Mark and Jan in Uganda

Final episode

2007-10-09T22:31:00.000-07:00

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

2007-09-10T00:59:00.000-07:00

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

2007-07-30T10:23:00.000-07:00

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

2007-07-24T22:23:00.000-07:00

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

2007-07-15T08:16:00.000-07:00

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

2007-07-02T21:30:00.000-07:00

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

2007-07-01T22:14:00.000-07:00

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

2007-07-01T22:06:00.000-07:00

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

2007-06-20T00:42:00.000-07:00

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

2007-06-15T23:49:00.000-07:00

Reasons

Ten reasons I love Uganda

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

Ten reasons I hate Uganda

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

2007-06-10T21:56:00.000-07:00

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

2007-05-30T10:56:00.005-07:00

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

2007-05-30T07:10:00.000-07:00

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

2007-05-26T20:57:00.000-07:00

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?

2007-05-26T20:43:00.000-07:00

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.

2007-05-19T11:48:00.000-07:00

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

2007-05-19T10:40:00.000-07:00

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

2007-05-15T20:26:00.000-07:00

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

2007-05-14T11:46:00.000-07:00

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

2007-05-06T21:07:00.000-07:00

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

2007-05-06T21:00:00.000-07:00

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

2007-05-04T10:46:00.000-07:00

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.....

2007-05-02T11:51:00.000-07:00

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

2007-04-22T10:09:00.000-07:00

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

2007-04-15T04:15:00.000-07:00

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

2007-04-07T09:27:00.000-07:00

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

2007-04-05T20:53:00.000-07:00

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:

Providing medical support to the outpatient clinic and liaising with Hope Ward, IHK which provides us with inpatient facilities.
Teaching the trainees on the HIV care programme.
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.
Working with the pharmacy and stores to develop robust record keeping and ordering systems. to avoid out stocking and reduce vulnerability to theft.
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.
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

2007-04-01T06:40:00.000-07:00

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

2007-03-31T12:35:00.000-07:00

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?

2007-03-12T11:04:00.000-07:00

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

2007-03-12T10:49:00.000-07:00

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….

2007-03-04T08:42:00.000-08:00

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

2007-02-27T10:02:00.000-08:00

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

2007-02-23T09:26:00.000-08:00

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

2007-02-19T19:13:00.000-08:00

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

2007-02-18T19:48:00.000-08:00

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

2007-02-12T12:30:00.000-08:00

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

Ishaka project for feeding malnourished babies

2007-02-12T12:23:00.000-08:00

Jan has worked hard on this proposal and we are aiming to fund the programme for its first 6 months. (Thanks to those friends and family who have already pledged support!) We want the hospital to apply for grant funding to continue with it from then on. All contributions are gratefully received. Email us and we will send the account details for deposits.

Nutrition Programme at Ishaka Adventist Hospital

The programme will be run by Sister Grace and Clinical Officer Festus.
The programme will cover any child under the age of 5 admitted with a weight to height ratio of 70% or less.
The standard protocol sheet must be used and adhered to for a child to qualify for the programme.
The cost of the admission will be covered by the programme up to a maximum of 30,000Ush per child and 600,00Ush per month.
If the child is HIV positive, the usual discounts on medication will apply, and will be taken into account in the preparation of the bill.
If the total bill is less than 30,000Ush the business office will prepare a receipt for Sister Grace or Festus. The patient will not be charged, and will be allowed to leave. On the next working day, Sister Grace or Festus will arrange with the treasurer for the exact amount to be transferred.
If the total bill exceeds 30,000Ush, the business office will prepare two bills. One for 30,000Ush which will be dealt with as previously. The balance bill will be met by the attendant prior to discharge in the usual way.
Sister Grace or Festus will authorise payment on each occasion by writing NUTRITION PROGRAMME on the charges chart in red, and signing this notation.
High Energy Milk is part of the programme, and will be costed at 300 Ush per litre. This represents the cost of the cows’ milk.
Sister Grace is authorised to purchase sugar, oil, kerosene and other materials necessary to the programme using programme funds.
Sister Grace will arrange for a nurse assistant to prepare the High Energy Milk each morning between 6 and 7 am. She will also advise the mothers on the quantity and frequency of administration of the HEM. This will be done outside normal working hours. The nurse assistant responsible for this task will receive 20,000Ush per month from the programme funds.
A standing order will be set up, transferring 650,000Ush per month into the hospital account. This is made up of;
600,000Ush to meet patients’ bills
30,000Ush to purchase sugar, oil and kerosene
20,000Ush to pay the nurse assistant.
The treasurer will notify Sister Grace if the 600,000Ush has been used in any one month period.
Any moneys left over at the end of the month can be carried forward to the next month.
The programme will run for 6 months. At the end of that period the hospital will make a report outlining the successes and problems with the programme.
The hospital should seek continuing funding for the nutrition programme as a matter of urgency. Organisations such as UNICEF, SCF and Oxfam are likely sources of such funding.

jan.power@rosmellyn.cornwall.nhs.uk

Dr Janet Power and Dr Mark Russell

Bushenyi Prison screening day report

2007-02-12T12:19:00.000-08:00

BUSHEYNI PRISON HEALTH SCREENING AND TREATMENT DAY 9TH FEB 2007

INTRODUCTION
Busheyni is a small town in southwest Uganda and is the site of the district administrative headquarters and the district prison. There is a brisk turnover of prisoners since many are on remand.
Ishaka Adventist Hospital (IAH) has a pre-existing relationship with the prison. Some of the hospital staff undertake pastoral work in the prison, which includes an element of health promotion. PEPFAR funding has been applied for to begin HIV outreach work in the prison. The prisoners are brought to the hospital for medical treatment though attendance is limited by the lack of fuel for transport.
A large proportion of presentations to IAH outpatient department were for sexually transmitted infections (STIs). With the support of the prison officer in charge it was decided to screen and treat all the prisoners on a single day. Prison staff were also invited to take part in the screening.
Prior to the visit the main identified health problems were scabies, diarrhoeal illnesses, malaria, STIs (including HIV) and malnutrition. Poor funding results in very limited access to clean water, nutritious food, fuel for cooking and healthcare.

SENSITISATION
The prison was visited on 4 occasions before the testing and treatment date. The first visit was in mid January to establish the approximate numbers involved and that the project was feasible. The second visit was 10 days before the date, to check facts and confirm feasibility. The third visit was 6 days before the date, to undertake sensitisation amongst the prisoners. The final visit was the day before the test date to set up the site.
On the afternoon of 8th February, a meeting was held with all members of the screening team. At this meeting everybody was familiarised with the screening process(Appendix A), questionnaire(Appendix B) and treatment protocol(Appendix C).

PERSONNEL
The members of the screening team were as follows;
2 Medical Officers
3 Clinical Officers
4 Enrolled Nurses
2 Nurse Assistants
14 2nd year Student Nurses
4 HIV Counsellors (3 from Bushenyi Medical Centre)
1 Volunteer Counsellor
2 Laboratory Technicians
12 Laboratory Students
Bushenyi Medical Centre also supplied a centrifuge and some of the HIV determine rapidtests.

SCREENING PROGRAMME
After group counselling sessions all prisoners and staff were invited to opt into the screening programme. We used two rapid tests supplied free by Qualpro Diagnostics of India. The first, ‘retrocheck’ is a sensitive screening test for HIV antibodies in blood and serum samples. The second test, ‘syphicheck’ is a sensitive screening test for antibodies to Treponema Pallidum and indicates a previous or current syphilis infection. All who volunteered to be screened were also subjected to a sexual health questionnaire and a consultation with a clinical or medical officer.
All the prisoners were de-wormed with mebendazole.
All prisoners with symptomatic scabies were treated with benzyl benzoate.
All who tested positive for syphilis were treated with benzathine penicillin.
Genital ulcer disease, urethral/ vaginal discharge and lower abdominal pain in women were treated syndromically according to a pre-agreed protocol.
Those symptomatic for malaria were treated with co-artem (artemether and lumefantrine).
Some prisoners had bloody diarrhoea and were treated with ciprofloxacin and oral rehydration solution (ORS).
All those who tested positive for HIV received post test counselling(Appendix D) and were offered co-trimoxazole prophylaxis, multivitamins and a 2 week follow up for CD4 count.

RESULTS
On the day of testing, there were 407 inmates. Of the 21 female prisoners, 17 (81%) agreed to test. Of the 386 male prisoners, 320 (82.9%).
A total of 390 people were seen for testing and treatment. This comprised 17 female prisoners (4.36%), 12 female staff (3.1%), 18 staff children (4.62%), 1 prisoner child (0.26%), 320 male prisoners (82.06%) and 22 male staff (5.64%)

HIV
A total of 55 are HIV positive. Of these, five already knew they had HIV, two female and three male prisoners. Of the 50 new cases, 1 was a female staff member, 47 were male prisoners and 2 were male staff.
One prisoner was taken to court and released after testing but before the results were available (he tested positive for syphilis as well as HIV). One staff member requested syphilis testing only. His blood was tested for HIV in error, he was positive, but declined when informed of the mistake and offered the result.
Of the 17 female prisoners, 2 are positive (11.76%)
Of the 320 male prisoners, 47 are positive (14.69%)
Of the 12 female staff, 1 is positive (8.33%)
Of the 22 male staff, 2 are positive (9.09%)
Two male prisoners’ results were indeterminate. They tested positive with retrocheck, and were negative with HIV ‘determine’ and HIV ‘statpack’ (confirmatory tests). They were told their result was negative and were advised to retest after 3 months.
Syphilis
There were 108 positive syphilis tests.
Of the 17 female prisoners, 4 (23.53%) were positive.
Of the 320 male prisoners104 (32.5%) were positive.
No staff members tested positive for syphilis.
Sexually Transmitted Infections
There were 10 cases of Genital Ulcer Disease (GUD).
There were 37 cases of Urethral or Vaginal Discharge Syndrome (U/VDS)
There were 5 women with Pelvic Inflammatory Disease (PID)
Scabies
There were 239 people with scabies.
Of the 17 female prisoners, 4 (23.53%) had scabies.
Of the 12 female staff, 2 (16.7%) had scabies.
Of the 18 staff children, 1 (5.6%) had scabies.
Of the 1 prisoner child, 1 (100%) had scabies.
Of the 320 male prisoners, 231 (72.2%) had scabies.
Of the 22 male staff, none had scabies.
Malaria
23 prisoners were treated for malaria
Gastroenteritis
12 prisoners were treated for gastroenteritis

DISPENSING
A dispensary was set up and drugs were dispensed according to the protocol. Where possible single dosages were used, and prisoners were observed taking medication. Any prisoner who had received IM penicillin was observed for 30 minutes in case of anaphylaxis.
An estimate had been made of the incidence of HIV, syphilis, STI’s and scabies. Sufficient mebendazole was taken to treat everyone. Supplies ran out of doxycycline, erythromicin, benzyl benzoate and benzathine penicillin, and we restocked from the hospital pharmacy and local drug shops.

Total cost (rapid tests and labour provided free) 1,012,937 Ugandan Sh

This works out at 2600Ush ($1.45 USD) per test and treatment unit.

DISCUSSION
Sensitisation
Sensitisation at the prison worked well. The prison in-charge and staff were well briefed and cooperated very well on the day. The high take up rate amongst prisoners and staff indicates that the sensitisation was successful.
The briefing of health personnel was less successful. It was conducted in English, with no translation into Runyankore. On reflection, this was an error. Many of the forms were incorrectly filled, although this did not present a major problem on the day. The two visiting English Medical Officers had introduced protocols into the wards and outpatient departments at IAH, and had conducted weekly teaching sessions. It was intended that the week of the prison visit a session on STI’s was given, concentrating on syndromic management and discussing the protocol at length. This session was cancelled at short notice by the Clinical Officers. As a result, they were not as familiar with the protocol as they should have been. Some of their prescribing was not correct. This resulted in two prisoners being inadequately treated for syphilis (doxycycline 100mg bd for 7 days only), and several prisoners being over treated (doxycycline in addition to benzathine penicillin). This over treatment contributed to the shortage of some drugs later in the day.
Testing
We opted to use a TPHA based test kit. The weakness in this decision was the inability to differentiate between previous and current infection. We were aware of this at the outset, and made a pragmatic decision to treat with a single dose of benzathine penicillin alone.
We were very surprised at the low incidence of genital ulcer disease, and conclude that many of these positive tests reflect previous rather than current infection. It has been our impression from our work at IAH that syphilis is over diagnosed and genital herpes under diagnosed.
Dispensing
We decided to treat prisoners with symptomatic scabies only. This was a mistake. On reflection we should have treated all prisoners with benzyl benzoate as well as mebendazole.

RECOMMENDATIONS
We make the following recommendations;
IAH and Bushenyi Medical Centre to liaise about follow up of all HIV positive prisoners on the 22nd February.
The weekly health promotion talk by IAH staff should reinforce preventative methods of transmission of scabies and diarrhoea
The practice of using a single razor to shave the heads of several prisoners should stop immediately
All new admissions to the prison should receive testing and treatment for HIV and syphilis
All new admissions are treated with mebendazole and benzyl benzoate
Any cases of scabies are treated promptly to avoid spread of infection, the prison nurse will need a supply of benzyl benzoate
The prison nurse has ORS available to her for treatment of diarrhoea
The prison nurse stops dispensing chloroquine for malaria and has a supply of coartem instead
HIV positive prisoners who have indicated a willingness to disclose to the prison in charge and attend for follow up should be seen monthly and receive co-trimoxazole, multivitamins and antiretroviral drugs, if indicated. Any HIV positive prisoner should be seen promptly by a medical or clinical officer if they become unwell.
IAH should start the prison outreach as soon as possible.
Clinical officers at IAH should participate in training in the management of STI’s as soon as is practicable.

Jan.power@rosmellyn.cornwall.nhs.uk

Mark.russell@ciospct.cornwall.nhs.uk

Bushenyi Prison screening day

2007-02-10T07:12:00.000-08:00

Bushenyi prison, 6km up the road from us is currently home to 406 men and women who have commited a range of offences from underage sex (under 18 in Uganda), to assault, robbery and murder.

If you remember Midnight Express the physical conditions are similar though the staff are friendly and were supportive of the health intervention. The water supply is intermittent. Food is scarce, firewood fuel to cook it is not reliably available and the yellow pyjama’d prisoners are often to be seen at hard labour in the neighbourhood. Inmates for longer than 12 months are clearly malnourished so much so that we mistakenly assumed many more than actually were, to be HIV positive.

We had marshalled a small football crowd of 45 from Ishaka Hospital, 15 trained staff and 30 students. The prisoners were counselled in groups of 50 and offered the health intervention which included testing for syphilis and HIV. 337 of 406 (83%) opted in (as well as 58 staff and their families). All were dewormed. Those who were symptomatic were treated syndromically for sexually transmitted infections (STIs), scabies and malaria. This day came about because both Jan and I had seen large numbers of prisoners in the out patient clinic with florid STIs.

Of the 337 prisoners we saw, more than 300 had obvious scabies, 20 had acute diarrhoea and 10 were hot and fluey with malaria (probably).

105 (26%) had at some time suffered from syphilis (testing positive with syphicheck) and 14.5% were HIV positive (retrocheck confirmed by HIV determine). Two were indeterminate (retrocheck positive, determine negative, statpak negative).

The testkits were donated free of charge by Qualpro Diagnostics from Goa India (huge thanks to them!) The labour was free and the final cost of testing and treating the 395 was on average 75p per person. All those who were HIV positive were given septrin and vitamins and will be followed up with a CD4 count in 2 weeks time.

It was a manic day but every body worked hard in the most wonderfully production line approach to healthcare I’ve been involved with since fluvacc days at home. Even the hour and a half of torrential downpour and the late lunch didn’t seem to dampen spirits. There are some great characters here and we shall miss them when we move on. Sam in particular is a whirlwind of energy, and went backwards and forwards to the hospital and drug shops on urgent restocking expeditions with extraordinary good humour. Molly was fantastic in charge of the pharmacy and Duncan and Vicent did all 790 rapid tests between the two of them.
The bottom picture shows a patient queue of prisoners waiting for their scabies treatment (we were temporarily out of stock!)

The Blame Game

2007-02-05T07:19:00.000-08:00

Today at 2.45pm Brian died. He was 3 years old, had suffered once too often from malaria, and died for want of a pint of blood. He was in reasonable nick apart from his haemoglobin of 3.5g/dl. Just one of the 30,000 annual malaria casualties in Uganda.
Who is to blame for this catastrophe?
Museveni for being a time expired and corrupt autocrat in charge of failing public institutions?
His ex health minister Muhwezi for appropriating money from the global health fund and effectively denying all Ugandans the benefit of the fund for the next 3 years?
The IMF and World Bank for convincing Museveni that spending on health and education is the route to economic ruin (unlike having a sick or dead or uneducated population)?
The Adventist Church for not having enough money to send the car to Mbarara to collect blood for Brian this morning?
His parents for being too poor to buy a £3 mosquito net?
All of us for continuing to vote for governments that prioritise arms spending and oil security over peace and health.
Or me for shrugging off his death and carrying on with the rest of my day?

Infectious Diseases 101

2007-02-05T03:13:00.000-08:00

We are coming towards the end of our 6 week placement here at Ishaka Adventist Hospital and are feeling sad at the prospect of moving on. We have been made very welcome, have a comfortable home with a view to die for and have learnt lots of practical medicine. For the first time in 20 year medical careers we have looked after people with malnutrition, measles, malaria, TB, HIV, typhoid and rheumatic fever.
Most are rewarding conditions to treat. We have now had 3 small children unconscious and fitting with cerebral malaria for more than 48 hours who wake up, start eating and 2 days later are smiling, well, and soon on their way home. The wailing, miserable, scrawny malnourished babies usually take at least a week to make their first smile but they do. Except one baby which died this weekend. Even conditions like TB and HIV respond to treatment and patients become active and well again – though drug side effects of the regimes we use here are still an issue.
There remains much stigma and ignorance around HIV and so late presentations with full blown AIDS are an everyday occurrence. Cryptococcal meningitis, strange neurological syndromes and severe TB make the prognosis poor.
We’ve seen a few older people with GI cancers we can do little for. Probably the condition we are most shocked and surprised by is rheumatic heart disease. A benign streptococcal sore throat or skin infection damages the heart valves of young children who then present several years later with heart failure. Everyday in clinic we see children as young as 9 in heart failure, though most are teenagers or older. We can control their rapid heart rate with digoxin, their failure with frusemide (and have even chucked around some captopril and atenolol,) but they need new heart valves. You can have this done as a medical tourist in India for $4000 or in South Africa for $6000, not much help when 50% of the population live on less than $1 per day. It is a classic disease of poverty, worsened by overcrowding and poor nutrition. It is unheard of in the post-war generation in the UK. Interestingly enough after my last blog (moaning about the tendency to over-prescribe) the incidence of rheumatic fever fell dramatically after the zealous prescribing of penicillin to all children with purulent pharyngitis in Costa Rica.

Medicines madness

2007-02-04T07:42:00.000-08:00

Our little hospital has an attached nursing school and lab technician’s school. There is a private university a mile down the road with another lab technician’s school, clinical officer students and medical students. These students are an interesting barometer of attitudes to health care and consumption. It’s not unusual to see a 20 year old who has had a tickle in his throat for an hour and would like to be given a course of antimalarials and a week of broad spectrum antibiotics. This request is regarded as normal and acceptable. I will spend 10 minutes carefully explaining the difference between a minor infection with a cold virus and a life threatening infectious disease and the dangers of taking unnecessary medications (with gory descriptions of the worst allergic reactions I have ever seen). The student will leave much wiser but empty handed. Taking pity on him the obliging clinic nurse will shunt him off to see a clinical officer who will give him what he asked for and throw in some omeprazole, magnesium trisilicate and deworming tablets for good measure.
Typhoid fever or rather people who think they might have typhoid fever is another bete noir. When people are slightly unwell and think that on balance this time it isn’t malaria they are convinced it’s either typhoid fever or syphilis. They can be completely well with no convincing symptoms or signs of either illness but they want the tests. The typhoid test, at 75p is a days average wage here and is notoriously unreliable. We persist in doing it even though the way we do it is probably about as good as tossing a coin for all its scientific reliability. I patiently educate, counselling the patient to not waste their money, the nurse and clinical officer do their bit again, and an hour and a half later a fit 23 year old is led back in to seem me, cheerfully clutching a scrap of paper confirming his entitlement to 10 days of noxious (and unnecessary) antibiotic treatment.
The problem is that these illnesses are still common, often enough fatal and easily cured (in their early stages) by the use of appropriate drugs. When 30,000 (mainly young children) of a population of 27 million in Uganda are dying from malaria every year it’s a bit foolhardy to ignore the non-specific illness that is early malaria or early typhoid fever. Of course mothers are encouraged to present their children early for treatment and many village and small town health centres lack even a stethoscope or a thermometer let alone a laboratory for more sophisticated tests.
The management of diseases with antibiotics according to symptom complexes suggesting malaria or pneumonia or typhoid saves many thousands of young lives every year. But the consequence is a spiral of inappropriate drug consumption among older and much less sick people, serious drug side effects, the emergence of resistant organisms and unnecessary expense for an impoverished population.
Where does the balance lie? Better and cheaper diagnostic tests would help as would appropriate public health measures. The use of mosquito nets by children under 5 would almost halve the number of malaria deaths in this age group. Access to clean water and a good pit latrine would prevent most typhoid illness. Listening to radio 4 the other day I heard someone suggest that a 10% climate change tax on fuels would comfortably provide the funds to meet the millenium development goals necessary to eradicate the diseases of poverty. Why are we so reluctant…..

INSECT REPELLENTS

2007-01-29T08:07:00.000-08:00

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

2007-01-24T09:30:00.000-08:00

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

2007-01-23T02:33:00.000-08:00

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

2007-01-14T08:27:00.000-08:00

“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

2007-01-09T00:05:00.000-08:00

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

2007-01-03T09:13:00.000-08:00

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.......

Semliki

2006-12-29T07:57:00.000-08:00

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

2006-12-26T21:01:00.000-08:00

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

2006-12-12T07:45:00.000-08:00

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

2006-12-12T07:39:00.000-08:00

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

2006-12-10T10:07:00.000-08:00

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........

A nerds tour of local health centres

2006-11-30T07:02:00.000-08:00

We've just finished our fact finding tour of local health facilities and are left with an overwhelming mix of feelings. There just isn't enough money in the system so with a few notable exceptions such as Kitagata last week most health centres just don't get enough funding to function effectively for more than part of the time. Undersized budgets mean that even if the staff complement is good drugs run out 2 weeks into each month.
Kitwe HC4 is an hour down a dirt road, off the main road from Ntungamo. It has a good range of buildings, staff accommodation even a fully equipped operating theatre. But with no medical officer and no anaesthetist the theatre has been unused since it was built 5 years ago. Even when there was a medical officer in post a couple of years ago they are often new graduates and don't have the confidence to keep up a surgical practice. With no electricity, no running water and not much to do in the evenings it's hard to keep doctors there for any length of time. The team seemed bright and capable and were really trying to provide a good service. It's hard to see how they can stay optimistic in the face of their difficulties though. They had 2 clinical officers, 4 midwives 4 nurses , 3 nurse aides and a bunch of support staff.
Ruhama HC2 is a tiny enterprise started by a Ugandan in his old family house. Again, a good team, poor facilities but big ideas. Unfortunately it is less than 2 miles from a government health centre and the two seem to be in competition rather than collaborating to improve health outcomes. Why the NGOs and missionary outfits don't ever get involved in running and improving existing services I really don't understand. The Ruhama enterprise was interesting in its efforts to generate income locally to help fund the service. The running costs of $750 pcm which provided a nurse, 2 nurse aides, a lab technician , a finance officer and support staff were met 1/3 from user fees for medicines, 1/3 from the parent NGO and 1/3 from a variety of local projects. These included eucalyptus plantations to provide firewood for sale, a stone quarry and beekeeping enterprise as well as a savings and credit scheme. Addressing income in impoverished rural areas is vital.
Our third visit of the day was to a HC2 run by brazilian nuns. The 20 minutes down a very rough dirt road gave no hint of the splendour of the unit. From being almost impassable the road gave out to a wrought iron gate in a crafted stone wall worthy of a Hollywood mansion. The concrete driveway flanked by luscious palms led through a manicured but productive garden to a gleamingly clean and welcoming purpose built health centre. The quietly spoken and determined nun seemed to have sorted the ideal arrangement. She had persuaded the district to give the centre its own budget which amounted to $500 pcm, which they spent on drugs. They then sell the drugs and lab tests at cost and use that money to pay staff wages (the nuns come free, they employ an additional nurse, a clerk, a lab technician and household support staff). Oh and she keeps a firm grip on all the keys so none of the stock disappears. The place was beautifully kept with plenty of welcoming posters and messages on the walls and doors. Enough to make you believe in God (or nuns at least).
Our final visit was to Rugarama HC4 in Kabale. Another splendid example of a mission based health unit, operating semi independently of the district but with a government budget. Well staffed and efficiently run, it was clearly delivering a high standard of care compared with the government hospital up the road, but again was charging user fees and there seemed to be no communication between the two units. The Ministry of Health Grant of $4000 pcm paid the wages of almost 80 staff. There were consultation fees inpatient charges and drugs and lab tests were charged at cost. Capital costs are met by donations usually from the International Lions organisation. They are hoping to start obstetric surgery soon and want to build a paediatric unit to allow the maternity unit to expand. They need to build more staff accommodation as providing accommodation is the only way to make their salaries competitive with government ones. Nurses are on $150 pcm, clinical officers on $250 and docs on $500.
We've done with visiting! It's been great to see so many examples of good and not so good practice, the challenges faced by overwhelmed government units and the contrast with better resourced private ones.
We're both left unsure about the whole business of user fees. Coming from the UK it goes against the grain to charge people at all for health care, let alone the really poor for treatment of diseases of poverty. But at least with the brazilian set up the charges were as low as they could be and were posted on the wall so people knew what was being charged for. We heard stories in government centres of parents having to go to a drug shop to buy the syringe and needle for their child to get the injection of antimalarials they desperately needed because the hospital had run out, and that isn't right either.

I'm reminded again of Paul's concern about the investment in hospital facilities and the relative neglect of simple preventative measures that attend to clean water, sanitation, decent housing, enough to eat, vaccinations and malaria prevention all of which would save many lives.....

Mad dogs and muzungus

2006-11-26T09:17:00.000-08:00

Saturday we pitched up in Ntungamo to support Frouke's fundraising walk. Frouke is a Dutch VSO working for an NGO that supports a level 2 health centre (clinic + 1 nurse, 2 nurse aides + 1 lab tech) in Ruhama. Our carload of Muzungus from Mbarara arrived promptly for a 7am start. The childrens marching band arrived at 10 and the lorry load of walkers from Ruhama at1030. We've been relatively protected from Uganda time so far (though I have so far made 6 fruitless visits to the Ugandan revenue authority in an attempt to register the ownership of my car). It was a scenic walk in good company for the 25km to Ruhama through hamlets surrounded by matoke plantations and fields of beans, maize and sweet potato. We started off en masse behind the band in Ntungamo and when the band quit after 20 minutes the masses disappeared over the horizon in an extraordinary show of athleticism. (In fact there was a huge amount of scepticism about whether the soft muzungus would be able to complete the walk). For the last third I was in the company of (and struggling to keep up with) 2 teenagers including the streetwise Abdel, a 10 year old in barefeet sporting an umbrella, her mother and aunt both carrying babies and wearing flipflops and her grandmother holding an m&s bag containing her groceries. M
It turned out to be the most eventful sponsored walk I've ever been on. We marched around the small town of Ntungamo led by the 'chief walker' and in formation 3 abreast behind the banner and childrens band. People carrying home made posters in English and Runyankore with messages urging immunisation, safe sex and regular deworming. My favourite was the child walking along proudly holding aloft his poster reading 'participants register here'.
After 2 or 3 km Francis, the NGO director and event organiser fell heavily whilst running to catch up with the leading group and had an obvious fracture of his left arm. He was sweaty and in pain but after a makeshift sling and a couple of ibuprofen got up and hurried on. When I caught up with him near the end of the walk he told me they had a very good traditional healer at the health centre who would sort him out when he got there. He continued to lead from the front and finished the walk before coming over a bit queasy again and agreeing to come with us back into town for an xray and plaster of paris. The xray confirmed the fracture, and the POP, bought in a local pharmacy and applied by a Belgian medical student (with my inexpert help) looked a bit scruffy but seemed to do the trick.
We retired for barbecued maize, chapati, beer and aftersun....J

Kitagata noodle parlour

2006-11-22T08:46:00.000-08:00

We've just had a couple of good days visiting Allan Sande at the district hospital in Kitagata, an hour and a half west of us. Allan's a VSO GP from the Philipines who's been in post for exactly a year - a proper old fashioned GP probably quite capable of doing appendicectomies and caesarian sections on the kitchen table. He's one of 4 docs in the hospital and does literally a bit of everything. Not only did we have a fun time being cooked for and looked after by Allan (the Kitagata noodle parlour!) but he is a wonderful mix of funny, outrageous, kind, wise and plain sensible. Kitagata is a single dirt track of a town with open shop fronts just like in the cowboy films. We embarrassed ourselves playing pool with an audience of 60 Ugandans ( in varying states of sobriety) but were warmly greeted by everyone.

Allan's enjoying Kitagata, and its easy to see why. Kitagata Hospital works!! There are reasonable staffing levels, the pharmacy has nearly all its essential drugs nearly all of the time, and it can cope with most of the problems people present it with. This is very unlike our experience of all the other government health units we've come across so far. The consensus seems to be that it works is because of effective leadership. Wilber has been medical superindent for 5 years. There is no obvious corruption here. A good job is done by capable people at all levels of staff and morale seems high. An important lesson.

I remember one of Alastair's important ingredients for a better Uganda was to improve the use of existing resources. This was brought home today during a chat with the cheerful and bright pharmacist Olive. Yes, national medical stores are a nightmare & disgrace. This organisation in Kampala is meant to provide all government health units with their essential drugs every 3 months - and it doesnt. Kitagata frequently has to buy in drugs from a private provider. However, Olive spontaneously suggested that pharmacy stock would go further if only the clinicians stuck to the principles of rational prescribing. Some of this tends to be the I'm not quite sure what is going on here with this feverish person so Ill give them an antimalarial a broadspectrum antibiotic and something for the indigestion they also happened to mention. Some of it is also about patient expectation. Various members of staff would come in to see us after consultations and say the patient says you haven't given them anything - don't you think you ought to. But they're perfectly fine and they haven't even got a fever. Yes I know but really the patient won't be happy unless you give them something.....or do something to them. At Bwindi numbers are especially high on Thursdays - ultrasound day. Everybody wants a go with the new machine. Witchdoctors magic.. and familiar old stuff.....!!!

Shopping.........

2006-11-20T04:37:00.000-08:00

Those of you who know me well will already be familiar with my aversion to shopping (apart from the occasional dash into Wildlife for a bit of retail therapy after a particularly bad day). Here I shop at least once a day, every day. And I quite enjoy it.
Shopping involves a 20 minute walk past George the stork, along a murrum road, across a golf course, then murrum road into town. On the way I greet and am greeted by literally dozens of people, schoolchildren in their smart uniforms, women carrying improbably bulky loads on their heads, boda boys trying to persuade me I want a life on the back of their motorbike (interlude here – it seems incomprehensible that I would want to walk, I must have money as I’m muzungu, so why don’t I get a lift? When I’m out running I can see people watching mystified, then turning to the person next to them and saying “Oh, she’s taking exercise!”).
Some days I go to the dairy. This is about a further 10 minutes out of town, basically in a house. It’s a family business, making yoghurt and cheese (‘feta’, ‘gouda’, ‘cheddar’ and ‘mozzarella’ all tasting roughly the same). Then to the market where I cause great amusement trying to buy using only runyankore.
The availability of food is directly seasonal. The first mangoes are appearing on stalls, and the grasshoppers have just hatched(?). There are clouds of them flying around, and piles of them in the market. Some fresh and green and still with legs and wings, and others without (I think although I’m too squeamish to get close enough to know for sure) and fried brown.
And I usually end up buying a basket or two. They’re just great. And very cheap, ranging from 10p to 70p depending on size and shape. Irresistible.

Mark and Jan's VSO placement baseline assessment

2006-11-20T04:33:00.000-08:00

For those insomniacs who aren't really sure what we're doing here..........

ASSESSMENT OF THE CONTINUING POTENTIAL FOR A DEPARTMENT OF FAMILY MEDICINE AND COMMUNITY PRACTICE AT MBARARA UNIVERSITY OF SCIENCE AND TECHNOLOGY – NOVEMBER 2006

Background
Uganda faces considerable health challenges;
50% of the population do not have access to clean water
Average life expectancy is 45
320 people (mostly children) die every day from malaria
One and a half million people are known to be living with HIV/AIDS
51% of the population are more than 5km from any health facility
1 in 200 women who get pregnant will die from a pregnancy related complication
Infant mortality is 87/1000
There is less than 1 doctor per 10,000 of the population
80% of the population live on less than $1 a day, 96% on less than $2.

The Health Sector Strategic Plan (2000-2005) envisaged a strengthening of Primary Care with most care delivered by Health Centres 1-4 (each level with more sophisticated infrastructure and staffing) rather than by District or Regional Hospitals. This is a sound plan. Part of the development of this strategy requires strengthening the medical presence in Health Centre 4s, to provide comprehensive primary care as well as effective intrapartum care and some emergency surgical services. It was to meet the demand for these Health Centre 4 Medical Officers that the Ministry of Health supported the creation of the two Ugandan Masters Courses in Family Medicine and Community Practice (one at Makerere and one in Mbarara).

There are many significant blocks to the successful delivery of effective Primary Care;
The Health Sector as a whole is under-resourced. Government spending on health is 8% of an already small Gross Domestic Product (GDP). A Save the Children Fund report recommends 12-15% of GDP funding to meet already stated objectives
Undergraduate medical training is still largely specialty hospital focussed, although Makerere has had a more community orientated programme since 2003
Most medical students are from Kampala and prefer to follow careers in Kampala
There are too few medical graduates. The three major teaching hospitals are struggling to fill their own intern posts. Only 33% of rural medical posts are filled
Well funded NGOs offer higher salaries and draw doctors away from the public sector
Collaboration between NGO and Government facilities is poor with many NGO programmes concentrating on the delivery of disease specific services for HIV/AIDS or TB. In practice, there is no concept of comprehensive primary care.
In the public sector the level of commitment among doctors is low. Many public sector doctors spend much of their working time in the private sector to boost their income
Doctors are reluctant to work in remote settings under difficult physical conditions many hours distant from their families
Poor remuneration at medical officer level makes recruitment difficult
Lack of career progression and career opportunities is de-motivating
There are no opportunities for continuing medical education or support
Accommodation and facilities in remote settings are poor
There are often inadequate levels of support staff
Supply of drugs and equipment are outside the control of the individual doctor and are at best sporadic
Lack of infrastructure for performing operations e.g. caesarian sections leads to deskilling of the doctor and thus a total loss of the service at HC4 level
Widespread corruption and theft of supplies further impedes service delivery and damages morale.

Mbarara Placement
We have been recruited by Mbarara University of Science and Technology (MUST) to help consolidate the Department of Family Medicine and Community Practice. This Department currently exists only on paper. Dr Vincent Batwala has managed the Masters Programme in Community Practice and Family Medicine under the auspices of the Community Health Department for several years.

Current issues facing the Programme in Family Medicine:
There is no Clinical Department. This is a vital pre-requisite for teaching postgraduate and undergraduate students in a clinical discipline
There is no office space
There are currently no members of staff in the department and no-one associated with the University has a background in Family Medicine
There is no budget
The curriculum needs to be rewritten to prioritise the learning needs of the students and the Health Sector’s demand for generalist practitioners
At present the students are regarded by their placement departments as an extra pair of hands – the educational component of their attachments is poor
Student assessment is burdensome and not tailored to the practice of Family Medicine
There are currently no students in the first two years of the course.

Minimum requirements for a successful department to be established;
A secure funding stream must be established
At least one and preferably two Ugandan lecturers with a Masters in Family Medicine should be appointed as soon as possible
A follow on VSO volunteer lecturer in Family Medicine should be appointed to begin before September 2007
The department will need an office, a library, IT equipment and furniture
There needs to be a clinical teaching base for students of Family Medicine. In the successful South African model, the Department of Family Medicine runs a generalist triage service for the emergency room and the outpatient department
Lecturers in Family Medicine should have a clinical service commitment of at least 2 days each week
The Course Curriculum needs to be rewritten to reflect the objectives of Comprehensive Primary Care Delivery in Uganda with an emphasis on the management of HIV/AIDS, TB and malaria as well as on the delivery of effective child and maternal health programmes
Traditional courses are unsuitable for this Masters programme. Students come from backgrounds with very different work experiences. The course should be flexible enough to meet individual learning needs. Course assessments should reflect this
A programme of continuing medical education (CME). This requires a commitment to resource and support graduates in order that they can undertake an annual minimum level of CME
Institutions that deliver excellent Primary Care and individuals who practice Primary Care to a high standard need to be identified and supported. Students will be placed at these sites in apprenticeship roles with a comprehensive programme of mentoring and supervision. This system will require funding of the supervisors and supervising institutions
3-5 students need to be recruited into each academic year.

In order to meet these targets the ongoing support and sponsorship of the Faculty of Medicine, MUST and the Ministry of Health (MoH) is essential.

The Faculty of Medicine and MUST will need to provide;
office space
funding for the Lecturer posts and
support for the establishment of a clinical department of Family Medicine.

The MoH will need to commit to the funding of;
Tuition fees
Government salaries whilst students are on the Masters Programme
Travel and subsistence grants for community placements
Special Medical Officer status with a salary enhancement for Masters graduates
Grants for continuing medical education for Level 4 Health Centre Medical Officers
A salary structure which reflects training, experience and length of service.

Jan Power and Mark Russell. November 2006

The 'C' word

2006-11-19T08:18:00.000-08:00

The VSO training session I found most interesting, and most demoralising, was given by a representative from Anticorruption Uganda. We’ve already mentioned our frustrations at the hospital in Mbarara where drugs are stolen from the pharmacy and reagents from the lab such that neither department is able to provide a service. Petra, working for the women’s cooperative manufacturing candles soaps and other products from lemon grass in Ntungamo, arrived to find that the chairwoman of the committee had stolen the lion’s share of their £3000 grant. Amber’s employing NGO gets paid for running fictitious workshops, as does Fabiens.

Foreign aid constitutes the largest sector in the Ugandan economy, with more than 50% of government income coming from donors. This is big business. Ambitious and greedy people go into politics and use their connections to set up or get involved in NGOs. They have access to salaries, cars and, via various scams, a criminal income. There are now 6000 NGOs working on HIV alone in Uganda. They compete, sometimes aggressively, for scarce resources. Because they are in direct competition with each other there is a disincentive to work collaboratively. There is no effective control over their policies and practices, so they rarely work with the same aims, and it seems even more rarely in line with overall government strategy. Result; ineffectiveness, chaos and duplication. This is just one area. The country is full of NGOs. There’s a part of me that thinks all the money should be directed through central government so that they can work effectively to a sensible strategy, and part of me that knows that would be even more hopeless as the money would simply disappear.
This form of entrepreneurialism is effectively modelled by president Museveni, his family, friends and political colleagues. Museveni and his family have stolen hundreds of millions of dollars from the Ugandan people. This is corrosive stuff. When his health minister Jim Muhwezi was found after a commission of enquiry to have stolen millions of dollars from the global fund (destined to help Uganda fight HIV, TB and malaria), Museveni protected him, refusing to sack him. Largely, it was suspected, because Muheza knew too much about Museveni’s dodgy dealings. His own corrupt and some say murderous habits mean Museveni has a strong incentive to stay in power for life to evade investigation and accountability for his record - what democracy there is here may be no more than a sham. The Global Fund (worth $100m to Uganda) has been suspended since July 2005, and has just been suspended again until next year at the earliest.
Nearly everybody steals or expects things to be stolen. Corrupt practices hamper sensible business development and investment because the playing field is biased and unpredictable. Funds don’t reach their targets so infrastructure is poorly developed; the roads are bad, electricity unreliable (the national electricity company is run by Museveni’s daughter).
On Thursday we met Paddy and Mike Martin from Marazion. They’ve been coming to Uganda for 5 years and have invested heavily in the construction and supplying of a primary school north of Kampala. They are now switching their energies elsewhere after a catalogue of abuses, with building supplies stolen, school equipment stolen, and teachers barely turning up for work.
Our dilemma then, is, do you engage with or disengage from corrupt organisations? VSO’s view seems to be one of constructive engagement. The ‘muzungu’ sticks the course, models a European work ethic, insists on transparent practices, is appalled by any hint of corruption and thereby educates people about good governance. Our experience is that this is a fairly ineffective approach. The corruption becomes more covert or the muzungu is unwelcome. Judith, who was posted to the corrupt pharmacy department at Mbarara hospital, was ignored and not spoken to for her first 3 months here until she decided she should get a job elsewhere. I favour a process which sets high standards for the partner organisations, maybe even aiding them with short term placements at start up to regularise issues of accounting and governance. VSO’s ‘bums on seats’ approach to maximising placement numbers seems to us to be counterproductive in this situation.
Ugandans love to talk politics and most are fed up with Museveni. However, alongside that discontent many still have vivid memories of 20 years of mayhem, brutality and bloodshed from a few years after independence in 1962 to Museveni’s overthrow of Obote in 1986. During those years most administrators and civil servants were murdered, expelled from or fled the country. Museveni has brought relative stability though little in the way of economic development or the regeneration of civil society. Uganda is a fertile country with plentiful food and some valuable natural resources, equatorial sunshine, plenty of rain, the Nile for energy and now apparently some oil reserves but there seems to be no way out of the present predicament short of another bloody revolution at some point down the line.
We enjoyed the thought advertised in the press recently of a prize for the African president who voluntarily stands down after no longer than 2 terms, having left the country in a better state than when he arrived. The prize was a pension of $5m pa for life. Local people quipped that that’s probably as much as Museveni steals in an average day!!!...........

Bed with a view

2006-11-19T08:14:00.000-08:00

Soon after waking this morning I unzipped the tent flap and peered from my comfortable bed across the still waters of the Nile just as the first sunlight reflected across it. A fish eagle took off from its treetop perch swirled in the air and dove into the water. Flocks of snowy egrets swooped low over the river and cormorants cruised along inches above the river dipping down over the thundering rapids. Two otters paddled beneath us. (Jan – I initially thought they were crocodiles and nearly dropped my cup of tea, brought to us in the tent by a very nice waiter, as I’d been happily swimming yards from the spot minutes earlier). This was much better than telly!!!
We spent the weekend with Frouke and Petra exploring the source of the Nile where it leaves Lake Victoria at Jinja. Saturday night’s idyllic campsite was at The Haven, a small encampment 10 miles north of the busy colonial town of Jinja. The Haven sits high on the bank of the Nile, above a set of its famous grade 5 rapids, as the river courses through lush green countryside. There are yet more goat shed style buildings here, beautifully decorated and finished, so they provided plenty of inspiration for our next venture.
There is no hint of development in the surrounding area. Small hamlets of brick and mud huts melt into the matoke and sugar cane plantations – the land is heavily cultivated but not in a manner we would recognise. From a distance it appears like an open woodland. Up close the trees are a mix of productive trees including many laden with impossibly large Jack fruits.
We’ll be going back and we are also definitely going to go over the rapids in a raft!

VSO in-country training

2006-11-19T08:10:00.000-08:00

November is green grasshopper (nsenene) season in Uganda so you'll often come across hordes of people out collecting these edible delicacies for selling and frying. The grasshoppers are particularly attracted to lights at night. We still haven't been brave enough to try them....

The 12 VSO volunteers in our cohort re-congregated at the Lwesa Conference Centre a few kilometres outside Kampala for a week of debriefing and political and cultural training 6 weeks into our placements. The high stodge institutional food and solitary TV for entertainment provided the background for our varied and various grumblings. VSOs overriding priority - as a result of donor pressure - is volunteer numbers rather than quality of placements. Half its funding comes from the Department for International Development and it is set various targets to meet. So when we complain of jobs that don’t bear any resemblance to job descriptions (like ours) or jobs with unsupportive employers (crap housing or failure to pay the subsistence grants) or jobs with organisations that are blatantly corrupt, the response from VSO sometimes seemed a bit half-hearted…..
In order to keep morale up, we both skived off several of the sessions as the ones we attended, though interesting, tended to be of a Ugandan style lecture based format and could easily hit 2 hours long without a break. My attention span is a maximum 20 minutes in that kind of setting. Instead we hit the shopping centres, finding ourselves wandering dazed and drooling through the huge and shiny shopping malls of downtown Kampala. We’ve bought loads of books to satisfy Jan’s thirst for reading.
Kampala is a medium sized, grotty, smog choked traffic jam of a city so it was good to discover some of its nicer aspects. We ate really well! First with Mya and Alastair, then at the Café Roma, Le Petit Bistro and finally at the Speke resort. We also spent a comfortable afternoon (and then most of Jan’s birthday) lounging in the luxurious environs of the Speke resort. This is a deluxe hotel complex on the shore of Lake Victoria with possibly the nicest 50 metre swimming pool ever built.They also had 2 storey goat sheds in their grounds!!

Bwindi Community Health Centre

2006-11-15T04:39:00.000-08:00

A WEEK AT BWINDI COMMUNITY HEALTH CENTRE

Bwindi Community Health Centre was established by American Missionaries Scott and Carol Kellerman in 2002, to bring healthcare to the Batwa Pigmy Community. The Batwas are traditional hunter gatherers displaced from their natural forest home by the incursion of agriculturalists and by the creation of the national parks. These people now live in extreme poverty with no culture of food growing and no means of earning an income. Childhood mortality is 60%. Scott has created a charitable foundation that works with the Batwa people to provide housing, sanitation, water and schooling as well as providing health services.
The health centre has in patient facilities for adults and children, a busy outpatient department, an antenatal clinic as well as an immunisation programme. In-patients are mainly children with severe malaria or with malnutrition.
Paul and Vicky are two VSO volunteers who have been working at the centre since Easter this year. They have worked hard to introduce professional standards of care with clear protocols for the management of the common conditions. There are regular teaching sessions and staff meetings. The service is currently run by a medical officer, 2 clinical officers (nurse practitioner equivalent) and 5 nurses. There are basic laboratory, Xray and ultrasound facilities and hopes to open a surgical unit next year. Proactive HIV screening starts on December 1st (world AIDS day) and access to ARVs will come soon.
The annual running cost is currently about $200,000 of which half comes from charging the non Batwa users of the service and half comes from funds raised by Scott mainly in the USA. (Currently TB treatment, feeding of malnourished children and HIV testing are free. The Batwa community have a completely free service).
Scott is now spending half the year in Bwindi and half the year raising funds in America.
Compared to the other services we have had experience of since we’ve been in Uganda this service is excellent. (Remember it is common for there to be no drugs, no IV fluids, routine laboratory tests unavailable, poor medical care, non-existent nursing care).
We spent our week either on the ward or in the outpatient department. On Friday we joined Vicky and Paul at an outreach clinic in a Batwa village, 40 minutes from Bwindi. King, the manager of one of the local tourist camps brought a few of his staff for crowd control and to act as interpreters and we rattled through 80 people with an assortment of problems including coughs, colds and fevers.
We were well looked after in the guest house at the centre and had the good company not only of Paul and Vicky and the permanent staff at the centre but also of a couple of Danish medical students and Steve from Lake Tahoe who has been working as a general handyman here for the last 3 months.
Paul and Vicky are facing many challenges. Good timekeeping, regular ward rounds and teaching sessions and good record keeping depend on their continued presence and tend to slip when they leave Bwindi.
BCHC has up to now had a hand to mouth existence. It is very dependent on funds raised by Scott. When Scott isn’t around cash-flow can be problematic. Paul has taken to schmoozing with tourists visiting the national park to raise funds for important new projects (very successfully). A VSO volunteer is coming for 3 months in the new year to establish a formal accounting and budgeting system. Paul is also setting up a ‘Friends of Bwindi’ group, who he hopes will make regular financial contributions and provide regular income. One of the financial challenges is the extent to which the centre develops as a mini hospital. The current limited x-ray and ultrasound facilities are expensive to run and of dubious priority given the low immunisation rate, poor access to antenatal care and high incidence of the big killers – malnutrition, malaria, TB and HIV.
The establishment of a surgical unit will impose further financial strain on the centre. Whilst it makes sense to offer caesarian sections when maternal mortality is currently so high and the transfer time to the nearest surgical facility is 2 hours it will involve large revenue costs with surgical, anaesthetic and nursing staff as well as equipment and supplies. Paul worries that high cost interventions that help the few will limit the organisations capacity to make low cost interventions that help many more people such as community education, vaccination, antenatal care and family planning (a familiar tension in all health systems).
We were enormously impressed by the health centre and by the work Paul and Vicky are doing. This is a well organised, corruption free project. Within the confines of a low resource setting the health centre is providing extremely high quality care. Paul has identified improvements in maternal and child healthcare, and reducing the very high mortality rates as one of their most important priorities. In order to achieve this they have appointed a midwife, Evelyn, to provide antenatal and intrapartum care. She is great. Competent and kind, she is proving very successsful at persuading women to attend for antenatal care where several simple interventions can be made to dramatically reduce maternal and child mortality. Specifically, the treatment and prophylaxis of malaria and worms reduces anaemia and the likelihood of death from Post Partum Haemorrhage. Screening and treatment for HIV and syphilis (both probably with around 10% prevalence) reduces congenital transmission, and tetanus vaccination prevents neonatal tetanus. She and Paul are developing protocols for identifying women who are at higher risk of running into problems in pregnancy or labour to target them for more intensive antenatal care and to try to persuade them to attend the centre for delivery. She is seeing about twenty new women a week in a weekly antenatal clinic.
Large family sizes are the norm. This is entirely understandable. Women expect that at least half of their children will die before the age of five and the role of children in the family is to collect water, herd goats and look after younger siblings. Access to family planning is poor. Prolonged and obstructed labours in isolated homes are very common and cause large numbers of stillbirths and maternal deaths.
It has previously been a struggle to encourage women to attend the centre for delivery but Evelyn’s popularity is changing this. As word is spreading amongst the local women, her workload is increasing rapidly. Evelyn is on call 24hrs per day for 25 days then has 5 days off, when labour ward and antenatal clinic are covered by the only other nurse with any obstetric experience. In the week we were there she was up most of the night every night, and looked completely exhausted. There is an urgent need for a second midwife. It would cost approximately £150 per month to cover her salary and other costs. Before we left the UK some of our friends asked us to identify a small project that they could contribute to directly. This could well be a good one. Check out Bwindi’s website at http://www.bchc.ug/ or mail us for more information.
PS I had my first Ugandan snake encounter in the bathroom in Bwindi. Just turned and noticed the snake sitting on a ledge a foot away from where I was brushing my teeth. Made me jump and I had to be rescued by the security guard who whacked it with a very long stick!

Examiners

2006-11-02T09:22:00.000-08:00

This week we found ourselves in the role of examiners for the two graduating students on the Masters Programme in Family Medicine. Over the last fortnight they've done MCQs, written papers, clinical case exams and vivas in each of Surgery, Medicine, Paediatrics and O&G. A huge burden for them and something we hope to change. They've both done OK and probably better than I would have done!
Fortunately for us the external examiner, Atai, came from the departmentof Family Medicine in Kampala. She's a bright and dynamic Ugandan woman who has been the Head of Department there for 3 years. Now, finally, after several long conversations with her, we've begun to understand what's expected of us and can start to make plans.
These revolve around establishing a proper department of Family Medicine, with office space and lecturing staff and some form of clinical component to it's activity. Initially we'll be looking at creating a presence in the outpatient department of the University Hospital here. Many of the patients self refer to outpatients even though they have problems that can be dealt with easily in Primary Care (chest infections, hypertension, malaria). Given that Primary Care isn't well established some form of Primary Care clinic as a first stop seems sensible and works elsewhere... Needless to say it'll have to go through a lot of committees.....

Constructive engagement

2006-10-29T19:44:00.000-08:00

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.......

2006-10-26T22:24:00.000-07:00

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....

On the medical ward.

2006-10-21T04:09:00.000-07:00

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…….

Our new home!

2006-10-15T11:28:00.000-07:00

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

2006-10-15T11:13:00.000-07:00

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).

Robert Kagwa intensive Runyankore language training

2006-10-13T13:52:00.000-07:00

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.

Lake bunyoni

2006-10-11T10:15:00.000-07:00

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.

What exactly are we meant to be doing?

2006-10-05T11:08:00.000-07:00

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.

Home for the moment

2006-10-03T10:05:00.000-07:00

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.

George the stork does the business

2006-10-02T20:35:00.000-07:00

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!!

2006-10-02T11:15:00.000-07:00

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

Museveni telling it how it is

2006-09-28T05:44:00.000-07:00

President Museveni took power after a guerilla war in 1986 and has led the New resistance Movement since then , voting additional terms of office for himself and reluctantly it seems agreeing to a form of multiparty democracy this year though there continue to be stories of harrassment of opposition supporters.
He and his 69 cabinet ministers have just been on a well publicised 3 day retreat in Entebbe. Museveni is known as a blunt speaker and accused his ministers of sleeping and being lazy and inefficient. Museveni is keen to attract foreign investment and expand business growth. The current political motto is of developing a first world eceonomy in Uganda. Museveni criticises the main university for wasting its time training environmentalists and psychologists rather than businessmen and says Ugandans are a nation of hairdressers who need to learn how to work hard in order to get rich.
In the meantime power is on alternate days in the capital. The hydro generator at the start of the nile river on lake victoria has been half closed because lake levels have dropped over recent years.
Needless to say MPs have just each voted themselves a bonus of a brand new $40,000 4 wheel drive car......
A UK oil consortium has just bought exploration rights in Uganda. There may be large untapped reserves. One positive outcome of this is that there now is a huge incentive to resolve the ongoing war with the Lords resistance army in the north and for the first time in years people are optimistic that the peace talks in Sudan may be successful.......

Induction week in Kampala

2006-09-25T04:56:00.000-07:00

Whisked from Entebbe airport on Friday morning to Lwesa training centre on the outskirts of Kampala - home for the next week and a gentle introduction to Uganda. Its a missionary training centre on top of a small hill with a landscaped garden of mango trees and palms populated by buzzards and green monkeys. ( These turn out to be the local version of grey squirrels, general troublemakers, thieves and robbers of orchards). There are "sea glimpses" of lake victoria in the distance.
The compound is protected as are most shops in town by an armed guard and at night by some mythical but very noisy dogs (please don't go out between midnight and 6am because the dogs are loose!!)
We've done our patriotic duty - walked 2 hours down to the lake and back yesterday in the middle of the day with no protection and now have distinctly red faces and arms. Hundreds of children everywhere shouting hey muzungu at the party of white folk out for their midday stroll.
Everywhere (apart from the roads which are mayhem) is friendly and safe.
Runyankore language training starts tomorrow.....