all our friends and family,
We’ve been in Africa for 4 months today. It’s about time for another begging letter…. so here goes.
We are working at a hospital in the remote rural community of Ishaka. At any time we have 4 or 5 children on the ward with severe malnutrition. They are all under 5 years old, some are babies as young as 6 months. Some are HIV positive, some are just unlucky enough to be born to very, very poor families. Without proper treatment half of these children are currently dying.
This situation is particularly uncomfortable for us. In the UK we treat patients for free, often for illnesses which arise from excess (smoking, drinking, eating). In Uganda we have to charge the poor for treatment of the diseases of poverty. The charges are low by UK standards, but are simply unaffordable to most Ugandans. More than 50% of the population live on less than $1 a day here. So parents often take their children home before they are better tosave money.
Ideally, we would like the children to stay in hospital for a week, to be fed with high energy milk and be given vitamin supplements, immunisations and antibiotics. This costs £10 and reduces the mortality rate to less than 10%. We would also like to send them home with a mosquito net, a bag of high energy soya and some multivitamins. This would cost another £3.50.
We are setting up a trust fund at the hospital. It would cover the cost of this treatment so that when malnourished children are admitted they are offered the full weeks treatment package for free. The hospital is corruption free and the treasurer would give us regular accounts of how the money is spent. We can continue to deposit money into the trust fund after leaving.
Will you help us do this? Please email me if you feel you can. Thanks.
jan.power@rosmellyn.cornwall.nhs.uk

Bridesmaids Dresses

Gender can be tricky here. Children are often dressed in what can only be described as bridesmaids dresses. They’re beautiful. Ivory or pink satin, chiffon and lots of bows. My guess is they start as ‘Sunday Best’ and as they get tatty or outgrown are worn all the time. Worn by whomever they fit best, although I admit I’ve never seen one on a boy above 2 or 3. In Runyankore she and he are not differentiated, so no clues there either. Names? Well, sometimes helpful but not always. Robert – always male (so far), Annet (ditto female). But its not always that obvious. Polly was male, as was Pauline. And Johnson was female. And some names give no clues at all. Immaculate, Chance, Admire and Generous, I’m just left guessing…..

Ka Wareba

“Ka wareba” means “I’m sorry for your troubles”. It’s used when people die or when you’re breaking really bad news. I’d just seen a woman with a threatened miscarriage in outpatients, to be told by Jeffrey the medical student sitting in with me that in those circumstances ka wareba would not be appropriate. Its use would imply that the situation is hopeless and that the baby was already dead. He explained that it used to be said when people were diagnosed with HIV (here the disease is called ‘silimu’ because of the weight loss associated with AIDS) but that now ka wareba is no longer appropriate. With routine prophylaxis for opportunistic infections, and with ARV treatment people can live a healthy and positive life after diagnosis. It seems to be perfectly OK to ask people if they’ve had syphilis, or been treated for it recently. Syphilis is startlingly common and probably even overdiagnosed. I don’t bat an eyelid asking anyone about it, mothers about whether their children have been tested, priests etc. They expect to be asked and don’t mind being tested at all, or so it seems. It’s not unusual for someone to have tested positive for syphilis or gonorrhoea but not even thought about HIV testing. However, as soon as I follow up the syphilis question with the inevitable (to me) question about HIV testing, the staff roll their eyes and look embarrassed, and the patient shifts about uncomfortably as though I’ve committed a terrible faux pas and accused them of loose morals. Many people diagnosed still don’t disclose their condition to friends or family. There’s clearly a stigma and an understandable fear attached to the diagnosis.
Despite the church and politicians banging on all the time about abstinence, sex is everywhere here. Family planning is rarely used, large families are the norm, infidelity is common and polygamy is not unusual. Two days ago I saw a prepubertal 12 year old boy with full blown gonorrhoea. I’ve seen 2 people this week who have waited until they are dangerously ill with AIDS before coming for testing and treatment.
With our everyday experiences we’re still not really sure how Uganda has achieved its remarkably low HIV prevalence of about 6% (down from around 30% in the early 90s). There are plenty of billboards everywhere encouraging testing and access to ARVs is improving all the time. Unlike in many other African countries at least there has been a political will from the outset not to ignore or, worse still, to deny the crisis. Health education has focused on the ABC programme of Abstinence, Be faithful and use Condoms.

Last Friday 10 prisoners from the local jail pitched up to outpatients in their stripey yellow pyjamas and chains. 9 of them had syphilis so we are trying to get a team of 30 healthworkers together to go into the prison on the 9th feb to screen all 528 for syphilis and hiv......
The pictures are of the outpatient department at Ishaka Hospital, and snaps from the local Queen Elizabeth gamepark (half an hour and a wonderful drive down into the rift valley away) of a colobus monkey and a kob probably the most ubiquitous of the antelopes around here.

Mpangos and porters

Whilst walking up Mount Elgon there was plenty of time to think. Strange juxtaposition of lives. We were paying our porters £2.50 a day to carry our heavy rucksacks (sometimes on their heads), fetch water for us, wash up our things, and (so I was reassured) carry us back down the mountain in the event of us injuring ourselves. I felt a mixture of emotions. Guilt, obviously. Yet they were delighted to have the work. And our guide was going to get his first Christmas day off in 8 years as we were coming down Christmas Eve and he would have to spend Christmas Day ‘washing his uniform’. Any food we left over they promptly ate. And of course there was the opportunity, never to be missed by a Ugandan, to talk politics.
Sitting round a bonfire one night at 3500m with 15 young Ugandan men was a privilege (we were sharing the tin shack with a party of 11 path clearers). They were faultlessly polite and helpful. They dried our wet clothes, made us tea, cooked our strange food for us (rice and a packet curry – not bad actually). From black carrier bags they’d carried up the mountain they produced dried beans, onions, dodo (a sort of small leafed spinach), a cabbage, three tomatoes, curry powder and ghee, and proceeded to cook a nutritious meal from scratch.
In the countryside if you pass a male older than 3 they will be carrying a machete (mpango / panga). It’s a multipurpose tool. I was reminded of the Rosmellyn awayday where we had to think of as many things as possible to do with an item from our handbags. (for those of you who were there, remember the credit card – to remind yourself of your name, guess the number on long car journeys, for self defence, go for the throat…)

Things I have seen one used for.
to chop wood
to cut a walking stick
to hack yourself a path through dense vegetation
as a strimmer
as a lawnmower
to finely shred cabbage/dice an onion
as a toaster
as a walking stick
as a poker
as a chisel (furniture making)
as a plane (furniture making)
unfortunately as a weapon. We all know about the horrific events in Rwanda in 1994 when many of the 800,000 killed were butchered with machetes. One of my first mornings here on the ward in Ishaka was spent trying to sort out a 12 year old who had been attacked with a machete by her 16 year old brother and badly wounded. It had happened 12 hours earlier, no-one seemed to know why. He was in police custody but she had had to wait until daybreak, when her stepmother persuaded the village elder to bring her to the hospital (no-one had any money). She was badly injured, cold, and terrified. We had no blood for transfusion, so after resuscitating her, cleaning her up and assessing her wounds we packed her off to Mbarara (in a taxi!) in the vain hope that she might see an orthopaedic surgeon who may be able to save her right hand….

Living with Matoke

We packed up and left Mbarara yesterday having to hire a pick-up to move just 3 months worth of accumulated "stuff". Our new home is a bungalow within the Ishaka Hospital compound with magnificent views towards distant hills and the sunset in the west. The Hospital compound occupies an entire hill with the accommodation at the crest and the wards, outpatient department, nursing school and lab technician training school lower down. There is a bustling trading centre outside the gates and a private university with attached brand new teaching hospital being constructed down the road. Our responsibilities for the next couple of months are to look after the medical wards and the outpatient department, and we'll be supported by two Philippino Missionary doctors , one an obstetrician, the other a general surgeon.

Our garden is a permacultural feast with papayas, avocados, and matoke trees. Matokes are the plantains that have been the staple carbohydrate in Uganda for the last 2000 years. Perennial, low maintenance, high calorie and easy to cook they are the ideal food crop and the whole of south-west Uganda is a patchwork of homesteads with attendant Matoke plantations. We have 2 big bunches almost ready to harvest.......