Last week was a week of mourning for the Baganda (people of the kingdom of Buganda). Many of them wore a strip of bark cloth or olubugo tied around their waist or pinned to their clothing. The inner bark of the Mutuba tree (ficus natalensis) is harvested after the rainy season and then beaten with wooden mallets to make a suede-like, terra-cotta colored cloth that swaddled and draped the Buganda royalty. The bark cloth reportedly dates back some 600 years to the second Kabaka. In more ancient times, the cloth was used as a shroud for the dead. As such the cloth is a potent symbol of Buganda culture and a sign of mourning.
The mourning Baganda also mounted photos of the Kabaka (Ronald Mutebi, king of Buganda) on their bicycles and motorcycles and matatus. The loss of the Kasubi tombs (see last week’s post) has hit the people hard. It is difficult for us to understand how people can mourn the loss of a tomb (the bodies of the four previous Kabakas, interred in the tombs, were undisturbed by the fire). In a way it seems odd to mourn for what has already been mourned for, but for the Baganda, fighting to maintain their culture in a rapidly changing world, it seems like the tombs were their link to the past glories of their kingdom. The tombs will be rebuilt. Maybe this time with better security, or wiring, but will they be the same?
On my side of town, Prasandan and I taught an ACLS-type course to the medical staff at IHK. Prasandan is the cardiac anesthetist from Kerala who has landed the unenviable task of starting the new IHK Heart Centre (this morning I asked a medical officer what the EKG showed for a patient that had gone into shock—and was told that the hospital’s lone functioning EKG machine was broken). ACLS is Advanced Cardiac Life Support and is a copyright of the American Heart Association, and, as such, if we were to teach an ACLS course here we would have to have the blessings and sanctions of the AHA, which we did not, hence ‘ACLS-type.’
ACLS mostly focuses on the skills and knowledge needed for resuscitation of people in cardiac arrest, although lately it gives some emphasis to the early treatment of heart attack and stroke as well. In a US hospital, the paramedics, most of the ER and critical care nurses, and many of the doctors would be certified in ACLS. Here in Uganda, where resuscitation is a new thing, the only people certified in ACLS are ex-pats or medical personnel that trained abroad. Given that IHK is about to become a ‘Heart Centre,’ I thought it a good idea that we begin teaching our medical staff the basics of cardiac life support. Prasandan agreed.
I will, up front, confess that my ACLS instructor certification expired during the Clinton administration. But I did manage to research the current ACLS curriculum and guidelines and put together an impressive array of shamelessly copied powerpoint slides. And our doctors stayed awake, for the most part, even after the traditional 1300hr bolus of matoke and gravy. Although they did seem amused by a few of the ACLS recommendations. For instance, the thought that you could get an EKG within five minutes of coming to the ER (at IHK, the EKG machine, when it works, is in cardiology, and you send the patient, without a monitor, to cardiology to get the EKG. The walk to cardiology alone would take up your 5 minutes). Or a head CT within 45 minutes (even if it worked, it would take that much time just to locate the key to the room). Too dang funny. What kind of stuff is the AHA smoking anyway?
My evenings in the Casualty ward at Mulago were a little less didactic. At least this week no one was shot (or, if they were, they weren’t brought to Mulago while I was in attendance). But, at one point I was taking care of 3 patients with Glasgow Coma Scales of less than 8. (the Glasgow Coma Scale or GCS was, not surprisingly developed in Scotland as a prognosticator of head injuries, anything below 9 is considered a major head injury) As is typical of my unflagging optimism, I tried to get some CT scans of my patients damaged brains. Unfortunately, the tech that runs the scanner had gone home and ‘couldn’t be called back in unless it was a true emergency…’
I have decided that I really do not wish to be around Mulago when the ‘true emergency’ comes through the doors.
Fortunately I was not at Mulago on Friday when the Baganda mourning was brought to a close and the bark cloth was unknotted and the tears were dried. The Kabaka and the Nnabagereka (his queen) came to Kasubi to officially bring an end to the mourning period. The tens of thousands of people at the site pushed forward to see the Kabaka and between 150 and 250 people were injured and 2 people trampled to death.
Monday, March 29, 2010
Sunday, March 21, 2010
another trauma update
Last Friday we had a case conference to discuss a trauma patient who sat around at IHK for over two weeks with an undiagnosed, unstable neck fracture. The conference, in itself is progress—actually getting doctors together to talk about a bad outcome and make plans for prevention of future occurrences is a huge step forward here. (I’ve been trying to get IHK to start having a monthly morbidity and mortality conference since I got here, but, as it turns out, nobody really wants to talk about minor details like how many patients died last month) Granted, if we had been having this particular case conference back home, we would have been sitting down with our insurance company to decide just how much money we should give the patient and the patient’s lawyer to keep them from suing the bejesus out of us.
But, as it were, we sat down with the director of nursing, the director of OPD, the orthopaedist, the radiologist, the ward doctor, the head of physio, and the medical director (one of 3) for the hospital and talked about what went wrong. Well, okay, actually the discussion seemed to focus on what went right. We didn’t kill the patient (or worse, make the patient a ventilator dependent quadriplegic) despite having multiple opportunities and trying really hard several times. And the physiotherapist didn’t choke the living shit out of the ‘spine specialist’ even though she had every reason.
It turns out, according to the orthopaedist who removed the patients stiff collar based on his ‘clinical judgment’ (despite looking at an x-ray, which, albeit a pretty crappy excuse for a film, showed the fracture on the patient’s first night in the hospital), that missing neck fractures is an everyday occurrence and we shouldn’t make a big deal of it. He suggested that we ‘Google missed cervical fractures’ and we would find loads of them. I was going to do this, but the internet is down today.
I tried to suggest how following certain protocols for patients with multiple trauma—such as the one where patients with head injuries or distracting injuries (another painful injury that might take the patient’s mind off their neck) similar to this patient had to have a complete series of neck x-rays (not done) and maybe a CT (not done) and have those films reviewed by someone who actually knows how to read x-rays (not done) prior to the collar being removed—might keep this from happening again. But I was shouted down by the orthopaedist and the radiologist. They weren’t going to start ordering a bunch of extra films or CTs on patients just because we missed one little neck fracture.
The general consensus among the doctors present seemed to be that the care was ‘good enough for Uganda,’ and that my ideas for a trauma team, and protocols, and forcing the radiologist to actually look at all x-rays taken in the ICU, well, they were all well and nice for ‘over there,’ but they just weren’t practical for IHK.
So my question of the other day has been answered. (see one of the updates posts where I mentioned that IHK/IMG has a new vision statement—to deliver medical care to ‘international standards’) To which international standards are we striving?
Here’s to the international standard of being good enough for Uganda.
But, as it were, we sat down with the director of nursing, the director of OPD, the orthopaedist, the radiologist, the ward doctor, the head of physio, and the medical director (one of 3) for the hospital and talked about what went wrong. Well, okay, actually the discussion seemed to focus on what went right. We didn’t kill the patient (or worse, make the patient a ventilator dependent quadriplegic) despite having multiple opportunities and trying really hard several times. And the physiotherapist didn’t choke the living shit out of the ‘spine specialist’ even though she had every reason.
It turns out, according to the orthopaedist who removed the patients stiff collar based on his ‘clinical judgment’ (despite looking at an x-ray, which, albeit a pretty crappy excuse for a film, showed the fracture on the patient’s first night in the hospital), that missing neck fractures is an everyday occurrence and we shouldn’t make a big deal of it. He suggested that we ‘Google missed cervical fractures’ and we would find loads of them. I was going to do this, but the internet is down today.
I tried to suggest how following certain protocols for patients with multiple trauma—such as the one where patients with head injuries or distracting injuries (another painful injury that might take the patient’s mind off their neck) similar to this patient had to have a complete series of neck x-rays (not done) and maybe a CT (not done) and have those films reviewed by someone who actually knows how to read x-rays (not done) prior to the collar being removed—might keep this from happening again. But I was shouted down by the orthopaedist and the radiologist. They weren’t going to start ordering a bunch of extra films or CTs on patients just because we missed one little neck fracture.
The general consensus among the doctors present seemed to be that the care was ‘good enough for Uganda,’ and that my ideas for a trauma team, and protocols, and forcing the radiologist to actually look at all x-rays taken in the ICU, well, they were all well and nice for ‘over there,’ but they just weren’t practical for IHK.
So my question of the other day has been answered. (see one of the updates posts where I mentioned that IHK/IMG has a new vision statement—to deliver medical care to ‘international standards’) To which international standards are we striving?
Here’s to the international standard of being good enough for Uganda.
Crazy week in Kampala
The Kasubi Tombs go up in flames (photo credit: Fans of Kampala FB page)
President Musaveni's security detail clear the way for the presidential visit by 'shooting into the air' (photo credit: Fans of Kampala FB page)It has been a crazy week in Kampala
Kampala made the New York Times last week. That doesn’t happen very often.
Monday afternoon I was giving my emergency preparedness and basic first aid lecture to a large but near-comatose group of employees at Total (the Ugandan affiliate of the French mega-oil corporation). The employees at Total Uganda have their health coverage from IAA (International Air Ambulance--the health insurance arm of IMG which, ironically enough, doesn’t cover air evacuation or, for that matter, even have an air ambulance), and as part of this coverage they get to have little health promotion talks from people like me who haven't figured out how to say no loudly or quickly enough. David, from IAA sales, and Lorna, from customer care, had arranged my visit. Despite doing everything but smack myself in the face with a two by four, I couldn’t get an iota of audience participation to save my life. Until I put up the slide with ‘Questions?’ Suddenly hands all over the room flew up.
Wow, I thought, they really were paying attention and actually have an interest in the subject. I called on one eager looking man at the back of the room who, strangely, was holding a file full of x-rays.
And the man launched into a lengthy diatribe about a knee injury several years before when he worked for another employer, seen my multiple doctors in Uganda, surgically repaired in India, now causing him pain, referred to an orthopaedist at IHK who doesn’t accept IAA and only takes cash. The man with the sore knee finished off his tirade by pointing his rolled up x-ray folder at me and asking, ‘So I just want to know if you doctors are interested in helping people or are just in it to make money?’ Not exactly the question I was expecting to come to Uganda as a volunteer to hear, I will have to admit.
David and Lorna, as you may have guessed, had set me up. My lecture hadn’t been well attended out of an interest in first aid. Instead, almost every man and woman in the room had a beef or a horror story to share about their health insurance.
Monday night, the final rowdy campaigning for the student guild president of Makerere University (Uganda and perhaps East Africa’s most prestigious higher education institution) got a little out of hand at the God Is Able Guest House. The supporters of the Kenyan candidate tried to shut out the supporters of the Ugandan NRM (national resistance movement—Musaveni’s party) and things got a little nasty and the private security guard for the guest house thought that some of the car’s parked at the guest house might be damaged. The guard, who was described in the Monitor as ‘not a regular drunkard’ but ‘harsh and violent toward the students,’ discharged his rifle ‘into the air as a warning.’ Thus answering the question in all of our minds about whether or not those elephant guns left over from Ernest Hemingway’s last safari that the private guards carry are actually loaded.
Yes, they are. Or at least this one was. The bullet passed through one boy’s chest, through another’s and finally penetrated a third boy’s neck. The boys lay ‘in a pool of blood for about an hour’ until their fellow students got enough money together for a ‘special hire’ taxi to take them to Mulago where the two boys with chest wounds were pronounced dead.
Tuesday the students rioted. They broke into a carpenter’s shop to steal a coffin with which to parade around Makerere and into several confrontations with the riot police. At one point the word was passed that they were marching to Mulago (where I was helping take care of the students with baton injuries) to get the bodies out of the morgue so that they could be buried in the central square of Makerere. Apparently, riot police cut the march short with batons and tear gas. Students these days. No follow through.
Tuesday night, as I left Mulago, I noticed a glow in the western sky that I couldn’t quite place.
The Kasubi Tombs, final resting place of the last four Kabakas (Kings of the Buganda kingdom), were burning. As the ‘world’s largest grass thatched roof structure,’ you can imagine it went up like, well, like a (grass) house on fire.
The Baganda (the people of Buganda) gathered to express their grief at the loss of this monument to their culture, and, in doing so, reportedly blocked the Kampala fire brigade’s only two fire engines (one of them, reportedly, a tanker truck that no longer holds water) from responding to the fire. Both trucks were damaged and six firefighters assaulted.
The Tombs on Kasubi Hill occupy the site of the palace of Kabaka Mutesa I—the Muziba Azala Mpanga, built in 1882—the 30th Kabaka of Buganda, who was later buried there. Mutesa was the first Kabaka buried with his facial bones intact. The Baganda believed that a man’s soul resided in his jawbone, so it was removed prior to burial and a special shrine was made to the disarticulated mandible. You can imagine what the missionaries had to say about that.
The Tombs have been listed as a UNESCO World Heritage Site and they are Kampala’s biggest (only, if the truth be known, unless you consider kabalagala at 4am) tourist attraction. I am sad to say, lameass tourist that I am, I had not been to the tombs yet. (my excuse being that I thought it would be something that Nancy and I could do during her upcoming [!!]5 week visit to Uganda)
On Wednesday, President Museveni came to the Tombs to inspect the damage and offer his condolences to the Baganda. As you may remember, the riots that occurred last September involved a presidential edict limiting the travel of the Kabaka, so there is no love lost between the two leaders. A large crowd of angry people tried to block Museveni’s convoy from entering. To gain control of the situation, the presidential guard fired their weapons ‘into the air, as a warning.’ Again, defying most Newtonian Laws of Physics, six men were injured by these warning shots—the two that were later pronounced dead in the resuscitation room at Mulago had gunshot wounds to their chests.
Things have been relatively quiet since Wednesday. But there is much speculation about the possibility of arson. Some suggest that the fire was set by the opposition in order to further the rift between the Baganda and the NRM in advance of the 2011 presidential elections, whereas the Baganda seem to be accusing the NRM of setting the fire to deprive them of tourist income and out of general nastiness.
A UNESCO report from a year or so ago has surfaced suggesting that the wiring for the structure was unsafe. Additionally, part of the shrine was a fire kept continuously burning to symbolize the living Kabaka as part of the unbroken lineage dating back to the 13th or 14th century. So arson and political sabotage may not be the only explanation to what amounts to a huge loss for the Baganda and the people of Uganda as a whole.
Later in the week an announcement was made by the Assistant Chief Inspector of Police that private security guards at student hostels in Makerere will not longer be allowed to carry lethal weapons. We can only hope that maybe they'll expand this to all of Kampala. Although I wouldn't want to be the guy who comes to take away Wilbuforce's (who guards our gate) bow and arrows...
Tuesday, March 16, 2010
Some Lessons American Health Policymakers could learn from the Healthcare System in Uganda.
Last night was the Uganda Irish Society’s St. Patrick’s Day Ball. Guinness was flown in all the way from Dublin. As was the band. There may have been irish whiskey as well… and dancing on tables… who knows… I’m pretty much denying any firsthand knowledge of anything that happened after midnight. Any videos circulating on Youtube have obviously been doctored. All this to say that I’m writing with a wee bit of a headache and a queasy stomach. And this may make me just a bit of a contrarian.
So, yes, I do understand that really I’m supposed to be here teaching the Ugandan doctors what they can learn from American medicine, but, unfortunately, there is no way in hell that Uganda will ever be able to afford American-style medicine (neither, if truth be told, can the United States). It would take a hundred-fold increase in healthcare spending to bring medicine in Uganda within sight of medicine in the developed world. And, given that over ninety percent of the public healthcare budget in Uganda is provided by foreign aid, it is unlikely that the aid-giving countries would go along with such a ramping up of the budget. (Maybe this is the first lesson we could learn. Maybe we need to get our healthcare system is such disarray that the EU will take pity on us and we can get their taxpayers to pay for our healthcare. Don’t laugh, many of our healthcare statistics are drifting down to third world levels.)
Lesson 1: Free basic healthcare for everybody.
Okay, so nothing is free, let’s say taxpayer-funded access to basic healthcare for everybody. As a Ugandan citizen you can walk into a Ministry of Health (MOH) hospital anywhere in the country and be seen by a doctor or a nurse and, if you need to be admitted to the hospital, you will be assigned a bed, or a mattress, or a little piece of floor space. All for free. I can hear you saying that in America you can walk into any ER and get treated without paying a cent, and this may be the case, but always a bill is generated that most people can’t begin to pay. If you are truly destitute, sure, it’s free for you (wasn’t there a Janis Joplin song about that?), but for the rest of us, struggling to keep our hamster-wheels spinning, if you don’t have insurance (and sometimes even if you do), that bill will screw up your life.
Sure. In Uganda, basic healthcare is very basic. Very very basic. Appallingly, horrifyingly basic. But if congress can put together a trillion dollar healthcare bill, certainly we can decide upon an acceptable level of basic healthcare and find a way to pay for it. We have decided, for example, as a country of taxpayers, that we will pay to educate our children K-12. Basic education. Additionally we have decided to subsidize higher education. Surely we could determine what constitutes basic healthcare—annual health visits, childhood vaccinations, prenatal and postnatal care, emergency care, hospitalization, etc—and what would be covered entirely, and what would be subsidized.
Lesson 2: Price tags.
At Mulago, basic care is provided to all, without charge. Depending on what is in stock, this may include IV fluids, some medications, or a CBC (complete blood count). If you need a CT scan, however, it will cost you 150,000 shillings (about $75). A night in the ICU—300,000 shillings. A month of dialysis—3M shillings.
In most cases, the extra fees are demanded upfront. In cash.
In America, in contrast, nobody really knows what things cost. A CT scan might be $1200, but this price isn’t out in the open, it’s buried in a computer program somewhere—and Blue Cross might pay $605 for it while Aetna pays $660 and Medicaid pays $300. The true cost of the CT scan, however, would be a few cents for electricity and digital storage, a few dollars of time for the technician running the machine, fifty dollars or so to the bank that financed the purchase of the multi-million dollar scanner, and maybe throw in a few extra dollars of profit for the hospital—or, about $75.
In American healthcare, neither the provider nor the consumer has a complete grasp on the cost of the service. We all want the best possible healthcare, we want it immediately, and we want someone else to pick up the bill. And, oh yeah, while your at it, don’t even think about raising our taxes. You don’t have to be a Greenspan or a Keynes to figure out that this is not a sustainable economic system.
Only by putting price tags that actually reflect what things cost and making those price tags readily available, can we, as a country and as individual consumers, make educated choices as to how our healthcare dollars are going to be spent.
Lesson 3: Re-involve the family.
In Uganda, a patient comes to the hospital with one or many family members. While the patient is in the hospital, among other things, the family will keep the patient clean, feed the patient, and help the patient move to the toilet. If, for instance, the patient is suffering from some sort of meningo-encephalitis related to his advanced HIV and is delirious and thrashing about in bed, the family will calm the patient, keep the patient from harming himself, and clean up the urine and fecal matter afterward. In the US, the restraining of an agitated patient would divert most of the staff from a ward or unit, it would significantly disrupt care for all of the other patients on the ward, and the fact that strangers were involved would exacerbate rather than sooth the patient’s delirium.
Granted, a patient that comes to a MOH hospital in Uganda without family can actually starve to death on the ward. But there are ways around this. Family members for hire, for instance.
Having family present on the ward leads to a better transfer of information about the patient’s condition and better ongoing care when the patient is discharged. And the family that better understands the medical conditions is better educated to make the financial decisions involved (see Lesson 2). Will the family choose to continue grandma’s dialysis, or will they choose to spend the money on the grandchildrens University? I can hear the gasps of shock and indignation already. But isn’t it more honest to make these decisions at a family level than to defer the decision to Congresses’ budgetary obfuscation? (What? You don’t believe that there is a relationship between the cuts in funding for higher education and the tremendous costs of healthcare in the last year of life? And just exactly how does the easter bunny get all those eggs painted?)
Lesson 4: Let hospitals be hospitals.
Nowadays, hospitals in the US are judged more on the quality of the double latte at the espresso stand in the grand atrium with the dynamic sculpture garden and water feature, and less on the bacterial resistance of the bugs in the ICU. Hospitals in Uganda don’t serve lattes. They don’t have customer service representatives. But, with the exception of a few that, due to plumbing issues, don’t have running water, most hospitals have the basics that a hospital needs: beds, nurses, doctors.
Let’s go back to building hospitals (yes, as a matter of fact, I am advocating the building of new or the reopening of old public hospitals) designed for the practice of medicine and stop with the idea that a hospital should look like a Grand Hyatt and have a five-star restaurant to match. A hospital should not be a place that you look forward to visiting.
Let the families (see Lesson 2) take care of the patient’s food and bedding. If the family wants to bring poached salmon and 1400 thread count linens, so be it. Let the hospital worry about the competency of their medical staff, not the quality of their catering.
Lesson 5: The ER is for emergencies.
The American ER has morphed from a single room into one of the most efficient (and expensive) places for accessing healthcare. And success is burying it. The American people like waiting for their CT scan just about as much as they like waiting for their Double Cheeseburger. The definition of what constitutes an emergency has been diluted to the point of absurdity. Additionally, the unfunded mandate that is EMTALA (emergency medical treatment and active labor amendment) makes the ER the only place that many uninsured and underinsured patients can get healthcare.
The entrance to the casualty ward at Mulago has a sign in English and Lugandan. It says that if you don’t have a life or limb threatening problem you should go away. When you enter the lobby area, the eyes of dozens of sick or injured patients scan you for outward signs of illness or injury—a mental triage to decide if you are going to bump them further down the waiting line. You are ushered behind the triage curtain and the nurse takes your complaint and vital signs. The nurse’s assessment may take a few minutes. If the nurse thinks you have an emergency she makes a color-coded dot on your chit, signifying your priority in the queue. If she doesn’t think you have an emergency, she may refer you to one of the outpatient clinics. She may just tell you to leave.
Lesson 6: More creative use of floor space.
Most of America’s hospitals are operating near or over capacity—either they actually have all the beds full, or they don’t have the nurses to staff the ones they choose to leave empty. What this means to you is that if you are sick and in the ER and need to be admitted to the hospital, you may lie for hours or even days in a corridor of the ER until a bed comes ready in the hospital. And it may mean that the ambulance that you think is taking you to the hospital where your doctor works may get ‘diverted’ to another hospital miles away because your hospital is closed. It also means that hospitals in the US have no ‘surge capacity’ as seen this past flu season when many US hospitals were overwhelmed by the relatively mild H1N1 pandemic.
Mulago doesn’t close. There’s always room for another patient.
Ward 3BEM is the holding ward for medicine admissions. Anybody that is admitted to the hospital from the casualty ward after 4pm has to spend the night in 3BEM before going to the wards. The ward was designed for 18 patients. Currently there are beds for nearly 40 patients and, in the far corner, a tall stack of foam rubber mattresses. When the beds run out, the patients’ families come in and pull a mattress over find a piece of floor space. When the floor space runs out, the patients spill out through the door into the hallway.
Lesson 7: More clinical involvement of the medical students and residents.
Back when I was a medical student (and it wasn’t that long ago, okay, so maybe it was along time ago, more than two decades) an intern was left to supervise us on the medical or surgical wards, while the residents and the attendings were off doing important stuff like heart surgeries or colonoscopies or lunch or something. Nowadays, things like that don’t happen. Medical students are barely allowed to touch patients, let alone make decisions about their care. Interns and residents are no longer allowed to act independently as physicians—every patient interaction needs to be overseen and countersigned by an attending (a board-certified, residency trained doctor).
This is the result of several things: fear of malpractice suits, legislation limiting the work-week of a physician in training, and convoluted Medicare billing regulations. The result is that medical students and residents get less hands on clinical teaching and practice now then they did twenty years ago. It means that they’ve been educated in a system of fear and paranoia that hasn’t taught them basic clinical skills (such as the physical exam) and has taught them to mistrust the clinical skills they do have and to only feel comfortable when they’ve ordered several thousand dollars worth of imaging studies and lab tests to back up even the most insignificant decision.
At Mulago, if you see anyone with a white coat, that person is likely to be a medical student or an intern. Most of the care is provided by the interns (the interns actually show up to work, as the internship is a requirement for registration in medicine in Uganda) under the intermittent supervision of the residents. It is a rare thing when a consultant walks the public wards. I’m not saying that the interns always make the right choices. Far from it. But at least they are out there day after day, meeting the patients, examining the patients, learning how to make medical decisions based on a very small amount of information—not just reading about it, or practicing on a computer simulator.
So, yes, I do understand that really I’m supposed to be here teaching the Ugandan doctors what they can learn from American medicine, but, unfortunately, there is no way in hell that Uganda will ever be able to afford American-style medicine (neither, if truth be told, can the United States). It would take a hundred-fold increase in healthcare spending to bring medicine in Uganda within sight of medicine in the developed world. And, given that over ninety percent of the public healthcare budget in Uganda is provided by foreign aid, it is unlikely that the aid-giving countries would go along with such a ramping up of the budget. (Maybe this is the first lesson we could learn. Maybe we need to get our healthcare system is such disarray that the EU will take pity on us and we can get their taxpayers to pay for our healthcare. Don’t laugh, many of our healthcare statistics are drifting down to third world levels.)
Lesson 1: Free basic healthcare for everybody.
Okay, so nothing is free, let’s say taxpayer-funded access to basic healthcare for everybody. As a Ugandan citizen you can walk into a Ministry of Health (MOH) hospital anywhere in the country and be seen by a doctor or a nurse and, if you need to be admitted to the hospital, you will be assigned a bed, or a mattress, or a little piece of floor space. All for free. I can hear you saying that in America you can walk into any ER and get treated without paying a cent, and this may be the case, but always a bill is generated that most people can’t begin to pay. If you are truly destitute, sure, it’s free for you (wasn’t there a Janis Joplin song about that?), but for the rest of us, struggling to keep our hamster-wheels spinning, if you don’t have insurance (and sometimes even if you do), that bill will screw up your life.
Sure. In Uganda, basic healthcare is very basic. Very very basic. Appallingly, horrifyingly basic. But if congress can put together a trillion dollar healthcare bill, certainly we can decide upon an acceptable level of basic healthcare and find a way to pay for it. We have decided, for example, as a country of taxpayers, that we will pay to educate our children K-12. Basic education. Additionally we have decided to subsidize higher education. Surely we could determine what constitutes basic healthcare—annual health visits, childhood vaccinations, prenatal and postnatal care, emergency care, hospitalization, etc—and what would be covered entirely, and what would be subsidized.
Lesson 2: Price tags.
At Mulago, basic care is provided to all, without charge. Depending on what is in stock, this may include IV fluids, some medications, or a CBC (complete blood count). If you need a CT scan, however, it will cost you 150,000 shillings (about $75). A night in the ICU—300,000 shillings. A month of dialysis—3M shillings.
In most cases, the extra fees are demanded upfront. In cash.
In America, in contrast, nobody really knows what things cost. A CT scan might be $1200, but this price isn’t out in the open, it’s buried in a computer program somewhere—and Blue Cross might pay $605 for it while Aetna pays $660 and Medicaid pays $300. The true cost of the CT scan, however, would be a few cents for electricity and digital storage, a few dollars of time for the technician running the machine, fifty dollars or so to the bank that financed the purchase of the multi-million dollar scanner, and maybe throw in a few extra dollars of profit for the hospital—or, about $75.
In American healthcare, neither the provider nor the consumer has a complete grasp on the cost of the service. We all want the best possible healthcare, we want it immediately, and we want someone else to pick up the bill. And, oh yeah, while your at it, don’t even think about raising our taxes. You don’t have to be a Greenspan or a Keynes to figure out that this is not a sustainable economic system.
Only by putting price tags that actually reflect what things cost and making those price tags readily available, can we, as a country and as individual consumers, make educated choices as to how our healthcare dollars are going to be spent.
Lesson 3: Re-involve the family.
In Uganda, a patient comes to the hospital with one or many family members. While the patient is in the hospital, among other things, the family will keep the patient clean, feed the patient, and help the patient move to the toilet. If, for instance, the patient is suffering from some sort of meningo-encephalitis related to his advanced HIV and is delirious and thrashing about in bed, the family will calm the patient, keep the patient from harming himself, and clean up the urine and fecal matter afterward. In the US, the restraining of an agitated patient would divert most of the staff from a ward or unit, it would significantly disrupt care for all of the other patients on the ward, and the fact that strangers were involved would exacerbate rather than sooth the patient’s delirium.
Granted, a patient that comes to a MOH hospital in Uganda without family can actually starve to death on the ward. But there are ways around this. Family members for hire, for instance.
Having family present on the ward leads to a better transfer of information about the patient’s condition and better ongoing care when the patient is discharged. And the family that better understands the medical conditions is better educated to make the financial decisions involved (see Lesson 2). Will the family choose to continue grandma’s dialysis, or will they choose to spend the money on the grandchildrens University? I can hear the gasps of shock and indignation already. But isn’t it more honest to make these decisions at a family level than to defer the decision to Congresses’ budgetary obfuscation? (What? You don’t believe that there is a relationship between the cuts in funding for higher education and the tremendous costs of healthcare in the last year of life? And just exactly how does the easter bunny get all those eggs painted?)
Lesson 4: Let hospitals be hospitals.
Nowadays, hospitals in the US are judged more on the quality of the double latte at the espresso stand in the grand atrium with the dynamic sculpture garden and water feature, and less on the bacterial resistance of the bugs in the ICU. Hospitals in Uganda don’t serve lattes. They don’t have customer service representatives. But, with the exception of a few that, due to plumbing issues, don’t have running water, most hospitals have the basics that a hospital needs: beds, nurses, doctors.
Let’s go back to building hospitals (yes, as a matter of fact, I am advocating the building of new or the reopening of old public hospitals) designed for the practice of medicine and stop with the idea that a hospital should look like a Grand Hyatt and have a five-star restaurant to match. A hospital should not be a place that you look forward to visiting.
Let the families (see Lesson 2) take care of the patient’s food and bedding. If the family wants to bring poached salmon and 1400 thread count linens, so be it. Let the hospital worry about the competency of their medical staff, not the quality of their catering.
Lesson 5: The ER is for emergencies.
The American ER has morphed from a single room into one of the most efficient (and expensive) places for accessing healthcare. And success is burying it. The American people like waiting for their CT scan just about as much as they like waiting for their Double Cheeseburger. The definition of what constitutes an emergency has been diluted to the point of absurdity. Additionally, the unfunded mandate that is EMTALA (emergency medical treatment and active labor amendment) makes the ER the only place that many uninsured and underinsured patients can get healthcare.
The entrance to the casualty ward at Mulago has a sign in English and Lugandan. It says that if you don’t have a life or limb threatening problem you should go away. When you enter the lobby area, the eyes of dozens of sick or injured patients scan you for outward signs of illness or injury—a mental triage to decide if you are going to bump them further down the waiting line. You are ushered behind the triage curtain and the nurse takes your complaint and vital signs. The nurse’s assessment may take a few minutes. If the nurse thinks you have an emergency she makes a color-coded dot on your chit, signifying your priority in the queue. If she doesn’t think you have an emergency, she may refer you to one of the outpatient clinics. She may just tell you to leave.
Lesson 6: More creative use of floor space.
Most of America’s hospitals are operating near or over capacity—either they actually have all the beds full, or they don’t have the nurses to staff the ones they choose to leave empty. What this means to you is that if you are sick and in the ER and need to be admitted to the hospital, you may lie for hours or even days in a corridor of the ER until a bed comes ready in the hospital. And it may mean that the ambulance that you think is taking you to the hospital where your doctor works may get ‘diverted’ to another hospital miles away because your hospital is closed. It also means that hospitals in the US have no ‘surge capacity’ as seen this past flu season when many US hospitals were overwhelmed by the relatively mild H1N1 pandemic.
Mulago doesn’t close. There’s always room for another patient.
Ward 3BEM is the holding ward for medicine admissions. Anybody that is admitted to the hospital from the casualty ward after 4pm has to spend the night in 3BEM before going to the wards. The ward was designed for 18 patients. Currently there are beds for nearly 40 patients and, in the far corner, a tall stack of foam rubber mattresses. When the beds run out, the patients’ families come in and pull a mattress over find a piece of floor space. When the floor space runs out, the patients spill out through the door into the hallway.
Lesson 7: More clinical involvement of the medical students and residents.
Back when I was a medical student (and it wasn’t that long ago, okay, so maybe it was along time ago, more than two decades) an intern was left to supervise us on the medical or surgical wards, while the residents and the attendings were off doing important stuff like heart surgeries or colonoscopies or lunch or something. Nowadays, things like that don’t happen. Medical students are barely allowed to touch patients, let alone make decisions about their care. Interns and residents are no longer allowed to act independently as physicians—every patient interaction needs to be overseen and countersigned by an attending (a board-certified, residency trained doctor).
This is the result of several things: fear of malpractice suits, legislation limiting the work-week of a physician in training, and convoluted Medicare billing regulations. The result is that medical students and residents get less hands on clinical teaching and practice now then they did twenty years ago. It means that they’ve been educated in a system of fear and paranoia that hasn’t taught them basic clinical skills (such as the physical exam) and has taught them to mistrust the clinical skills they do have and to only feel comfortable when they’ve ordered several thousand dollars worth of imaging studies and lab tests to back up even the most insignificant decision.
At Mulago, if you see anyone with a white coat, that person is likely to be a medical student or an intern. Most of the care is provided by the interns (the interns actually show up to work, as the internship is a requirement for registration in medicine in Uganda) under the intermittent supervision of the residents. It is a rare thing when a consultant walks the public wards. I’m not saying that the interns always make the right choices. Far from it. But at least they are out there day after day, meeting the patients, examining the patients, learning how to make medical decisions based on a very small amount of information—not just reading about it, or practicing on a computer simulator.
more updates
More Updates on Updates:
The week I was walking in the Rwenzoris (‘the place from which the rains come’) was a rainy week for much of Uganda. Mudslides on the slopes of Mount Elgon (to the east of Kampala) loosed some massive boulders and wiped out the village of Bududa, killing and injuring an estimated 500 people and displacing hundreds of thousands more. Mudslides on the western side of the country near Kabale closed the road to Rwanda and brought the number of homeless people to nearly a third of a million. Stacey, a nurse manager and fellow volunteer, contacted the VSO office to see if VSO was planning any actions in relief of the mudslide victims. She was curtly rebuffed and informed that such actions were not considered part of ‘VSO’s mandate.’ (this is the first time I’ve heard that VSO even has a mandate) Sarah, who loves her memoranda of understandings, did mention that maybe VSO should have a MOU with the Uganda Red Cross in the case of natural disasters.
We contacted the Uganda Red Cross directly to offer our respective professional services and were told that the best thing we could do is donate old clothes.
Cholera has struck the UDPF camp of soldiers cleaning up the mudslide.
The rains have been hard on Kampala as well, flooding the slums and washing away the already tenuous road surfaces. Cholera is back in Namuwongo. Two patients from Namuwongo and a patient from neighboring Kibuli were admitted to Mulago in the emergency medicine holding ward with profound diarrhea last week. They were transferred to the ‘cholera camp’ (a series of tents out behind the hospital—see previous post about the cholera camp) the next day, but not until after sharing a toilet with 50-60 other patients and caregivers on an open ward…
My walk to work has been seriously eroded as well. Which is actually a good thing as MSF has diverted the flow of SUVs in and out of their compound, slightly decreasing my likelihood of being struck dead by a Toyota Landcruiser speeding through a residential neighborhood, late for yet another meeting at the ministry (with the trendy no weapons bumper-sticker--as if that was the big threat). One of the roads that slopes down past the La Foret to the hospital had been shored up with white fiber bags that I had mistaken for sandbags at first glance. But the other day, one of the bags had been struck by a car and torn open to reveal its contents—it was stuffed with used disposable diapers… I don’t know, maybe they have something here. Maybe they’ve found the perfect, environmentally sound use for this otherwise impervious substance.
The week I was walking in the Rwenzoris (‘the place from which the rains come’) was a rainy week for much of Uganda. Mudslides on the slopes of Mount Elgon (to the east of Kampala) loosed some massive boulders and wiped out the village of Bududa, killing and injuring an estimated 500 people and displacing hundreds of thousands more. Mudslides on the western side of the country near Kabale closed the road to Rwanda and brought the number of homeless people to nearly a third of a million. Stacey, a nurse manager and fellow volunteer, contacted the VSO office to see if VSO was planning any actions in relief of the mudslide victims. She was curtly rebuffed and informed that such actions were not considered part of ‘VSO’s mandate.’ (this is the first time I’ve heard that VSO even has a mandate) Sarah, who loves her memoranda of understandings, did mention that maybe VSO should have a MOU with the Uganda Red Cross in the case of natural disasters.
We contacted the Uganda Red Cross directly to offer our respective professional services and were told that the best thing we could do is donate old clothes.
Cholera has struck the UDPF camp of soldiers cleaning up the mudslide.
The rains have been hard on Kampala as well, flooding the slums and washing away the already tenuous road surfaces. Cholera is back in Namuwongo. Two patients from Namuwongo and a patient from neighboring Kibuli were admitted to Mulago in the emergency medicine holding ward with profound diarrhea last week. They were transferred to the ‘cholera camp’ (a series of tents out behind the hospital—see previous post about the cholera camp) the next day, but not until after sharing a toilet with 50-60 other patients and caregivers on an open ward…
My walk to work has been seriously eroded as well. Which is actually a good thing as MSF has diverted the flow of SUVs in and out of their compound, slightly decreasing my likelihood of being struck dead by a Toyota Landcruiser speeding through a residential neighborhood, late for yet another meeting at the ministry (with the trendy no weapons bumper-sticker--as if that was the big threat). One of the roads that slopes down past the La Foret to the hospital had been shored up with white fiber bags that I had mistaken for sandbags at first glance. But the other day, one of the bags had been struck by a car and torn open to reveal its contents—it was stuffed with used disposable diapers… I don’t know, maybe they have something here. Maybe they’ve found the perfect, environmentally sound use for this otherwise impervious substance.
Monday, March 8, 2010
updates
Breaking news update on IHK:
IHK and its parent organization IMG (International Medical Group) now has a new vision statement, or is it mission statement: ‘Providing Healthcare to International Standards’
Not surprisingly, it took a 3-day strategic planning session with hired consultants and all of the IMG’s top managers to come up with this new mission/vision statement which is even slightly more vague and even more impossible to measure than the previous vision statement: ‘Making a Difference in Healthcare for Uganda.’
Healthcare, unfortunately doesn’t have any ‘international standards.’ Even the US and the UK can’t agree on something as simple as CPR (the American Heart Association teaches breaths before compression while the British Heart Association teaches compressions before breaths). Who’s going to set the ‘international standards?’ Will they be set in Europe, or Asia, or the Americas? Boston or Bangladesh? And if they are set, will they even be applicable in Uganda?
IHK and its parent organization IMG (International Medical Group) now has a new vision statement, or is it mission statement: ‘Providing Healthcare to International Standards’
Not surprisingly, it took a 3-day strategic planning session with hired consultants and all of the IMG’s top managers to come up with this new mission/vision statement which is even slightly more vague and even more impossible to measure than the previous vision statement: ‘Making a Difference in Healthcare for Uganda.’
Healthcare, unfortunately doesn’t have any ‘international standards.’ Even the US and the UK can’t agree on something as simple as CPR (the American Heart Association teaches breaths before compression while the British Heart Association teaches compressions before breaths). Who’s going to set the ‘international standards?’ Will they be set in Europe, or Asia, or the Americas? Boston or Bangladesh? And if they are set, will they even be applicable in Uganda?
Wrecked in the Rwenzoris (Climbing in the Mountains of the Moon)
for more pictures of the hike
“Born to walk on pavement.”—Anonymous. (scrawled in charcoal on the wall of the Kitandara Hut, 4023 meters above sea level [ASL] in the Rwenzori National Park)
I have hiked and climbed in many places in this world, some of them paved, most not, but I have never felt my senses of balance and proprioception tested like this past week trekking the central circuit of the Rwenzoris. Apparently, given the graffito above, I am not alone.
I think in a previous posting, I mentioned the 1990 movie Mountains of the Moon. Reference to the Mountains of the Moon first appeared in Ptolemy’s Geography. Ptolemy or Ptolemaeus (a Greek guy, citizen of the Roman empire, living in Egypt in the first century AD) noted that the trader Diogenes got lost on his way back from India and landed in Rhapta in East Africa from where he traveled west for 25 days until he found a giant, snow-covered mountain range which he dubbed the Mountains of the Moon, and the source of the Nile. Diogenes, many believe, may have been the first european to view what is now known as the Rwenzori Mountain Range. Many others, however, believe that Diogenes was a fabricating sack of dog poop.
In either case, the Uganda Wildlife Authority UWA) refers to the Rwenzoris as the Mountains of the Moon, and the area has been given National Park and UNESCO World Heritage Site status. Herbert, my ever-so arrogant RMS lead guide still holds to Diogenes’ otherwise universally disregarded assertion that the snows of the Rwenzoris are the source of the Nile. The Rwenzori Mountaineering Service (RMS) has a monopoly on guiding in the Rwenzoris. So if you want to go hiking or climbing in the Rwenzoris, you will need to talk to Elisha or Jerome (‘tourist officers’ for the RMS), or, most likely, both of them… many times.
As a wannabe climber hanging in East Africa, naturally I have thought long and hard about climbing Kilimanjaro (5895 meters ASL)—the legendary dormant giant volcano in Tanzania that towers to Uhuru peak, Africa’s high point. But I must admit to being put off by the thought of climbing in the company of hundreds (about 15,000 people try to climb Kili a year: 40% of them succeed, on average 10 of them die) of my fellow tourists, most of them nauseated with altitude sickness, on wet-wipe littered hiking routes that require little or no mountaineering skill. Don’t get me wrong, it may be a walk up Kili, but it is a long and strenuous walk to a very high altitude and anyone who has made this walk should rightly feel proud of their achievement. But, in the end, I set my sights on a lower, slower (only about 200 people climb in the Rwenzoris each year), and more local summit: Margherita Peak of Mount Stanley (5109 meters ASL)—highest point in Uganda, third highest peak in Africa, and home to what will soon be the last remaining glaciers in Africa.
And so, after many phone calls (hint: don’t even bother with the email), and after many changes in dates and plans (the dry season, theoretically, ends the first half of march, so I was under some time constraints trying to get a trip planned, and Elisha was trying to tag me onto to a group of American climbers, but they canceled, so he put me in with a Polish team), and after a 12 hour bus experience, I found myself in Kasese at the Sandton Hotel having dinner with my four new trekking/climbing partners: Pavel, Magda, Janocz, and Janocz.
Magda is a second year psychiatry resident at the Mayo clinic. She would find herself, later in the week, in the position of interpreter, moderator, and voice of reason ('I have absolutely no testosterone.') for the group. Her father, Pavel, and the two Janoczs had traveled together and climbed Kilimanjaro in the past ('My father says there was nothing this hard on Kilimanjaro.' Magda would confide later). Magda had a brand new ice axe and pair of crampons in her pack.
The next morning, before breakfast, I met Herbert and we took a walk to the Bata shop to purchase the essential piece of Rwenzori mountaineering equipment: a pair of rubber boots. I opted for the 19000 shilling boots with the molded heel and tread as opposed to the more slippery soled 12000 shilling model. The extra 7000 shillings would turn out to be a worthwhile investment. Even so, the boots still had less padding under the balls of my feet than my flip-flops. I tried to have a conversation with Herbert about the conditions in the mountains, but couldn’t get him to contribute more than a few grunts and an enigmatic ‘it will be very wet and very hard.’ More than anything, he seemed annoyed that he’d had to get up 15 minutes early to make this errand.
I have been fortunate to climb with some excellent mountain guides. In the early stages of an expedition, most guides would be trying get some idea from the clients as to just exactly what their level of climbing skills were, so as to make an assessment on whether they were suitable to take into the mountains and what additional safety or climbing gear might be needed. Herbert had no such curiosity. He soon decided that the Poles could not understand what he said, so he addressed all of his comments to me—expecting me to tell the rest of the climbing team what to expect. Fortunately, Magda was able to re-direct.
After breakfast we loaded up the gear and drove an hour on a dirt road out of Kasese into the mountains to the village of Nyakalengijo. At the RMS headquarters we were greeted by over a hundred men in rubber boots with their faces pressed through the gaps in the bamboo fencing. According the RMS fee schedule, the climbing fees include one guide and two porters per climber. The village men have been lining up here to carry loads into the mountains for over a hundred years since the Duke of Abruzzi came to climb the peaks of the Rwenzoris in 1906. It is not mentioned just how many men were involved in the first ascents in the range, although initially the string of porters was over a half a kilometer long. It also isn’t mentioned how many of the porters died on the initial expedition, but Herbert said that at least 3 fell to their deaths trying to ascend the Kicucu cliffs, the new path discovered by the Duke’s guides into the heart of the Rwenzoris.
I have some mixed feelings about using porters. Part of me feels the need to have the packstraps digging in around my shoulders to get the full-on masochistic climbing experience. The other part of me wishes the porters would carry up lawn chairs and a pony keg as well. But since the mines closed in the 60s and all of the game has been killed off, portering is one of the few opportunities for employment in the foothills, so I feel okay letting them carry my pack as a contribution (however small for the toil involved) to the local economy. The porter who gets my pack lucks out—it is a good five kilos under the 18 kg limit (maybe I should have brought more warm clothes).
For our first day we walk from Nyakalengijo to Nyabitaba camp (1600m-2651m). Herbert says it will take us a maximum of four hours. It takes us five. We walk with Nehemiah and Jomad, Hebert’s two subsidiary guides, who might speak English, but since they never opened their mouths, it was hard to tell. Jomad would walk a random number of steps (4-17), and then stop abruptly and turn to see if we were still following. Invariably we were. After bumping into him from behind on several occasions I learned not to follow Jomad too closely.
We walked along the Mobena river through a forest of moss drenched cedar and giant ferns. The occasional massive banana tree loomed unasked for by the side of the trail. We could hear monkeys in the trees and catch glimpses of them in the canopy. But we never got enough of a view to identify them as the rare red rwenzori colobus monkey as opposed to the usual black ones. At one point in time, the bush elephant roamed the foothills. It would have been an amazing thing to run into an elephant on a climbing trip, but they were killed off in the 70s or 80s, so it was not to be.
We reached the Nyabitaba hut just as the rain starts. An Austrian climber, Franc, has beaten us there. A rain-sodden Japanese team of four photo/video journalists dragged in just before dark and promptly set up their camera and start filming us taking our tea on the veranda (if you happen to be watching the Japanese Discovery channel next year and see a documentary on climbing in the Rwenzoris, please post it on You-tube and let me know). Franc and the Japanese will be the only Mzungus we encounter during our week in the mountains.
Pavel and the Janocz, in their limited English (but, much less limited than my Polish) show me why their packs are so much bigger than mine. They are loaded with Polish Cheese and Sausage and nearly a gallon of pre-mixed Margaritas. We toast irridescent green tequila containing substance to the peak we will never truly see: ‘Margherita!’
Rwenzori comes from the Bakonjo (Bakonzo?—one of the two local tribes that make up the recently established Rwenzururu kingdom, a splinter of the Toro kingdom) language and roughly translates as ‘place from where the rains come.’
The rains come down in earnest on our second day’s walk from Nyabitaba to John Matte hut (2651m-3505m). Herbert says the walk will take us a maximum of seven hours. It takes us eight. You may be picking up a trend here. We descend off the ridge to cross the Mobutu river just below its junction with the Bujuku river—both running brown and high with the recent influx of rain and mud. We criss-cross the Bujuku on increasingly more fragile bridges as we wander through a bamboo forest and then into thickets of mossy rhodedendron looking trees. Again, Jomad leads the way in his walk-stop, walk-stop hokey-pokey, but today he throws in the additional movement of bending over to probe the mud holes with his iceaxe. He doesn’t let us know the findings of his soundings, but we quickly learn to follow where his boots have gone.
That evening, waiting for the Japanese team to drag in with their embarrasingly long train of porters (carrying, among other things, a portable generator), the clouds break and we see a waxing moon, a few stars and our first sighting of Mount Baker (4843m). Herbert announces that the weather is changing and that tomorrow will be clear. The rain pounding on the corrugated metal roof wakes us at 5 am.
In Herbert’s defense, the third day’s walk from John Matte to Bujuku Hut (3505m-3962m) was relatively rainfree and there was a 20 second interval of sunshine. We crossed the Lower and Upper Bigo Bogs—huge expanses of wetland with African mountain swampgrass (carax runzorensis) and helichchrysis (a Labrador Tea looking shrub with closed up white flowers) interspersed with Giant Lobelias and Giant Groundsel trees. It was a surreal, other-worldly sort of landscape—beautiful but not quite graspable. The lower bog had a one-year old board walk, raised on plastic barrels with randomly spaced boards to keep your attention on your feet. The upper bog’s boardwalk had partially rotted away and was sunk beneath the surface of the swamp making the bog crossing problematic and messy.
Without the aid of a boardwalk, the porters each set their own path across the bogs, as using a single path would have quickly churned a waste deep trough of mud. If you were a wetlands conservationist, you would be driven to tears, or violence, at the destruction caused just by our group of travelers.
Hopping from tussock to tussock, with occasional slips into the boot-top deep mud, we made our way around the shore of Lake Bujuku to the Bujuku camp. At dusk, the clouds lifted just high enough to tease us with views of Mount Speke (4890m) to our north, Mount Baker to the south and Mount Stanley to the west. Herbert prognosticated that the weather was good and tomorrow would be clear.
The next morning Herbert told us that Nehemiah was suffering from altitude sickness and was heading back to base camp. Needless to say, this was an omen that didn’t bode well for our little group. Not only were the guides unacclimatized, but now we were left with only two guides, neither of whom really liked to talk to us. It would seriously limit our climbing and rescue options. Not that the rescue options were very good to begin with. The Rwenzori Rescue Plan (RRP) is, well, you die. Okay, so it’s a little more complicated than that—if there’s an emergency, one of the guides will return to a point where they can get mobile phone service (Nyabitaba hut or lower, if they have battery life, or airtime) and call a rescue team which will proceed on foot to the injured or sick climber. (even in good weather, neither of the two civilian helicopters in Uganda could make it that high into the Rwenzoris) So basically you would wait 2-3 days for a rescue party. Like I said, you die.
Franc, the lone Austrian, and his guide had decided that the weather would be clear as well and they would go for the summit from the Bujuku hut (as opposed to the higher Elena hut), so the fourth day started with the sounds of Franc’s alarm watch in addition to the driving rain on the tin roof at 4:30 am. Unfortunately, Franc couldn’t find his guide, so he rewoke us coming back to bed. Franc and his guide would leave about seven.
We continued our trek—from Bujuku Hut to Elena Hut (3962m-4541m)—in a drizzle, up hill through the bog until we hit rainslick granite and quartz boulders which gradually transform into cliff faces. Still wearing our rubber boots, we began to make progressively more technical rock climbing moves. In the rock-climbing vernacular, this would be called ‘pretty freakin’ gnarly, dude.’ But in layman’s language, you would have to call this a recipe for disaster.
So naturally, while walking along a tiny ledge, Pavel slips. Luckily, he manages to grab the ledge as he slides by, because the alternative would have been a long, bone-crushing fall. Herbert’s reaction to this is: ‘sorry’ along with a contemptuous look that indicates he thinks Pavel is clearly retarded for not being able to negotiate a two inch crack while wearing hip-waders. We manage to get Pavel up to a safe flat spot, but he isn’t moving his right arm. On examination he has a dislocated shoulder. (Oh, no, I can hear you say, enough with the dislocated shoulders… Okay, so it is basically a party trick, but, hey, if you only have one trick, it’s good that the people getting hurt around you are cooperative enough to play into it)
We (Pavel and I, Herbert seems to think that Pavel is faking not being able to move his arm) manage to get Pavel’s shoulder relocated and get him up to the Elena hut otherwise unscathed. I suggested to Herbert that we at least get a harness on Pavel and get him short-roped to someone, but, as you might expect, Herbert had nothing of the sort in his pack. Neither, I am sad to say, did I—one problem with letting the porters carry all your gear.
I haven’t been able to identify the Elena that the Elena hut is named after. When the hut was first put up nearly fifty years ago, the glaciers started at the front door. Now they have retreated to small crescents on the horizon and a slippery rock face slopes down to the cabin. Two rock pillars guard the entrance to Mount Stanley: Nyabibuya to the left and Kitsemba to the right—named for to Bakonzo deities thought to reside in the mountains and strike down those who perform acts contrary to the cultural norm (i.e. mountain climbing).
Somewhere a little further up in the hanging clouds lurks Margherita peak.
Pavel initially thinks that the rocks may dry up, and that he will continue the climb. But our general anxiety over what has happened to Franc, who we last saw in the early morning, supersedes further discussion. According to the guides, Franc should have been down hours ago. I ask Herbert is he has been in contact with Robert, Franc’s guide. He tells me that their cell phones won’t work up here. I ask if we should start putting a party together to go up and look for Franc. He looks at me like I’m deranged.
Just as the last vestiges of light are disappearing, Franc and Robert appear on the ridge top and start slipping down the rocks. The summit attempt that Herbert says should take a maximum six hours has taken them eight. Pavel asks Franc about the advisability of trying for the summit using one hand. Franc smiles and shakes his weary head. No.
Pavel, Magda and the Janoczs sit down with their remaining bottle of Margarita and confer. They decide that, in the morning, they will all head down to Kitandara Hut with Jomad. That leaves me and Herbert to make the try for Margherita. Herbert looks at the momentarily clear sky and tells me that we will have good weather in the morning. He announces we will leave at five. I tell him that I won’t be doing the rock face above the camp in the dark if it is raining. He says it won’t be raining. The weather has told him all he needs to know.
0400: wake to pounding rain on the tin roof
0415: Elisha, our cook, puts a thermos of hot water on the table (I stay in my sleeping bag)
0430: Elisha puts French toast on the table and tells me breakfast is ready (I still stay in my bag)
0445: Elisha comes and shines his head light in my face and tells me breakfast is ready (still in bag)
0450: Herbert comes in and shines his light in my face and says that the weather is good and we’ll leave at five. (still in bag)
0500: I get out and dressed and just about kill myself in the slippery fog outside the hut trying to pee. I find Herbert and reiterate my statement of the night before about not climbing the rock face in the dark when it’s raining.
0700: The sun starts to cast a dim light through the low clouds and the drizzling rain. I get up and dressed again, eat some cold French toast and go looking for Herbert.
0745: We head up the hill.
Words that you really don’t want to hear from your mountain guide: ‘Can you put the rope in your pack?’
Something that makes these words more frightening: you notice that he’s not bringing a pack. (Usually on summit day, the guide has the biggest pack—he/she will be carrying the rope, the climbing gear [including appropriate snow or rock anchors] and survival gear, in addition to the usual food, water and extra clothing) Herbert has a couple of beeners and an ATC clipped on his harness, nothing else. I’m carrying a backpack designed to carry my laptop, stuffed to capacity.
Something that makes it even worse: the rope he hands you isn’t even a legitimate climbing rope, its 7 or 8mm cord.
I foolishly ignore all the warning lights and sirens going off in my head (it is hard, after slogging uphill through mud for four days, to suddenly let go of the climb a few hours short of the peak) and follow Herbert up the slick rocks above camp. All I can think of as we shimmy up the rock face into the face of the small cascades of rainwater is just how scary it will be to come down. But we manage to make the ridge top and the lower edge of Stanley glacier.
Mount Stanley, in case you were wondering, was named for Henry Morton Stanley, of the ‘Dr. Livingstone, I presume’ fame. Stanley, a Welsh journalist, explorer, and mercenary who managed to fight for (and desert from) both sides of the American civil war, led an expedition into the interior of Africa to rescue the Emin Pasha and in 1889 was with the first modern Europeans to see the Rwenzoris.
We rope up. I put a rescue coil (extra rope to lower into a crevasse) at my end of the rope. Herbert doesn’t. I rig up my prussics for crevasse self-rescue. Herbert looks on in bored disinterest. Herbert probably weighs 50kg with all his gear. Me, 85. I might be able to pull Herbert out of a crevasse. There would be no chance in hell of Herbert pulling me out. I suspect that his plan for the event of my crevasse fall would be to cut the rope and move on.
We are now climbing over 5000 meters and the air is scarce. I am panting like an overheated Saint Bernard. We traverse the Stanley Glacier and the buttress for Alexandra Peak and head up Margherita Glacier into a snowstorm. I don’t know if you remember the scene in the mountains from The Fellowship of the Ring where Legolas, the elf, is walking on top of the snow while the rest of the party pushes through waist deep snow, but this is how I felt on the glacier—Herbert walked easily on top of the crust while I broke through up to my knees. Herbert kept tugging on the rope and turning to look at what was wrong with me.
There were some rickety ladders blowing in the wind at the peak. I used a prussic for a margin of safety on the frayed fixed line and we manage the remaining climb to the summit. I had hoped for some view of the Rwenzoris from the top, but it was not to be. I could see a couple hundred feet down the ridge, and that was all. I snapped a few pictures, and we got the hell out of there.
I was walking first down the Margherita Glacier as it flowed over a hump in the mountain—a decompression zone in the glacier where cracks and crevasses form. Herbert chose this moment to shorten the distance between us by holding several coils of rope in his hand—increasing the risk of both of us falling into the same crevasse, and ensuring that if I did fall, the speed and depth of my fall would be exponentially increased by the length of rope in his hand. Fortunately, most of the crevasses were fairly well defined and of jumpable width. Unfortunately, Herbert had the annoying habit of yanking the rope taught just as I would start to make the jump over a crevasse, stopping my forward momentum and nearly dropping me in the crevasse on several occasions.
We managed to get down the glaciers without further incident. At the final rock face, Herbert unroped, despite my suggestion that we stay roped up until the hut. He clearly did not trust my rock-climbing skills enough to want to be tied into me on this part of the descent. I stooped to take off my crampons, but he indicated I should leave them on. Granted, the rain was still sheeting down and the rocks were slippery, but I didn’t think the crampons were going to make them any less so. A bit later, as we made a traverse around a large boulder in a narrow crack, I leaned just a bit to far into the rock, and the width of my boots levered the relatively narrower crampons out of the crack and I slid for nine or ten feet down the rock into a heap at the bottom. I took my crampons off.
Adrenaline, and a thorough understanding of the Rwenzori Rescue Plan, got me to my feet and down to the hut and, a bit later, down to the Kitandara Hut (4023m), where I could finally sit down and make an assessment: right leg—one huge coalescing bruise from the hip down to the ankle; right knee—sore, creaky, but no unstable ligaments; right ankle—swollen, purple, but stable and probably not broken; left knee—sore but stable. I am dehydrated (Herbert drank over half my water on the summit climb as he brought none of his own) and starving.
Pavel and the other climbers had made it safely off the wet rock and were enjoying the relatively warmer weather and the beautiful lake at the lower hut.
The next day we climbed back up over 4000 meters into Freshfield pass and took one last fleeting look at Mount Baker and Mount Luigi di Savoia (the Duke of Abruzzi). And then descended gingerly to the Guy Yeoman Hut (3450m). Ski poles and consistent doses of ibuprofen kept me upright. The final day we descended under the cliffs of the Kicucu rock shelter and down into the bogs to enjoy the sensation of mud overflowing the boot-tops one final time before rejoining the trail just above the Nyabitaba hut and making the descent back to Nyakalengijo.
I bought the porters a well-deserved round or two of lukewarm beer and soda at the base-camp tavern. Strangely enough the number of porters suddenly doubled.
Herbert told the Polish climbers that ‘next time they would reach Margherita Peak.’ Magda translated and they all started laughing. What was said in Polish was no doubt something like ‘not a chance in hell will there be a next time.’
I have to agree. I am glad that I hiked the circuit in the Rwenzoris. Even in pouring rain the landscape and mountainscape is unique and beautiful around every muddy bend in the trail. But I am also glad that I won’t have to do it again.
The 2006 book Don’t climb Kilimanjaro (Climb the Ruwenzori) will no doubt increase the traffic of hikers and climbers into a park where infrastructure is not in place to protect the environment and the guides and the rescue systems are not prepared to keep the hikers from harm. This is too bad. My recommendation would be that if you do wish to climb in the Rwenzori, unless you are an expert climber, that you travel with one of the several groups per year that bring their own European mountain guides.
In Kasese I said my goodbyes and shook hands with Herbert. ‘I feel fortunate to have survived climbing with you.’ It was hard to read any more into his fixed facial expression of general disdain. I’m sure he was thinking, ‘likewise.’
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