Matatus

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

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

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

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

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

Global Fund Shenanigans

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

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

Weighty matters

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

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

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

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

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

Where is boss?

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

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

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

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

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

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

Tuberculosis and poverty. Time for more donations please.

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

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

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

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

Mark299@gmail.com

The picture shows Mycobacterium Tuberculosis in culture using the MODS technique

Old men learning new skills

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

Global Fund Fiasco

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

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

VSO critique

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

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

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

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

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

Buying shoes

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

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

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

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

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

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

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

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

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

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

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

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

Job done.

Financial crisis at Hope

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

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

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

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

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

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

He’s thinking about it over the weekend.

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

Reachout Catchup

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

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

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

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

Translation

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Extraordinary people

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

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

Mabira Forest and popular democracy

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

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

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

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

Simplicity

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

Mark at Reachout

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

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

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

My work plan over the remaining few months will include:

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

mark.russell@ciospct.cornwall.nhs.uk

Jan at Hope

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

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

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

Enter the queen of the protocol.

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

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

I know which I’ll choose next time…

Lonely Hearts

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

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

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

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

Jack and Jill went up the what?

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

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

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

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

Wangye

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

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