one last road trip

One last road trip

Over the course of the year, I have traveled with Alison (reintroduction: Alison is a London GP here with the VSO who has been assisting the training team for the IMC clinics) to nearly all of the outlying IMC (International Medical Centre, the clinic portion of the IMG conglomerate) clinics to teach emergency medicine topics to the doctors and nurses.

The most isolated of the IMG clinics in Uganda is in Pader. If you were to plot health resources on a map of the country, the Pader district would show up as a big, gaping blank spot in north central Uganda. The IMC Pader clinic is a joint venture between the IMG and the local health district. We had been trying to plan a visit to the Pader clinic since last October, but the higher powers kept shutting us down because no one was sure the public/private partnership would hold up. Now that I was in my final weeks at IMG it appeared that the partnership was up against similar time constraints. Ultimatums had been made. Tensions between the IMG employees and the local ministry employees were high and morale low.

And so it was that I found myself in Jasper (the Cowan’s 4WD minivan) with Alan and Alison and the kids (Amy, Zoe, Bella), headed north on Bombo Road regaled by multiple verses of Amy and Zoe’s school song: ‘we are the children of Rainbow School, we take pride in the things we do…’ and the ever popular ‘my Bonnie lies over the ocean… (with an ear-splitting emphasis on the Bring Back).’

As I maybe have mentioned. Richard and Pat have reappeared on the IMG/VSO scene and are trying to facilitate the merger of the IMC and Charis clinics in Lira (see the December 2009 posting ‘back to gulu’) with the hope of turning the project into a level 4 (HC-IV) health center. An HC-IV is what you might consider a small hospital: an outpatient clinic, inpatient beds, a delivery room, an operating room, a lab, maybe x-ray, except that all of this would be run by one doctor, a clinical officer (think PA or NP), a few nurses, and a lab tech. Yow. Fortunately, the doctor they have chosen is one of my favorites, Dr. Leonard, and he seems to be thriving on the challenge.

Richard and Pat had asked that we stop in Lira on our way to Pader and do a little training at the clinic. Given that there is nowhere to spend the night in Pader, and given that Richard and Pat have guest rooms (what they call ‘boys’ quarters’ here), we thought that was a pretty good idea. So after 5 hours on the road we stopped at the clinic, and I did a session of basic life support with the clinic staff while enjoying a little irony in the knowledge that the topic most in demand is one I don’t practice at home because I am surrounded by nurses and techs and paramedics much more skilled at CPR than I am.

We had a passable spicy barbeque chicken pizza at an internet café overlooking Lira’s town square, where, down below, they were warming up for a free concert by Dr. Jose Chameleon and Bebe Cool to promote the electoral process (it’s good to see Uganda’s hip hop community coming out to support voting rights). And then the next morning we headed north on increasingly sketchy roads to Pader.

I was navigating. So naturally we go lost. Just after I made the comment that, ‘surely Pader will be a bit more built up than this,’ we missed the single track turn into town. We drove about 5 kilometers down the road to Ayam before one of the local men set us straight: ‘Mzungu, you are lost.’

Pader was part of the UPDF (Ugandan People’s Defense Force, ie, the army) strategy to combat the LRA (Joseph Kony’s Lords Resistance Army, now thought to be hiding somewhere in the Congo) by clearing the land of people so the LRA could have no support and no children to kidnap to use as soldiers. So, in order to keep the LRA from raiding and pillaging villages and farms, the UDPF burned the villages and farms and moved the people of the countryside to crowded IDP (internally displaced people) camps in and around Pader. To use a quote from a Caledonian rebel named Calgacus, describing the Roman empire a couple thousand years ago: "They create a desolation and call it peace"

Nearly all of the people moved to the camps lived a subsistence agricultural lifestyle. It is thought that many more people have died in IDP camps in this area from malnutrition and diseases brought on by overcrowding, than have died at the hands of the LRA. Some have called this an unheralded genocide against the Acholi people of North Uganda.

Now that the LRA is thought to be less of a threat, the UN’s World Food Program is trying to wean the IDP camps off the teat of flown in food. But the crops haven’t come in yet. Debs, one of the VSO volunteers in Lira, was out in the northern reaches of the Lira district (just below Pader) and found that the people who have left the camps had nothing to eat but mangos and ants. But apparently the ants were quite tasty.

The Pader district is also an area to which VSO prohibits travel of their volunteers (although the ‘no-fly zone’ document has not been updated recently). So naturally we brought Amy, Zoe and Bella along for protection.

The Pader clinic is an HC-III striving for HC-IV status. Through the continued generosity of one optimistic UK donor, the IMF (International Medical Foundation—the charitable arm of IMG) has been able to keep the clinic staffed with a doctor and nurse and provide medications that otherwise would not be available. The ministry of health (MOH), for their part, provides a clinical officer and a couple more nurses. Several new buildings were recently constructed—a new labour and delivery wing, medical ward and operating theatre—interestingly enough, by the US Army. A new bore hole was drilled by an Italian cooperative nearby with a solar operated pump to help the water up into two huge storage tanks. Unfortunately, due to some quirk in gravity, the water won’t flow uphill into the HC-III plumbing, so the clinic has no running water. And, although power lines have been brought in to within a stone’s throw of the clinic, no one has connected the clinic to the grid. And (I know, it keeps coming) the new buildings, without water or power, also have no beds or medical equipment.

And the nearest hospital is an Italian mission hospital in Kalonga, 40 kilometers northeast on a scrabble road. At least the IMF project was able to fix the ambulance and put petrol in the tank.

Dr. Hillary is the IMG doctor exiled to the north to witness the experiment. The fact that he continues to smile and work in the face of such desperate circumstances and despite overt sabotage and theft by the ministry workers speaks loads about his character. Apparently the project had been functioning surprisingly well until the original clinical officer who had embraced the partnership was replaced by a more senior and hardened clinical officer who seems to be on a mission to send the IMF packing. Hillary had managed to instill some pride and work ethic at the clinic until Peter showed up and reverted to business as usual—not showing up for work, not seeing patients, diverting medication from the pharmacy into the private sector for personal profit.

The Pader clinic, built almost entirely with foreign aid, remains firmly under MOH control. The clinic officer is the appointed manager of the clinic despite Hillary’s seniority, and he has used his managerial position to bully the rest of the staff into behaving as typical MOH employees would. The project seems destined for failure unless the IMF team gains some managerial control—but even then it will be a long uphill battle. Chances are good that the people of Pader will soon be left with a half finished health center with an empty pharmacy, a permanently parked ambulance and an absentee medical staff.

Alison and I held a poorly attended training session. We are happy to report that the IMF receptionist at the health center is now certified to provide CPR.

Jasper and the Cowans were headed across to Sipi falls for the weekend. But I caught a ride back to Kampala with Phil and Clea, UK volunteers for the IMF, so that I could catch a flight to Kigali for a little LSTM (Liverpool School of Tropical Medicine) reunion.

one last boda ride...

One last Boda ride.

Last monday’s hash was way out past Kireka (home of Uganda’s Nelson Mandela Stadium) on the road out to the Namugonga martyrs shrine (a shrine that commemorates an effort by Kabaka Mwanga to purge his court of Christians—apparently some 30 people were hacked and/or burned in May of 1886 after being given the chance to renounce their newly adopted faith). It was Cara’s last night in Kampala (she’s now somewhere down in South Africa in the wind up for the 2010 World Cup—I wish her well). We caught a ride to the hash with Ian in the X5, careening across town in a haphazard route, attempting to beat ‘the jam.’ Ian was in an affable mood and seemingly oblivious to the jerking around Cara had recently been given at the hands of his HR department. He gave us his take on the motivation behind the massacre of the martyrs. Something about homosexual eunuchs and pedophiles.

The hash was held at the Linda Country Club. No tennis courts. No golf course. No driving range. But it did have a pool. Unfortunately the pool was so clouded over that you couldn’t see the bottom. In the shallow end. So, sweaty and dusty and hot as we were after the run, no one mustered the courage to take a dip.

It was my first hash, or my first run for that matter, in over a month, so my legs were whining at having to chase down the pack upon our late arrival. But the efin beer (imported from turkey, of all places) chugged hot from the bottle seemed to help anesthetize my thighs at the first beer stop. The run had all the elements of a good hash: Confusing trail markings. Very little tarmac. Lots of amused spectators to point and laugh. One or two rabid dogs. Warm beer and pineapple at the finish.

I can’t remember the offenses I committed causing me to be called into the circle to swill beer, but considering the severity of the punishment, I’m sure they were heinous.

Given that my days in Kampala are numbered and it is hard to get good matooke in San Francisco, I was looking forward to one last Ugandan buffet dinner (the 7000/= entry fee for the hash entitles you to a ‘free’ dinner). Sadly, though, the caterers had forgotten the matooke, and I had to settle for rice and sauce. But, I will have to admit, it was some of the best goat spine I’ve had in a while.

Sitting in a plastic chair sipping a Nile as the sweat evaporated from my tee shirt, chatting political gossip with the hashers, most of whom I know only by their ribald or otherwise obscene hash ‘handles,’ as a crescent moon burned through the smoky haze of the night sky of a city half a world away from home, it suddenly struck me as the perfect way to spend a Monday evening.

And then the hashers drifted away in ones and twos to make their way home across the potholed lunar landscape that is the Kampala road network. I caught a ride toward town with Cara and some of the teachers from the International school, but when they turned onto the ‘northern bypass’ (my home slum is south), I got out and waved for a boda boda.

J. Maarten Troost, in his epic memoir/travelogue about life on an atoll in Kiribati, The Sex Lives of Cannibals, best describes a phenomenon that happens when you live for an extended period in a place where life is cheap and pestilence and bloodshed are everyday occurrences. Acts of simple self-protection or personal hygiene, like fastening your seat belt or putting on deodorant, fall by the wayside as silly, inconsequential rituals. One of my favorites from the book: “At a funeral, I had a generous helping of chicken curry. In front of me lay the corpse. It was the custom in Kiribati to lay out the body of the deceased for three days before burial. Kiribati is on the equator. I had seconds.”

And so, wearing a tee-shirt and running shorts, after a few beers, in a dark and unfamiliar part of town, I hopped on the back of a motorcycle piloted by a wiry, helmetless young man with a slightly manic smile and vaguely exophthalmic eyes. My helmet, as you might expect, was safely sitting on the counter in my office. I put my sunglasses on, to shield my corneas from road grit—heightening the sensation of night flight.

I had a general idea of the route we needed to take home: mbuya, bugolobi, cut through the industrial area, and into namuwongo and finally bukasa, so I wasn’t too disturbed as he wheeled into an increasingly complex maze of backroads. I was running the words of a long forgotten Grateful Dead song through my head and reveling in the warm night breezing around me. And we came around a corner directly into the path of a speeding matatu.

One of the doctors I work with lost her mother a few weeks ago. On a boda, struck by a matatu.

I had just about enough time to contemplate if I’d be able to get off a call for the IHK ambulance before I lost consciousness and someone pried the phone out of my stiffening fingers.

But my driver threw the bike to the left, and, although I felt the wind from the mini-van’s rhino bar on my elbow, we avoided the impact by a good several millimeters. Half sideways, we catapulted across the ditch. I braced myself for the sensation of gravel on bare skin. Instead, we crashed through a chapatti stall. Charcoal embers traced red arcs around us a la evel kneivel. Everything went black. I couldn’t see, and I couldn’t breath. I pulled the midnight blue satin that was once a prom dress off my face. I took off my glasses. The bike had come to rest in a roadside dress shop.

As my driver frantically kicked at the starter of his stalled bike, people gathered around us, coalescing into a proper mob. Dozens of hands prodded him. With a conscious effort not to lose control of my clenched sphincters, I got off the bike and tested my legs. They worked. I pulled the last of my money from my pocket—a few thousand shillings more than the ride home would have cost me--and handed it to the driver. As I backed out of the circle, one woman kept her cupped hand in my face while shouting at me. It seemed she wanted me to buy the dress.

I walked home.

updates

a lioness in the Serengeti enjoys a little fresh gnu.
for more pictures of the serengeti


a mommy and baby black rhino in Ngorongoro
for more pictures of Ngorongoro crater


Yes, it has been a long time. I even managed to forget my password, so for a moment there it looked like the very future of this blog was in jeopardy. But even with the password, I am sorry to report that the future of this blog remains perilous. I am scheduled to leave Uganda on May 28th. I will be back at work, in the Emergency Department on June 7th (those of you who live in the San Francisco bay area may want to be extra careful the second week of June). I am thinking that it will be difficult to continue Random Uganda from a coffee shop in Noe Valley. But maybe those of you who remain in Uganda can send me pictures and stories of random events and we can keep it alive. I’ll let you think about that.

So I’m back at work. Or at least we’ll say, back at the office. I think Nancy had a good visit. But maybe you should ask her. I certainly had a great time touring Uganda and Tanzania with her.

On the housing front. I have finally moved down to VSO village into a 2 bedroom apartment with Richard and Pat. Richard and Pat are in Lira most of the time, however, so I have the place pretty much to myself. But the apartment is in compound where Alison and Alan and Jeanne and Roger live and next door to the compound where Diane and Stacey live, so I haven’t been too lonely.

But in a classic finish to the gong show that has been the management of my housing, the HR office didn’t tell my housemate Cara that she was to move out until after they’d left for the airport to pick up Prasandan and his family. So basically she was given 40 minutes to pack. And the housing that they had decided to move her to was the guest house at Ian’s, where Prasandan was staying, except that Prasandan hadn’t moved his stuff out of there yet. Nancy and I had stopped by the house to pick up some laundry from Grace during the fiasco, so Nancy got to meet Dorothy as she stood scowling in the door. Up until that time, Nancy would later comment, she had been under the impression that the Ugandans were a universally polite and gracious people.

In an update on the posting about the Rwenzoris. Apparently the main icecap/glacier on Margherita peak just recently split in half, making it impossible to climb that peak at the moment. Sorry guys, you may have to wait until the glaciers fully melt (sometime in the next 20-40 years) before you can climb it.
For more info on the Margherita glacier.

what Africa needs...

Okay. So I may be a little slow. It has taken a while to sink in.

Maybe it should have dawned on me when I was at the Serengeti visitor center (a lovely facility funded by the $50 per person park fee paid by tens of thousands of annual visitors and kept spotlessly clean by a well fed team of rock hyraxes and dwarf mongooses—mongeese?) and half way through a much needed pee break I felt a warm sensation between my toes. The brand shiny new urinal I was using drained into a pristine stainless steel pipe, which went down to the floor… where the urine was directed onto my foot.

And maybe It should have hit me when I went to Uganda Interpol to get my fingerprints done (just as I had to get fingerprinted by the California state police to get a clearance before coming over here, VSO wanted me to get fingerprinted just to make sure that I hadn’t committed any crimes during my sojourn here in Uganda—never mind that there is no computer fingerprint database in Uganda and this set of prints will no doubt be filed by date or color in an ever-expanding, completely useless collection of never to be seen again charcoal smudges). After all ten digits had been smeared in tenacious ink and ceremoniously rolled in various orientations across the card I was directed ‘down the hall’ to where I could ‘wash my hands.’ As I walked down the hall I noticed that the walls seemed to be decorated with long swathes of parallel quadruple streaks of black. The sink was broken. There were no paper towels. I was wearing khaki pants and what once was a white shirt.

And certainly I had a glimmer of recognition when I tried out the shower in my new housing arrangement, which, as is typical, is without a shower pan and flows directly to the floor and theoretically into the bathroom’s floor drain. The floor drain, however, seems to be situated at the high point for the entire house. So any shower lasting more than 30 seconds floods the living room.

And a nascent revelation began to solidify while I was working in the casualty unit at Mulago, a four bed (and I use the word bed loosely under the definition of slightly elevated flat surface), two room unit where hundreds of injured people are cared for daily. I came to the realization that—due to a lone sink out of which, when it works, you can only coax a trickle of toxic looking black effluent—I was working in a place where blood literally flows more freely than water.

But it finally hit me while I was at IHK (according to Wikipedia, an ‘upscale, tertiary care medical facility’), in the A&E and I went to wash my hands and, after filling my hands with liquid soap from the dispenser which, uncharacteristically, had soap in it, I had to go from one broken sink, to another, to another, before I finally could rinse the sticky goo from my hands:

VSO and all the other aid organizations are going about this all wrong.

Africa doesn’t need our doctors. Africa needs our plumbers.

Seriously. Africa trains a boatload of doctors a year (a boat steaming, for the most part, away from the continent). But maybe more of them would want to stay and work in their home country hospitals if they knew that they might be able to wash their hands after caring for an infectious patient, or if they knew they didn’t have to go into urinary retention during their twelve hour shift because there was a functional toilet somewhere in their workplace.

And, for about the millionth year in a row, the first or second leading cause of death in children under 5 is diarrhea—or, as they like to say in England and Uganda, where vowels are cheaper, diarrhoea. I know, diarrhea isn’t as sexy and topical as HIV. The Gates Foundation hasn’t recently announced a multi-billion dollar campaign to eradicate diarrhea (as it has for malaria). But diarrhea kills kids—1.5 million of them a year (and an estimated 2 billion people will suffer from diarrhea every year). And you don’t need expensive medicines and doctors to combat diarrhea (with all due respect to Dr. Paul Offit and the new rotavirus vaccine). You need plumbers. You need a safe, reliable water supply. You need a way to direct sewage away from that safe and reliable water supply. And once all that is in place, having a way to wash ones hands before meals would also be a lifesaver. Plumbing. It’s all about the plumbing.

I know that by saying this, I am decreasing my chances of ever being invited back. Unless I decide to get a job as a plumber’s apprentice upon my imminent return to the states. But, in part, this has come to me because I think the doctors here have known this (plumbers, not doctors) all along. Or maybe they haven’t had the revelation, they are just tired of foreign doctors showing up and telling them how much better things could be if they only had a little running water and an MRI scanner.

When I tell a Ugandan doctor that my specialty is emergency medicine the typical reaction is an amused smile or a suppressed laugh. In their world, emergency medicine is a task left to the interns—immediate post-graduates from medical school, the lowest link in the food-chain. ‘He must be really stupid,’ I can hear them thinking, or saying, ‘If he never made it out of Accident and Emergency. Who would choose a practice where mostly all you do is watch people die. And even if they survive, they have no money to pay you.’

Not that there aren’t things a Ugandan doctor could learn from a foreign doctor. If they were willing to set aside the monster ego they have developed to shield themselves from the desperate state of medical care here.

Case in point. One of our volunteers got a puncture wound to her foot. It hurt. For a few days. She went to one of the mad expat mzungu doctors recommended in the VSO Uganda handbook. She underwent what, in a civilized country, would amount to torture and medical malpractice. Her foot swelled up to twice its normal size. Two of her toes went numb and white. She wound up in the hospital on IV antibiotics. One of the drips infiltrated into her subcutaneous tissue and her arm also ballooned frighteningly.

About this time Nancy visited. As most of you know, Nancy is an orthopaedic surgeon specializing in the foot and ankle. So, for the few weeks of her visit, she would have been, by far, the most uniquely qualified person to care for this problem in the country, if not all of East Africa (if she were licensed to practice medicine in Uganda). She looked at our friend’s foot and felt that, even though the swelling had gone way down and the doctors wanted to discharge her, there was still a nidus of infection. She recommended a surgery to open and wash out (we call this irrigating) the wound.

Reluctantly, the medical team requested a surgical consult. The hospital’s chief surgeon was called in. Instead of a surgery, he said that all he’d need to do would be to pull the scab off the wound at the bedside, ‘so it could drain.’ When asked about how he planned to anesthetize the foot, he basically said that it was going to hurt and she would just have to suck it up. Needless to say, after having been recently tortured in a similar way by another doctor practicing antiquated medicine, our friend was reluctant to undergo this bedside procedure.

In short, here was a highly regarded surgeon who, even though he now practices in an ‘upscale tertiary care hospital’ that aspires to ‘international standards,’ was unwilling to put aside bad habits from his intern days at Mulago and try to learn from a visiting surgeon with years’ more experience and specialized expertise in the patient’s problem.

But, I digress.

My point here is. Maybe we need to rethink the model of sending doctors to places without consistently running water. Maybe we need to get the sinks in the hospitals working so that the doctors that are already there can wash their hands. And maybe we need to consider whether the host country is ready for the western (or northern, whatever) medicine specialty being proffered by the volunteer—maybe Uganda isn’t quite ready for emergency medicine yet, maybe we need to flood UTV with ER episodes for a few more years.

Oh yeah. In case you were wondering about my fellow volunteer’s foot. Eventually surgery was performed. Nancy’s assessment proved to be accurate. There was an infection that went nearly all the way through the foot. And even though his assessment and initial plan were incorrect, the surgeon's ego still prevented him from learning from the experience. He refused to open the foot as Nancy recommended and refused to fully irrigate the wound. The patient is back in the UK. Here’s to her full recovery.