random uganda

Return to Random Uganda

2011-08-16T11:19:00.000-07:00

Yes, I understand, this blog is beyond resuscitation.

What is the saying about flogging a dead blog?

Well. I am sure I won’t be the first. Or the last.

But, as some of you know, I am back in Uganda. And a few of you (a polite few) have asked for an update. And since I’m too lazy to figure out how to mail a postcard…

About three weeks ago, I found myself sweating anxiously in the passport control line at Entebbe airport. A few things have changed since I left Uganda in May of 2010. For one thing, $50 dollars (despite the Chinese berating us for our fiscal irresponsibility, the US dollar is still Africa’s currency of choice) will only buy you a 30 day visa (instead of 90). And for another, a man that I pissed off to the point of apoplexy in the waning days of my last placement has recently become the first mzungu elected to public office in Uganda since the colonial days. So I was half expecting to have my passport stamped “persona non grata” (or the luganda equivalent) and to be escorted back onto the KLM flight returning to Amsterdam. Fortunately, organization is not one of the changes that has struck Uganda since my departure.

Soon Robert, our driver, had us racing along Entebbe Road, and the familiar smells of smoldering matooke peels and meat-on-a-stick roasting over a charcoal fire were bringing tears of remembrance to my eyes. It was after midnight when we reached Kampala and the suburbs were dark. Load sharing. The new dam on Bujagali falls that was supposed to come on line in 2010 to satisfy the growing energy demand is a little bit behind schedule.

After a restless night reacquainting myself with the joys of sleeping under a net (and the joys of trying to struggle through said net to get to the toilet while diuresing the fluid overload of 20+ hours of travel), I woke to the cawing hadada ibis and the hammering of rocks outside my window that signals morning in Kampala. And before I could even say Nile Special, we were informed that we’d be moving upcountry (every place outside of Kampala, even if it is south, or of a lower elevation, as is Mbarara, is upcountry) in a few hours. Since we weren’t going to start work until Monday (3 days hence), I was hoping to spend the weekend tracking down a few remaining VSO buddies and reacquainting myself with the Kampala pub scene, but, alas, it was not to be. I made the suggestion that maybe we travel on Sunday, but it was declined. The Mbarara team, we were told, was waiting to welcome us.

The Kampala-Mbarara road has gotten somewhat better since last I traveled it. Still a bit sketchy starting out as it winds through the papyrus swamps en route to Masaka, the seemingly endless stretches of speed humps that marked road construction during my road trips of 2010 have yielded a nice wide highway that even has, wait for it, wait for it, a few passing lanes.

Mbarara is much as I last left it. A dusty confluence of roads with a town center crowded with electronics shops, banks and NGO offices. A giant cement Ankole bull marks the roundabout onto High Street. Just down the road a sprawling slope of dilapidated one-story wards makes up the Mbarara Regional Referral Hospital, with the Mbarara University of Science and Technology (MUST) just across the street.

Our accommodation is quite plush. Hot water, refrigerator and satellite TV (when the power is on). And Sheila (our cook) and Opio (our housekeeper). Shortly after our arrival, the director of the Mbarara office popped in to introduce himself. He said that he was here to give us our orientation. When we looked up, he was gone. We figured he must have gone out to get his notes. We haven’t seen him since. We sat around waiting for everything to be made clear, but, when it became apparent that that wasn’t happening, we did what was necessary. We went on safari.

A few hours later we were at Lake Mburo National Park, walking through the woods with an armed ranger, stalking zebra, impala, waterbuck, buffalo and the elusive eland.

While we were off in the wilds, the Mbarara team was staging a ‘prayer fast.’ We must have missed that item on the itinerary (which, like the orientation, was still in the anticipatory stages). Several of our team, on Monday, let us know how our presence at the prayer fast was missed…

Okay. You should probably know. I am here working for an FBO (faith based organization). As an aspiring Buddhist and recovering catholic, my grasp on faith has always been a little tenuous, but, if you are going to work in Africa, having faith on your side is probably a good thing. When you don’t have some of the things you take for granted (for instance, electricity, clean water, medicine, aseptic working conditions), it can be good to have a little faith.

Monday. An hour drive on a dusty washboard track into the Nakivale Refugee Resettlement Area—a good-sized chunk of the Isingiro district that has been under the control of the UNHCR (UN High Commission for Refugees) since the 1950s. Some of the refugees that have been resettled here are on their second and third generations. Some of the Rwandese refugees cannot return home because of potential political persecution… if they were to return home they might face prosecution for their part in the genocide of 1994.

Refugees are trucked into Nakivale from the regions bordering on war and famine. The camp is gearing up to receive 30000 Somali refugees (trucking in from the Kenyan border) from the latest drought in the horn of Africa. When the refugees arrive they are registered and given the usual ubiquitous white and blue UNHCR tarps, a source of clean water, food from the WFP (world food program) and a small plot of land on which they can build a shelter (most build huts by driving a palisade of sticks into the ground, weaving a basket of twigs and grasses and then smearing mud into the structure to make walls topped by a tarp roof) and grow food. The UNHCR tarps and the WFP food can be bartered at the ‘trading centers’ for more essential items… like Nile Special and airtime.

Our little part of Nakivale is the Kibengo Village Level 2 Health Care Center—HC2. (An HC 1 would be staffed by lay people. An HC3 would have inpatient beds, but no operating theatre, etc., so an HC2 is basically what you might think of as a clinic, except for the tent out back—left over from the cholera epidemic—where we can hold patients overnight for ‘observation’)

Kibengo Village area houses predominantly Congolese refugees that fled the resurgence of violence by the ‘rebels’ in 2008-09. They walked across the border to Ishasha and Busanza, managed to make nuisances of themselves by dying from cholera and malnutrition and were resettled into Nakivale.

Our HC2 provides primary care services (including childbirth) for the Congolese refugees as well as the local Ugandan population from the Isingiro district and from as far away as the Mbarara district. You might ask why someone who lives in Mbarara, home of the Mbarara Regional Referral Hospital might take a taxi or boda on 60 miles of bad road out to a refugee camp to seek health care. And the answer would be that our HC2 has a few things that you might not find at the MRRH or your standard MOH (ministry of health) run HC2 or HC3. Like medicines. Or staff that comes to work. Or a functional lab.

The Ugandan constitution guarantees the right of free health care to all its citizens. But what you get for free might scare the health right out of you. So when word gets around that an HC2 is actually dispensing medicines free of charge, well, you can see the attraction. You would probably drive to the Walmart in the next town if you heard they were giving away flat screen TVs, maybe even for drugs.

On a side note. And this is entirely hearsay. But during the elections this past spring, I am told that suddenly all the HCs out there had all the medicines they were supposed to have and, owing to the fact that their paychecks were rumored to arrive any day, the medical and nursing staff actually showed up for work… Shorty after Yoweri Museveni of the National Resistance Movement was re-elected, as he has been since 1986 in what was suggested might not have been a ‘free and fair’ election, the medicines disappeared from the shelves. It turns out that Museveni had other plans for the funds. A lavish re-inauguration for instance. And a few fighter jets.

In any case. Every morning at the Kibengo HC2, about 200 or so people line up to be seen. First come first serve. Triage is done by consensus. If your child is having a seizure, chances are good that you will be urged forward. If you look like you are cutting the queue for a fake injury, chances are good that you will receive a real one.

I sit in an office with Micah, a clinical officer (a 3 year diploma that allows him to do just about everything short of brain surgery), and Alice (or Iris, I’m not really sure, the Ugandans have this thing about Ls) my translator. Alice is pretty much running the show. Every 5 or six minutes a new patient will sit down. The patient and Alice will talk for a few minutes. She will take the patient’s temperature. If it is normal she will roll her eyes, if it is high she will raise her eyebrows and nod at me.

Alice: ‘Fever, cough, headache. 3 days.’

Me: ‘any other problems?’

Alice: ‘that is all’

Me: ‘no vomiting or diarrhea…?’

Alice (rolling her eyes to imply what part of that is all didn’t you understand): ‘no’

Me: ‘does the patient know her HIV status?’

Alice (rolling her eyes to imply like what does that have to do with anything, but not asking the patient anything): ‘negative, 3 months ago.’ Alice is already getting out the rapid malaria test kit. It will be positive.

If the patient is a child and starts crying, Alice will scold the mom. Heaven forbid the child coughs in my direction. I just know Alice is yelling ‘don’t let your child cough on my mzungu doctor, you know how weak they are, he might get a cold and die!’

Strangely enough, aside from the fact that my entire patient note can be scribbled in a space the size of a beer bottle label, the work here is much the same as at home. There are a number of really sick people mixed in with some people who are just overwhelmed with the aches and pains of living (of course living here involves cultivating your own food in red-clay soil using your hands and a hoe). And then there are some folks in line because we are giving away free medicines. And medicines can also be traded for airtime. These folks are trying to figure out what to tell Alice (before she tells me ‘that is all’) that will get the most medicines. They compare notes. Lower abdominal pain, dysuria and vaginal discharge were last week’s favorite. This week, after we instituted a rule that anybody with a complaint that might be an STI (sexually transmitted infection) has to bring their partner in in order to receive treatment, it seems to be epigastric pain and body itching.

With careful sifting, or maybe even some halfhearted sieving, it is amazing the kind of pathology that walks into the office. OK. Maybe not so amazing for the folks with filiriasis (elephantiasis). But amazing for me as one used to spending much of my workday sorting out problems directly related to the stresses and excesses of life in the developed world. In a few short weeks I have made my career’s first diagnoses of brucellosis, schistosomiasis, and congenital syphilis. Cool stuff. Unless you’ve got it.

It doesn’t take much diagnostic prowess to spot the sick kids. Their moms carry them in looking like half filled WFP rice sacks. It’s almost always malaria. Or malaria with malnutrition, or malaria with pneumonia or malaria with diarrhea. Moses, our procedure nurse, has outrageous skills at getting an intravenous line into the slack skin of dehydrated infants. And with a little fluid, some dextrose, some IV quinine and a random antibiotic or two, miracles happen every day. A child that was near death in the morning is sitting up eating a banana in the afternoon. This afternoon a visiting Ugandan doctor chided me for giving IV medicines to a child who could clearly have been treated on orals… I just smiled. This morning, when the mom unbundled the baby from her back, I was surprised to discover the baby was still breathing. (the other morning, another baby, same waxy look, wasn’t)

The news has been full of footage from the UK rioting and looting. My VSO friends from England have been calling home to check on their families—instead of vice versa. Uganda put out a travel advisory, telling its citizens planning on overseas travel to avoid England as their safety could not be guaranteed. The Ugandans are puzzled. Where is the tear gas? The water cannons? A peaceful march to protest the high cost of living (there has been 20% or more inflation in the year since I left) in Kampala a few months ago was met with gas and armored personnel carriers. The leader of the march Kizza Besigye (who lost to Museveni in the election) had to be hospitalized. In Kenya.

Also in the news. Starving children in Somalia. On the BBC, a Somali woman who has been a refugee on the Kenyan border for over a decade blames the UNHCR for the conditions in her country. (through an interpreter) ‘They (UNHCR) should stop feeding us here, then the people would have to go home and work out their problems…”

Sustainable seems to be the development catchphrase I keep hearing. Is this sustainable? A refugee camp where the refugees never leave? A country that receives more than 90% of their health budget from foreign donors and then uses the savings to buy fighter jets? An NGO that brings in a doctor to work who is so weak that he requires 3 or 4 Ugandans just to keep him alive.

I wonder.

Tomorrow will be my last day at Nakivale. The month has flown. In a few days I will be back to work in an emergency room in the states. Talking about unsustainable. It has been a good month. For me at least. In the grand scheme of things, perhaps akin to putting a hello kitty bandaid on the gaping wound that is Africa, but what are you going to do?

Increasingly more random... and far less Uganda.

2010-11-12T12:09:00.000-08:00

It's pretty sad when a blog that is already languishing in obscurity gets ignored by the only person who reads it (and writes it), soo.... I'm back.

For those of you who were wondering if I got lost on Bota somewhere on a muddy dirt backroad in Namuwongo and couldn't get back on the internet, no, my time with VSO expired (some might say that maybe I wore out my welcome) and I had to go back to the states to face the harsh realities of life in the developed world.

I would like to say that the reason I haven't made it back to the blog for nearly 5 months is that I have been horribly busy putting my experience and insights gained as a VSO volunteer in Kampala to work solving the American crisis in healthcare, but no, I'm afraid that I've been hiding in the basement of our Noe Valley cottage catching up on missed Glee episodes and steeling myself for my next visit to the olive oil aisle at Whole Foods.

Not that I haven't been working. At the moment I am working part time for 2 different emergency departments--one in Daly City (just south of San Francisco) and the other in Burien (just south of Seattle). Not only does this make for an interesting commute, but it means that I could be working more than full time (if I were french and subject to the 4 day work week), something I have spent the entirety of my adult life trying to avoid.

Well, actually, at this exact moment I am hanging in Ottawa—capitol of that big country to the north of us. I am here for the CUSO-VSO reintegration weekend. This evening, along with singing kum-ba-ya and other touchy feely things yet to be announced, I am supposed to talk about the ‘one thing’ that I remember most from my time in Uganda…

Show and tell was never my forte.

So I’ve been reading through my blog and scrolling through the 100+ gigabytes of still as yet unedited photos of Uganda and trying to find my ‘one thing.’ This is pretty much like letting a kid loose in the candy store and telling him to pick out one thing. OK. So, it’s pretty much like letting me loose in a candy store. Sometimes, like when you’re bouncing between rooms in a packed ED at 3 in the morning, having ADHD is a blessing. This is not one of those times.

For those of you who have actually read this, does ‘one thing’ stand out?

Let me know.

one last road trip

2010-05-27T23:25:00.000-07:00

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...

2010-05-26T00:41:00.001-07:00

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

2010-05-17T05:22:00.000-07:00

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...

2010-05-17T04:23:00.000-07:00

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.

brief update

2010-04-28T23:14:00.000-07:00

Sorry the blog seems to be languishing at the moment.
Don't be dismayed, there is plenty more cynical and injurious reflection left in me.
But Nancy and I have been having a great time exploring all the bits of uganda I haven't had a chance to see yet. And today we are off to Tanzania to see if we can check in on the migrating Wildebeest!
Cheers!

for more pics of our latest roadtrip!

Nancy goes on Safari!

2010-04-15T00:38:00.000-07:00

The rare Murchison Falls rock climbing hippo!

our first leopard spotting...

Nancy wasted no time at demonstrating superior safari karma, as she managed to spot a leopard (so to speak) on her first morning out. Above she has a visit with Bella and her baby Augusto at the Ziwa rhino sanctuary. And below, one of the 3 male lions we saw fighting for the affections of the lioness three pics below.

do these spots make by butt look big?

Nancy at the top of Murchison Falls.

For more pictures of the trip, click here!

signing off for a while...

2010-04-08T06:15:00.000-07:00

Nancy flew into Entebbe last night, after a brief stopover to visit Anabelle in Paris, and a quick plane change in Amsterdam. We treated her to the burning piles of trash tour of the Entebbe Road at night.

At the moment she’s back at the ranch taking a nap, but when she wakes up we’ll start checking out Kampala, and then greater Uganda. All this to say that the free time I would usually spend reflecting on the condition and meaning of life as manifested in rambling blog posts of questionable coherency will now be spent entertaining Nancy and making it up to her for leaving her alone in San Francisco for much of the past year. As such, this is likely to be the last posting for a while.

We are bound for the wine garage tonight and Murchison Falls for the weekend—hoping for some good safari karma, some rain-free mornings, and a kilometer or two of pothole free road.

On the housing front, we are still squatting at the old house. I did get an email from VSO last Thursday saying: “Hello Rob. Hope you are well, am writing to inform you that your house where you will be moving to is ready as per today i.e. its located in kironde in the same compound with the Cowans, hope you are ready to move please try to pass by office to receive the keys…” Needless to say, this piqued my interest, so I did pass by office to receive keys, and dropped by my new digs just to check things out. And, as you might expect, the place wasn’t quite ready for occupancy: the power was off, the water was off, there was no furniture other than a single bed, a small plastic table and four plastic chairs (this is a 2 bedroom house that I am going to share with another VSO couple, Richard and Pat, who apparently didn’t learn their lessons during their first placement and so are being forced to repeat them….), and there was not a single lightbulb to be found in the house. And, oh yeah, the place was a filthy mess.

So, as you might expect, I didn’t move in. Instead I wrote a polite email back pointing out the problems with the space that would need to be corrected to make it habitable. But I did cc the email to Richard. And apparently this struck a nerve because in September of ’08 they had been dumped into the exact same sort of situation at 5pm on a Friday night and were left to fend for themselves. So Richard shot off a rather scathing reply and cc’d to Kevin (IMG’s CEO) and Benon (director of VSO Uganda) saying something about turning right around and getting back on the plane… And apparently this got some people yelled at and rousted from their Easter Monday holiday, and this has made me immensely unpopular around the VSO and the IHK HR offices. Without even really trying.

I ran into Richard and Pat in the hall today (they are off on a drive to Lira tonight and back tomorrow, with Kevin, a punishment in its own right) and they suggested that the house might be ready to move into by the weekend…

And, in another interesting development, it appears that my little blog has come under scrutiny by the senior management of the hospital. The head of HR e-vited me into her office to “discuss your work in IHK, its value to both parties and agree on way froward/ specific achievable goals…” Appealing premise to address in the waning days of my placement, to say the least. It came out that although she herself had not read Random Uganda, others who had were afraid that my ‘cynical’ point of view might be ‘injurious’ to the Hospital. I explained to her that yes, I am a cynic by nature, but that I tried to find humor and amusement where I could find it. And I am not trying to be injurious to anyone, merely reflective on my own position here.

But it does beg the question. If the truth is injurious to an organization, what should that organization’s response be?

I will think about that. I will let you think about that. I am off to spend some time with the most beautiful, loving and understanding woman in the world.

Plight of the Bodas (part 2, up close and personal)

2010-04-06T03:47:00.000-07:00

The boda boda crackdown (see previous post, plight of the bodas) has eased up. Unlicensed, unhelmeted bodas have returned as the majority. Still, even without the police harassment, the life of a boda driver, despite the cachet of riding a motorbike for a living, is a hard one. Fuel prices in Kampala have shot up six or seven hundred shillings a liter in the last few weeks, eating into narrow profit margins. (most of the drivers rent their Indian made Bajaj Boxer 5 bikes for about 40000 shillings a day, making it twenty 2000 shilling trips just to pay the owner of the bike) And one slight misjudgment at one of the many universally disregarded traffic lights can land them on one of the cushionless blood stained gurneys in Mulago’s casualty ward.

One of my fellow VSO volunteers has fallen for her boda driver. Michael is an affable young man with a tight leather jacket and a winning smile. It is good to see them together. I’m jealous, among other things, that, after only a few months, she’s conversant in Lugandan, while I’m still stuck in the basic phrases and counting to 9 that I sort of learned my first few days in Uganda.

Last Saturday night we had an eviction party. (Dorothy had told us we’d be kicked out last Friday, but, as of this writing, the sheriff has yet to come beating on the door, and alternative housing has yet to fully materialize, so I guess, at the moment, we are squatting) A good number of my fellow volunteers got stranded by a rainstorm at the Wine Garage on their way to the party (fortunately, they did not suffer overly much), but a small and enthusiastic crowd made it and kept the loud music going for the neighbors until the wee hours.

And shortly after getting to bed, my phone rang. Michael had been found in a ditch by one of his fellow boda drivers, unconscious and bleeding from facial wounds. His friend Issac was called and took him to Mulago where they were unable to locate a doctor or a nurse. From Mulago they traveled to a clinic on the other end of town in Kireka where some unusually crude suturing (even by Ugandan standards) was perpetrated on his face.

I had to apologize that my alcohol level was probably not within a level you’d want your doctor’s to be. But I put her in contact with the IHK ambulance driver and, a bit later, caught a boda over to meet them at the hospital just as the sun was peeking up over the Kampala hills. Michael reclined on one of the gurneys. His head enlarged to half again its usual size. His left eye was swollen shut. Moses, our night doctor had already seen him and ordered a CT scan and neck x-rays as well as requesting consultations from a plastic surgeon and a neurosurgeon. Fearing the worst, I leaned in and called Michael’s name.

Slowly his good eye opened and focused with a hint of recognition.

He was going to be okay. But given that I wasn’t his doctor, and I was operating on a sliver of sleep and an incipient hangover, I figured it best that he go through with the CT scan. Which, not surprisingly, meant that he had to get back into the ambulance and go to a hospital with a functional CT scanner. The radiologist’s report from Kampala Hospital pointed out the obvious extracranial soft tissue swelling and some ‘mild cerebral edema,’ a finding that might be concerning in a setting other than Kampala where nearly every CT comes back with a reading of cerebral edema. To my eyes, the brain looked normal, but I have to admit that I’m out of practice reading the CT scan in multiple little 3 inch squares of film, since CT scans on film (now we read them on a monitor) disappeared from my practice 15 years ago…

So, given that Michael’s injuries were proving mostly cosmetic, the plastic surgeon swooped in for the kill. He wanted to take Michael to the operating theatre to reopen his facial wound and close it nicely. Estimated cost: another million shillings ($500, on top of the million and a half for the hospitalization and ambulance and CT). A bargain by American standards, but when you consider that VSO only gives us 500,000 shillings a month as a living allowance (and some volunteers aren’t fortunate enough to have a loving wife back home to support them in their folly, and so actually have to live within their allowance), it seems a daunting amount. And, of course, completely and utterly out of the question for a boda driver or your average Ugandan.

So stop and think about it for a couple of minutes. What would you do? Your loved one has a facial wound. There’s going to be a scar. The plastic surgeon seems very concerned (concerned enough to charge for 3, count’em 3, consultations for a 1 inch wound) and wants to make the wound look better. But it’s going to cost you another 2 months salary, on top of the 3 months you already owe. Think about it. Then pray that you never ever have to make this call.

We tried to get Michael onto the Hope Ward (IHK’s charity ward), but it was getting late in the day and Jemimah, the ward’s gatekeeper doesn’t like to work with this particular plastic surgeon due to his excessive billing issues.

At the end of the day, she took him home with the Frankensteinian sutures still in place.

I saw them on Wednesday. Michael was on his feet and looked one hundred percent better. His left eye was open and his smile was back. I wish I knew exactly how the scar is going to look a year from now. I can only hope it won’t be too bad.

Further Impressions of Mulago, Part 1

2010-04-04T23:57:00.000-07:00

A small boy walks tentatively into Casualty. In his left hand he clutches a fiber-plastic sack of clothes, in his right, a sheaf of rain and mud speckled papers. It’s about 5pm and all four stretchers are occupied by young men either coming to grips with their newly crippled status or completely oblivious of the fact due to the severity of their head injuries. Since you seem to be only one in the crowded room who will meet the occasional upward flicker of his sunken eyes, the boy shuffles over within reach. His scalp is a flaking field of scabs. He is dirty, dehydrated, and underfed. When he raises his right hand to offer you his paperwork, the minimal weight of his hand and its contents causes his forearm to droop like Harry Potter’s after Gilderoy Lockhart accidentally removed the bones.

The papers suggest that he is twelve years old, but to your eyes he’s an eight year old boy with eighty year old eyes. He has been abused by his father and step-mother. The police intervened and he was removed from the home and placed with, well, placed in the care of the state. In a country where the state has a lot more to worry about than the well-being and whereabouts of a lone 12 year old boy.

You examine his injured right arm. Both of the bones—the radius and the ulna—have been snapped in half. Then you notice that the arm holding the bag sways unnaturally as well. Both of his arms have been broken and untreated, from the dates on the papers, for at least 10 days.

You walk the boy over to the cast room and introduce him to the orthopedic house officer. Best as you can tell from the conversation, the house officer bawls the boy out for not coming sooner—now he’ll need surgery to fix the arms.

Later you find the boy on the crowded surgical holding ward. The boy now has plaster casts on both arms to above his elbows. His look of desperation grabs you by the trachea. You go to the canteen and buy a Fanta orange and a plate of chicken and chips and bring it back to the ward, feeling guilty as you walk by nine or ten other equally hungry patients. The boy looks at the food, and then to his hands—neither of which can now even begin to approach his mouth.

To the best of your ability, you feed the boy the greasy chicken and fries. You wipe the chicken fat and dirt from the boy’s mouth with a waxy napkin. You’ve heard, but never witnessed, that you can offer the nurses a little something to get them to actually pay attention to a patient, so, even though you have sworn to yourself that you would never do this, you go looking for a nurse. But 8pm is rapidly approaching and the nurses are making an exodus. At 8pm the ward will be down to night staffing: one nurse, one intern, 30 or 40 patients.

The night nurse and intern are nowhere to be found. You understand that the intern is probably in the process of barricading himself inside his call room. Much as you wish to help the boy, you have experienced what it is like to be the lone person in a white coat on a ward full of injured and dying patients (and their families) where you don’t speak the languages and you have nothing to offer more than another bottle of normal saline (if the IV fluids have been restocked today) and a helpless facial expression. You slink out the door behind the nurses.

The next afternoon you try to track the boy to the orthopedic ward and can find no evidence that he was ever in the hospital.

A relatively calm week in Kampala

2010-03-29T06:09:00.000-07:00

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.

another trauma update

2010-03-21T08:09:00.000-07:00

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.

Crazy week in Kampala

2010-03-21T01:10:00.000-07:00

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...

Some Lessons American Health Policymakers could learn from the Healthcare System in Uganda.

2010-03-16T02:10:00.000-07:00

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.

more updates

2010-03-16T02:08:00.000-07:00

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.

updates

2010-03-08T04:22:00.000-08:00

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?

Wrecked in the Rwenzoris (Climbing in the Mountains of the Moon)

2010-03-08T00:28:00.000-08:00

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.’

Pushing the envelope of helicopter medevac…

2010-02-23T00:50:00.001-08:00

kampala, looking east to lake victoria

Mbarara district referral hospital in the right lower corner.

Kampala's old taxi park (left lower corner), from the air

Dave flies the helicopter with a couple of patients lying next to him

February 21st

It’s Sunday afternoon and I’m visiting Guustaaf out in Ntiinda. I’ve decided to go climbing in the Rwenzoris next week and Guustaaf has been kind enough to lend me some of his gear.

(Just in case you get worried that postings here are drying up and I’ve disappeared or checked into detox or something—no, I’ll just be in the mountains for 8 or 9 days.)

Tom calls and asks if I want to fly to Mbarara. I say sure, but tell him I’m in Ntiinda (about 20 minutes by boda or 40 minutes by matatu from IHK). He says that they want to take off right away. I give him the option of sending Dr. Christine from OPD or waiting for me to boda over. He talks to Dr. Christine and tells me to get on a boda.

It is pretty clear my boda driver has no idea where IHK is. I have to turn him around after he makes a turn on Kira road towards town. So we’re headed down the Lugogo bypass (picture a big white guy sitting on the back of a small motorcycle wearing a backpack with an iceaxe attached to it…) and another bigger motorcycle goes by, slows, looks at me, looks at the iceaxe. Turns out its Dave, the helicopter pilot. I tell my driver to follow the guy with the yellow helmet and we make the illegal U-turn across Jinja road and scream through the industrial area. I show my driver the shortcut through the slum up onto Namuwongo road, so we beat Dave to the hospital by a good five seconds.

It turns out that a 4x4 full of evangelists blew a front tire about 9am outside of Ntungamo and rolled several times. An elderly couple from Tennessee were pretty banged up and couldn’t walk and a couple of other people were injured as well. They wanted to know if we could fly all four to Kampala—in a helicopter designed to carry 5 passengers seated. Typically, if we fly for a patient that needs to lie down, we take out the front passenger seat and fold up the back seats—which barely allows room for a stretcher to be strapped to the floor. Dave did the numbers, though, and figured we could carry 3 patients and me and my medical gear. We decided that instead of the stretcher, (or spine board, or any of that crap) we would just put a bunch of cushions down on the floor and squeeze the two supine patients in between the control column and the door…

While I was on the phone trying to track down the doctors in Mbarara, Dave was on the phone getting a guarantee of payment. (missionaries or no, the helicopter is a strictly mercenary business—Dave said he told the guy what the per hour charges were and how long the flight time, and the guy said okay, he’d pay for one hour of flight time, and Dave would just have to fly faster!) I managed to get one of the doctors at Mbarara district referral hospital on the phone. He said that he was taking one of the patients to the theatre. He said we should come and pick the patient in four hours. I told him that in four hours it would be dark. And we don’t fly in the dark. He said something to the effect that we had a big problem. And hung up on me. And didn’t answer his phone the next 4 times I called.

Fortunately the thunder storms from Friday night had abated and we have clear flying to the football pitch across the road from the hospital. Fortunately, as well, the field is surrounded by fencing which keeps most of the Mbararans from running into the area where helicopter blades are spinning (although later on we had to shout at the spectators snapping pictures of the injured patients with their cell-phones). Moving the patients to the helicopter proved problematic. Actually even moving them through hospital—strangely enough not equipped with ramps for wheelchairs or gurneys—was difficult. But we managed to get them slid onto the floor of the hospitals ambulance and over to the football field without damaging them any further.

Without being indiscreet, or violating patient confidentiality, let’s just say that our patients are not small people. And that getting them loaded into a space smaller than a twin mattress and getting the door shut took some doing.

The flight back to Kampala was relatively uneventful. Dave’s record of 9 years of flight time and never having an airsick passenger was interrupted as the third patient (sitting next to me) hurled into a plastic bag that later proved leaky. And the other two patients kept complaining of being hot. As I tried to explain to them that both the windows were open as far as they went and the helicopter didn’t come with A/C.

But we all survived the flight and managed to get them checked into the ICU without further drama or trauma and still able to move all their toes and fingers. Some where along the line, some perky 3rd year American internal medicine resident who somehow was related to the church sponsoring our patients showed up and started barking orders at the ICU nurses: ‘why haven’t the neck x-rays been done?’; ‘what are the CBC results?’; ‘what do you mean they haven’t had a CT scan done yet?’; etc., etc. I had to take him outside and explain to him that one (in case it wasn’t painfully obvious) IHK is not Mass General, and two, he didn’t have privileges work in Uganda, let alone IHK, and that he should just shut up and enjoy the ride.

As of this morning, the patients were doing well and getting ready to leave the ICU.

For a very unflattering picture of me (that’s me bending over, stabilizing the patient’s head and neck as he vomits next to the helicopter) in one of Uganda’s national newspapers.

trauma update

2010-02-19T07:13:00.000-08:00

Trauma Update: 12 February 2010

I’ve been having weekly sessions with our A&E (accident and emergency) nurses for almost a half a year now. We talk about trauma, and emergency medicine, and ambulance transport (most ambulance calls here go out with a non-medical driver and a nurse—there are no paramedics here, although I’ve been agitating to hire some clinical officers and train them to be paramedics), and other topics. Most days I think we’ve come a long way. At least they’ve started to laugh at my jokes.

Last Friday afternoon I was looking forward to the quickly approaching weekend and a cold beer at Fuego when Justine, senior sister (compare to nurse manager) in charge of OPD (outpatient dept.) and Linda, my emergency team leader, come and grab me to come see a RTA (road traffic accident—UK medical lingo). I’m a little disappointed that Linda feels it necessary to come with Justine as opposed to taking charge of her team, but I smile and head to the trauma room. Which is empty. (not a huge deal, since I’ve come to accept the fact that the trauma room is really a place to store obsolete, broken and esoteric unusable equipment) The patient is in one of the unmonitored beds in main 5 bed casualty ward. There are 3 nurses standing around him, none of them touching him, all of them watching as one after the other pushes the button for the automatic blood pressure cuff, which won’t seem to give a blood pressure value.

The patient was in a car crash earlier in the day in Masindi (about 3-4 hours north of Kampala by car—I've visited Masindi district hospital, see the Sept. 2009 post, it might explain why he didn’t seek care in Masindi). His coworkers tied a big piece of wood to his obviously fractured leg, threw him in the back to truck, and drove him to Kampala where, reportedly his health scheme covered his care at Kampala International Hospital.

It didn’t take much clinical prowess to see why they couldn’t get his blood pressure. He didn’t have one. He was cold, sweaty, pale (after 8 months, I am finally starting to get the nuances of just how pale a black man can be and what it means) and has no peripheral pulses. One hand on his left upper quadrant tells me that his spleen has ruptured, and the majority of his blood is now pooling inside his peritoneal cavity.

By this time there are now 5 nurses around the patient, still none of them touching him. Both the medical officers assigned to casualty have disappeared without a trace.

I try to nudge Linda into taking charge by reminding her of the ABCs (airway, breathing, circulation) and asking her what should we be doing first. ‘Well, we need to get the vital signs first.’ Sigh.

I coax the nurses into putting down the automatic blood pressure cuff and starting an IV line on our man (they look at me like I’m mad when I ask for a second line—‘can’t you see we just started one?’ I make a generally hopeless request for oxygen and a cervical collar. I track down one of our surgeons who agrees with me that the man needs to go to the theatre for a laparotomy.

And then the reception staff take over the casualty unit and everybody starts talking very fast in Lugandan. There’s been a slight misunderstanding. The patient’s health scheme pays for care at Kampala Hospital, not International Hospital of Kampala.

Suddenly my nurses, who have mostly been milling about for twenty minutes, leap into action and get the man loaded back up into the truck. The surgeon shrugs and says something to the effect that there is nothing we can do. This feeling is echoed by Justine. ‘What can we do?’
I feel like screaming, but I keep my voice well modulated. ‘We can do the right thing, and operate on him and possibly save his life.’
‘But he will have to pay cash for it.’
‘Can’t we worry about the money later?’

Apparently not. I tried to explain to the patient and his coworkers that he could easily die in the 20 minutes it was going to take for him to get across town. But they were having none of it.

I called over to Kampala Hospital and, after a number of transfers, spoke to their surgeon. He listened to my story, seemed surprised that I had taken the time to call, and thanked me for the heads up. Understand that in the US, making a call to say that you had just transferred a patient without a blood pressure in need of an emergent laparotomy (not even to mention in the back of a freakin’ truck) would basically be like begging to have your license to practice medicine revoked and all of your personal assets taken from you.

The patient survived his surgery.

He left the hospital 3 days later. The nurse I spoke with was unable to confirm if he was alive upon discharge.

Plight of the Bodas

2010-02-19T00:40:00.000-08:00

one last boda ride?
(photo credit: Irene Curley)

boda boys out of gulu

obeying the helmet law
(photo credit: kampala fan facebook page)

February 19th

Boda Boda Crackdown

I’m sure my previous posts have given the pros and cons of the Boda Boda, Kampala’s ubiquitous motorcycle taxis.

The daily carnage of the bodas is well documented and, now that I’m spending some time at the public hospital, has been presented to me on a personal level as well. But I don’t have a car here in Kampala (and even if I did, wouldn’t have a place to park it anywhere near Mulago) and it’s a long walk between IHK and Mulago and the trip in a matatu (2 minivan taxis, one from Namuwongo to the taxi park and the other from the park to Mulago) takes over an hour in good traffic and a third of a lifetime in the jam. So I have been forced to rely more and more on the bodas.

In my post from August 13th, I marveled at how the bota drivers in Kigali, Rwanda (they’re called motos there) all wear helmets (and carry one for their passenger). I mentioned to a Ugandan surgeon how this might help diminish the high rate of head injuries from boda accidents. He smiled. As it turns out, Uganda passed a law several years ago requiring boda drivers to wear helmets, reflective vests, and to carry a helmet for their single passenger (it’s not uncommon to see bodas with 2 or 3 passengers—plus a toddler sitting on the handlebars).

And, surprisingly enough, just in the last two weeks, the police in Kampala have started enforcing this law. News reports focus on the police jumping out of bushes and whacking the drivers over the head with clubs and confiscating their bikes if they don’t have the required permit, helmets and vest.

At the beginning of the crackdown, Friday before last, things were oddly amiss at Reste corner (the center of the south Kampala, vso volunteer universe—the Italian market, Palm café pizza, the wine garage and fuego cocktails all being within a stone’s throw). It took a while for it to sink in. There was not a single boda to be seen on a corner where usually you have to beat them off with a stick. That turned out to be because down the road in Kabalagala the police were actually beating them off their bikes with sticks. (the last time they had a boda crackdown, I’m told, there were riots in the downtown area, so this time the police have come with bigger forces and concentrated on one neighborhood at a time)

Two weeks later, there are still noticeably fewer bodas on the road. And many (but by no means all, or even the majority) have the vests and helmets. Although that doesn’t necessarily mean they have permits as a friend of mine found out the other day when his boda was stopped. He figured, since he’d only gotten half way, that he would only pay the driver for half the ride, but the police officer yelled at him and told him to give the driver full fare (so that the boda boy would have more extortable cash on him).

The boda drivers that hang in the lot across the street from the hospital know that I want to go across town to Mulago (going out of Namuwongo to town increases the risk of police apprehension), so they ignore my wave, unless they have the helmets. And the drivers with helmets have suddenly raised their fares 500 or even a 1000 shillings (25-50 cents—outrageous). And the helmets they are wearing range from the comical to the downright nasty. I was issued a helmet by VSO, but, I confess, had become a little lackadaisical in its use—until one of the drivers handed me this strapless bucket of a helmet smelling strongly of mildew and month-old perspiration. Now, the helmet travels with me.

I tried to get one of the residents in casualty excited about doing a study to compare pre and post crackdown head injury rates. He just gave me a wan smile as if to say, ‘silly mzungu, things here will never change…’

Rafting the Nile

2010-02-16T01:41:00.000-08:00

(didn't take my camera rafting, this picture shamelessly stolen off the Adrift website)

Rafting the Nile (or LSU medical students gone wild in Africa)

February 16th

I’m riding the shuttle bus to go rafting. In addition to being the world’s longest river, the Nile also has some kickass whitewater, and I’ve been meaning to check it out for a while. I had to get up early to catch the bus, so I’m hoping to snooze a little on the 2 hour trip to Jinja, but I happen to overhear a young man’s voice bragging: “…well, all of us know CPR and a third of us know how to do a crike.” I open my eyes. A group of young people has just boarded. Medical students, I think. Then the same dark haired, thick-browed young man goes on, “Yeah, I could do a crike with my swiss army knife. No problem.” Pure, unadulterated hubris. Definitely a fourth year med student.

A crike, for the uninitiated, would be a crichothyroidotomy, an emergency surgical procedure that involves cutting a hole in someone’s neck and inserting a breathing tube. I can think of a lot of scary things to do at work, and a crichothyroidotomy would top the list every time.

I think about engaging him in conversation… ‘So, buddy, assuming you’ve been very lucky and you’ve managed to get your ballpoint pen into the patient’s trachea (as opposed to the carotid artery or the esophagus), and you are now blowing air into a small tube in a poorly sealed hemorrhaging wound in some poor bastard’s throat, what are your gonna do next? Call 911?’ But, nah, I was him once. I turn up my iPod and tune him out.

The source of the Nile has been the subject of controversy for a number of years. In 1858, John Speke was the first to suggest that the Nile originated from the lake he named Lake Victoria. His travel partner, Richard Burton (get the 1990 movie Mountains of the Moon on netflix), called this a bunch of rubbish. Even now, the purists will tell you that the waters of Lake Victoria (and hence the Nile) come from many sources, the most remote being the Akagera river, which starts as the Rukarara River in the Nyungwe rainforest of Rwanda.

For rafting purposes, however, the Nile starts somewhere below the Owen Falls Dam in Jinja. (Although a new dam currently under construction at Bujagali Falls will eventually submerge most of the rapids we'll raft over). Unlike most of the canyon whitewater I’ve been exposed to in the US (certainly not an exhaustive survey, mind you) which is more narrow, rocky and continuous, the Nile is big and wide and has long stretches of flat water punctuated by high volume, waterfall-like rapids perfect for flipping rafts in. Fortunately, the water is warm, and the rapids spaced far enough apart to allow you time to find your paddle and get back into the boat.

Prior to the first big rapid, we practiced flipping the raft. Tutu, our guide wanted us to hang onto our paddles with one hand and the safety rope of the raft with the other. As we were flopping into the water with the raft on top of us, I felt an unnatural torquing sensation in my shoulder and thought, this would be the perfect way to dislocate a shoulder.

And sure enough, on the last rapids before lunch, the raft in front of us was tossed and one of the rafters was floating at an odd angle in the water holding his right arm against his lifevest. We pulled him along side and headed for shore. About this time the boat with the med students shows up and my buddy starts barking out orders about bed sheets and traction and makes the poor guy with a dislocated shoulder take his wet shirt off (next time you dislocate your shoulder, try taking your shirt off). The med student wants to use the traction/counter-traction method of reducing the dislocation—probably the most painful way ever devised to put a shoulder back in.

Lee, the lead guide, has been given the impression that the med students are doctors. Upon questioning, however, the young man has to sheepishly admit that no, he doesn’t graduate from medical school until June, and, no, he’s never reduced a shoulder dislocation in his life. But he points to one of his fellow med students and says that she is going to be an orthopedist and that she’s ‘put in hundreds of shoulders.’ (Turns out that she’s only a 3rd year student and, although, she would like to be an orthopedist when she grows up, she hasn’t even done her orthopedic rotation yet.)

Before the 4th year can do any more damage, we gingerly load the patient into our raft. On the flat stretch of river before the lunch island, I talk the man into extending his arm out to about ninety degrees and the shoulder pops back into place. At lunchtime, the man is ignoring the sling I put him in and is eating with both hands. The raft company pulls him from the trip, however, to go get an x-ray in Jinja.

We flip our boat in the rapids below the ‘Bad Place.’ I don’t hang onto the rope, or my paddle. I float the whitewater feet first and wait for Tutu to get the raft turned over.

another short, sweet trip to the Sudan

2010-02-12T05:46:00.000-08:00

in the cabin of the 206
Torit International Airport
Torit, South Sudan, from the air
The Irmatong mountains
Over Lake Kyoga

February 10th

Monday’s hash was in Bugolobi, or Mbuya, or somewhere toward the southeast outskirts of town. We got lost trying to find the starting point at Daytona Bar, so I was playing catch up from the get go. My phone kept going off. I know, you say, how stupid to run with a phone, but on the Kampala Hash getting lost is such a frequent occurrence you never know when you’re going to need to call a friend. On the hash, answering a mobile phone is a punishable offense (punishable by the threat of having to drink extra free beer at the finish…), so naturally I answered it.
Tom from transport was looking for a doctor to fly to Arua about seven in the morning to help transfer a patient down to Kampala.

So I said sure.

Modified phone log:

1900hr: Call from Tom. He has just texted me the phone number for the Doctor at the hospital in Arua.

1905hr: Call the doctor in Arua. No Answer.

1915hr: Call the doctor in Arua. No Answer.

1930hr: Call the doctor in Arua. Very bad connection. He’s in the theatre (that means the operating room here, not the cinema) can I call him back in a half an hour.

2030hr: Call the doctor (Patrick) in Arua. Ask about the patient. ‘Oh, he’s fine.’ Okayyy. He (the patient) just has end-stage liver disease with cirrhosis, portal hypertension and bleeding esophageal varices. He just had an upper GI bleed the other morning with a blood pressure of 70 and required a blood transfusion. I ask him what the patient’s hemoglobin level is now. He says he doesn’t know, but ‘clinically’ the patient is not anemic. I ask about when the last time Dr. Patrick saw the patient was. ‘Oh. I haven’t seen him all day, I’ve been in the Theatre.’ I ask him to go check on the patient and call me with his current status. (no further contact with Patrick.)

2045hr: Call our hematology lab to see if we have any O negative (free of the major blood antigens, so you can give it to anyone) they could pack up for me to take on the flight with me. ‘No.’ We have no blood, let alone Oneg.

2355hr: Tom calls to let me know the time of the flight has been pushed earlier. Can I be at the hospital at 5:30? A.M.? I tell him at 0530 he’s going to have to send a driver to pick me up. He agrees.

0500hr: Safari James from transport calls. ‘Did Tom tell you about the medevac to Arua?’
‘Uhhh… Yes, he did. He said you’d come pick me up at five-thirty.’
‘Are you ready to go yet?’
‘Is it five-thirty yet?’
‘Oh.’

0515hr: Safari James calls. ‘Can I come pick you now?’
‘Is it five-thirty yet?’
‘Oh.’
‘Come pick me up at five-thirty. I’ll be standing on Kironde Road.’

0540hr: (because the accepted behavior here for arriving at a closed gate is to lay on your horn until someone opens it, I have chosen to exit the gate and save my housemates from awakening to the sound of the ambulance horn. I have now been standing in the rain for 10 minutes.) Safari James calls. ‘I am leaving now. Are you ready to go?’

0620hr: We arrive at the Kajjansi Airfield. Aside from the night watchman that we wake up with our horn, we are the only people there.

About 0700hr a couple of people with luggage wander in. I’m thinking, ‘hmmm… what exactly has Tom signed me up for this time.’ Then the guy with the uniform wants to inspect the medical kit.
‘Do you have anything dangerous in there?’
‘No.’ Unless you consider an oxygen cylinder, a scalpel, and enough diclofenac (an injectable relative of advil that seems to be the preferred pain-killer and anti-pyretic in Uganda) to put the pilot into renal failure. I don’t bother to explain to him that if I was going to hijack anybody anywhere it would be back to my bed…

Then Dave, the pilot for MAF, comes in and explains our flight plan. First we’re going to fly to Entebbe to pick up two more passengers and clear immigration (Immigration? I thought Arua was in Uganda?). And then we’re going to fly to Torit. Torit? Torit, as it turns out, is in South Sudan… (you know that imaginary line that VSO has asked us not to cross? Torit is way across the line.) And then we’ll fly to Arua to pick up the guy who’s bleeding from his gut. So much for being back in Kampala for lunch. And I don’t have my passport. (VSO still has my passport—almost 8 month in and no work permit yet). Dave says he’s going to list me as crew, so I won’t need a passport.

At Entebbe, Dave checks the fuel to make sure it hasn’t been watered down, loads the luggage of the additional passengers, gives us a safety briefing, and says a prayer. (MAF stands for Missionary Aviation Fellowship) If the only guy standing between me and crash-landing somewhere out in the African bush where the chances of rescue are next to nothing wants to pray, then by god, let him pray. I say a little prayer for Dave’s continued health as he prays for the success of my mission to Arua.

We fly north over Lake Kyoga at 10000 feet. The dry season is in full effect up North and the sky is thick with dust and smoke from burning fields. Below, the land is a parched yellow brown. In the haze on the horizon sits the purple line of mountains just north of the Sudanese border.

Dave picks out a low point between peaks in the Irmatong mountains to pilot his Cessna 206 through. The mountains are free of trails and cell towers. Red rock with sparse green scrub.

A few more nautical miles (why do airplanes measure distance in nautical miles?) and the mountains subside, we cross a dry river bed, a few tracks appear on the plain, and Torit comes into view.

My time in Torit didn’t include the city tour, so my impressions were mostly from the air: a large sprawling village with a few rectangular single level buildings, but mostly round huts arrayed in packed dirt compounds set haphazardly on an irregular street grid. A creek or small river meanders southwest of town giving life to a winding swath of greenery and trees. The runway angles away from the east end of town. When the UPDF (Ugandan Peoples Defense Force—the army) chased the LRA (Lord’s Resistance Army) out of Uganda, the LRA hid in the Irmatong mountains and wreaked havoc on the people of the Torit district. At some point in the conflict, the LRA was reportedly receiving military assistance from the Sudanese government as payback for the Ugandan government’s support of the South Sudanese Liberation Army…

A WFP (world food program) plane is getting ready to take off as we land, and the crowd of people surrounding it moves to encircle ours. But we haven’t brought any food, only missionaries. Francis shakes my hand, ‘God bless you Dr. Riley.’ Motorcycles and bicycles criss-cross the runway as a herd of emaciated cattle stagger by in the dusty heat. There are no Sudanese immigration officials checking passports, so I go looking for a tree to pee against (the Torit International airport lacks a tower, terminal, even a latrine). I have to walk quite a ways. The huts line both sides of the runway. Their roofs are more peaked than in the north of Uganda, but otherwise similar.

We flew another hour or so west (and a little south) to get to Arua. Arua sits at the northwest corner of Uganda. Supporting aid delivery for a large refugee population from Sudan and the DRC (Democratic Republic of Congo), as well supplies being shipped by road into South Sudan, has made the Arua Airport the second busiest airport in Uganda next to Entebbe. When we land, however, aside from an Eagle Air LET-410 taxing out, the only other plane at the airport is an Antonov AN-2, a 1940s Russian biplane that the UPDF uses to drop paratroopers.

I was expecting an ambulance. But I have learned never to expect too much. I called the contact number for his employer at the UNDP and was told that the patient was at the airport. I notice a sick looking, emaciated man lying by himself on a bench by the small terminal building. Sure enough, that’s my patient. Fortunately, he still has a blood pressure. Fortunately, he was kind enough not to throw up blood all over the back of the Cessna, and we had an uneventful flight home. Naturally we had to drive at breakneck speed back into Kampala with the lights flashing and the sirens blaring.

On arrival at Kampala Hospital by the golf course (the patient’s doctor doesn’t come to IHK) we wheeled the patient onto the ward. The nurse asked, ‘Where’s the patient’s family.’ The ambulance driver said the patient was alone. ‘Well. Who is going to make the patients bed?’ Who indeed. I was carrying the patient’s suitcase. I asked him if he had sheets in there. He did. I put the sheets on the bed. And the transfer was completed.

for more pictures of the flight

Updates on previous postings

2010-02-07T23:47:00.000-08:00

Updates

February 7th

Re: It’s so hot.
It rained most of the day yesterday. We had planned to find a pool to sit by. We went bowling and to the movies instead. I woke up shivering cold in the middle of the night.

Re: Eviction notice.
Prashandan, the Indian Cardiac Anesthetist, had been housed in Sally’s spare bedroom pending our eviction. Prashandan’s wife got wind of the arrangement and raised a little hell. Prashandan is now living in one of Ian’s guest houses up on the hill. I let Dorothy in HR that I was expecting the same level of comfort in my new housing as I had in my old. This led to a flurry of emails between IHK and VSO. It now looks like they may rent a house for Richard and Pat (Richard’s a doctor from the UK who was working here, but went home in September, but are coming back for a short project) and give me a room in it.

Re: Another weekend in Wakiso
Bebe Cool was shot in the legs in a gun battle between the Special Police Constabulary Unit and his body guards that happened either at Centenary Park, the Nakumatt parking lot or the Lugogo Mall (depending on which paper you picked up the day after the much awaited but generally dissed R. Kelly concert in which Bebe was an opening act). Details of the shooting are blurry as well, but seem to hinge on a police unit interrupting a couple having sex in a parked car. Bebe was initially reported in ‘critical condition’ with ‘both of his legs shattered,’ but, after a visit from President Museveni, he was able to walk out of the hospital a few days later.

for more info on the shooting

First Impressions of Mulago

2010-02-07T23:37:00.000-08:00

5 Feb 2010

First Impressions of Mulago

Mulago Hospital is Uganda’s National Referral Hospital. Theoretically, Mulago would be the shining jewel in the crown of the Ugandan public health system. It would be the showcase hospital where the best minds and the best technology came together to tackle the really tough cases referred in from the outlying ministry of health hospitals. The equivalent hospital in the US might be Walter Reed, or maybe Massachusetts General Hospital (that is, of course, if the US actually had a health care system to take care of all of our citizens).

Mulago was founded by a British missionary doctor, Dr. Albert Cook (OBE), in 1913 as a clinic for venereal diseases and sleeping sickness. The current 1500 bed incarnation of the hospital on Mulago Hill was built in 1962 by the British as a parting gift to a soon to be independent state.

The Casualty Ward at Mulago occupies much of the 3rd floor of the hospital’s main wing (the hospital is built into a hill side, so that the 3rd floor is on the uphill side and ambulances and police trucks can drive up to deposit their patients). The main entrance to Casualty is guarded by its own police barracks. Once you make it by the police you enter a darkened waiting area reminiscent of a bus station in the deep south. There is a cage near the entrance for registration, and a small area cordoned off with 5 foot high portable blue-curtained partitions for the triage nurse amid a sea of waiting patients. The triage nurse will write your name and complaint and vitals on a small slip of paper. She will arbitrarily decide if your complaint is medical or surgical, and she will make a swipe with a colored magic marker on the chit—red means you get seen soon, orange means you may get seen, yellow means you will be waiting a long, long time.

The Medicine side of the ward operates out of a tiny 3 room cluster off the main hallway. When I visited last week, Edith, a recent graduate from what we would call an internal medicine residency, but now the clinical director of the Casualty ward, was explaining to an intern on her first day: ‘don’t clerk the patient (clerking is what we would call doing a workup and writing the patient up), just decide if they are sick or not.’ If they aren’t sick, in the eyes of a brand new intern, they go home. If they are sick they go to Ward 3BM which is a holding area. In Ward 3BM (for ward 3 area B, medicine, not that you’re going to have 3 bowel movements while waiting to see the doctor) the patient’s are seen by another intern with a little bit more time. This intern may order what few lab tests are available (a CBC, a blood smear and a fingerstick glucose, if they aren’t out of strips), maybe an x-ray, and then will decide what service in the hospital will admit you. Then they will tuck you in (I mean this metaphorically, as the only way you will get tucked in at Mulago is if you remember to bring your own sheets) and hope you are alive in the morning to go to your respective ward.

Last September I had my 3 month meeting with Sarah, VSO Uganda’s Health Program Manger. Sarah is one of many bright, well-trained young Ugandan doctors who have found it much more pleasant (not to mention lucrative) to avoid the actual practice of medicine and work for an NGO. (there is some irony in the fact that the NGOs set up to improve global health can actually worsen it by hiring away the best of the local doctors).

I had confessed to Sarah that the acuity of emergency medicine at IHK was, on average, fairly minimal. She had suggested that maybe I could do some work at Mulago as well. She had thrown this out there almost like a challenge—I don’t remember her actual words, but I do remember the tone in which it was made: ‘so you think you’re ready for Mulago white boy?’

So I said, ‘sure.’

And every few weeks afterwards I would send her an email, or query her as I wandered through the VSO offices, about how she was coming at getting me some work in Mulago. And she would respond that she was working on it. That they wanted this paper, or that paper, or somebody to sign off, or the department of surgery had to be approached, or the department of medicine…
Finally, upon my return after Christmas, her response was that ‘IHK has a MOU’ with Mulago, and so Kevin (IHK’s recently promoted CEO) should be the one to establish my relationship with Mulago.

MOU stands for memorandum of understanding (I had to ask). It’s going to take one hell of a memorandum to improve the understanding around here…

And Kevin is so far over his head trying to parlay a career in insurance sales into CEO of a private health care system in a foreign land in the developing world, that he would be the last person to arrange me work at Mulago.

So I called my friend Conrad, a Ugandan doctor who studied with me at the Liverpool school and trained at Mulago. He gave me the phone number of one of his classmates, an endocrinologist who finds himself in charge of the casualty ward. A day later I met with him. He wanted copies of my Ugandan medical license and my US registrations. I knew that VSO Uganda had copies of these on file, so I sent an email to Sarah asking if they could make me a set of copies for Mulago. I was informed that, no, I would have to pick up the paperwork and make the copies myself. (VSO Uganda has a photocopy machine and a fax machine that also makes copies)

But by the next Tuesday I had gotten the documents to Dr. Fred. And on Wednesday I had the approval of the Executive Director, the Deputy Director (who basically said, in so many words, what took you so long?), and the Chairman of the Department of Medicine to work and teach in the Casualty Ward.

And later on Wednesday I was standing on the endocrine ward with Dr. Fred and four fresh interns looking at a man who was dying from multi-organ failure. It appeared to me that the man’s liver and kidneys had shut down (it would have been hard to tell for sure since the only laboratory test the patient had had completed in his nearly 24 hours in the hospital was a fingerstick glucose which was mildly high—hence his admission to the endocrine ward). I talked about trying to rehydrate him without putting him into heart failure, and then, when asked, about some of the more invasive options available ‘in my country.’ After which Dr. Fred said wryly, ‘okay guys, get him on hemodialysis and sign him up for a liver transplant… but in the meantime, see if you can get him transferred to the Renal ward.’

I don’t know. Maybe Sarah, by her inactivity, was trying to save me from myself.

It's so hot...

2010-02-07T23:30:00.000-08:00

4 February

It has been hot this week.

I can hear you chuckling to yourself. ‘Doh. You’re in Africa.’

But even my Ugandan colleagues are complaining about the heat. They sit in their offices and fan themselves, still looking cool and crisp in a shirt and a tie and polyblend slacks, while I’m standing in a puddle of sweat and my rumpled cotton aloha shirt is clinging to my chest. Complaining about the weather, it would seem, is a universal pastime. For months we’ve been whinging about how long and wet the rainy season has been (as you, back home, have been complaining about how cold, or damp, or snowy it has been), and, now that the rains have relented, we can only complain about the heat.

Generally any complaint about the heat (or the rain, or the recent unpredictability of the seasons) will be followed by a gentle jibe about how the excesses of the developed world (me) is ruining the lives of the people in the developing world (them). And it is pretty hard to put up much of a defense. Even though I walk and take shared minivan transport for the bulk of my travel here (okay, the occasional bota bota… but I don’t have my own official white Land Rover with NGO insignia and driver), I think just the number of intercontinental flights I have made in the past year alone means that I am still, even here, perched on an untenable carbon footprint. And, of course, that footprint over the course of my 48 years… well… It would be pretty mean of me to point out that the goal of just about every man, woman or child I have met here in Uganda is to have a carbon footprint exactly this size or larger, so I just nod my head and mumble what passes for apology and commiseration.

Foam rubber mattresses don’t breathe. Just in case you were wondering. So for us mzungus over a certain age and body mass this means waking up in a pool of sweat about 3 or 4 in the morning and gaining appreciation for the morning sounds—the sounds that come even before the roosters and the call to prayer from the Kibuli mosque: the clicking and cawing of the night birds (Roger assures me that some birds sing at night—despite the training I received in my youth from a Daniel Boone episode—Fess Parker is explaining to a soldier how to signal by using a bird call. The soldier asks how he will know if it is the signal or just a bird. Mingo (Ed Ames) gives the soldier a withering look, ‘birds don’t sing at night…’), the gecko hunting on my screens (and occasionally on my mosquito net), the dogs prowling and yowling on the perimeter…

And so I drag myself from sodden sheets and wander around the house waiting for it to get light. I have some granola and head off down Kuta road toward the hospital. The other morning I heard singing, chanting, and the thumping of feet and sticks. I thought it a bit early for the church. Especially with not one hallelujah. Around the corner came a group of Tiger Security recruits (I’m assuming this since the man drilling them was wearing the paramilitary uniform and insignia of the Tiger Guard, and if they were full fledged guards, they would be hard at work behind the gates in kampala) jogging barefoot in formation carrying fenceposts. They were stripped to the waste and smeared in mud. They must have been running up from the Namuwongo swamp, as most of the mud in our neighborhood dried up weeks ago. The instructor barked a command and they all made their best menacing warrior face and raised their sticks overhead—ready to bash me 20 times over as they flowed around me on both sides. The kid at the back of the company gave me a sheepish smile and a nod.

The toilet turkey is back. (I saw a young boy kick him on thanksgiving day near a row of pit toilets on my way to work) He had been missing upon my return in January, so I had assumed he had wound up on someone’s Christmas platter. But the other morning he was there, tail feathers fully arrayed, patrolling the latrines.
The toilet turkey’s neighbors squat in the courtyard washing themselves with clothes and small buckets of water. I can only imagine how hot it gets inside the plastered brick huts with the metal roofs.

I cross the street and nod to Patrick at the hospital gate. Moses and Setchay(sp) are standing by the ambulances.

Moses looks to the sky and nods. ‘It’s going to be hot today.’

to kidepo and back

2010-01-31T23:56:00.000-08:00

headed home after a long day at the mud bath
view from 'Pride Rock'
lyin' in the grass
hiding behind a tree
ghost lion

To Kidepo and Back
In search of cheetahs.

January 26th

(roadtrip 16-21 Jan)

After the van overheated, and after Jack poured roughly a quarter of our drinking water into the radiator, we had lunch at the Kope Café in Gulu, stretched our legs a bit, and then headed off into uncharted territory (at least for me, and everyone else in our Matoke Tours pop-top safari van, including, as it turned out, Jack, the ‘experienced guide’ Matoke Tours had promised us). We were headed to the northeastern tip of Uganda that borders on Kenya and Sudan and holds the Kidepo Valley national park—Uganda’s most remote and least visited park.

Gulu is as far as the tarmac goes. We turned off the pavement and headed northeast to Kitgum and somewhere on the dusty red-dirt road we passed the imaginary line that VSO uses to demarcate the safe Uganda from the unsafe one. Having seen how painfully random the angel of death can be here, I have trouble assessing the relative risks of one geographic zone against another. I guess, given that I’m back in Kampala and I got to see an amazing park, the risk-reward analysis was the right one… or, as I’ve always maintained, it’s better to be lucky than smart.

Kitgum looks, to me, a lot like Soroti (without the rock): a sprawl of single level brick and plaster shops, interspersed with round mud and thatch huts, an IDP (internally displaced person—a refugee camp for the village people made homeless by the fighting between the UPDF and the LRA) camp or two just beginning to empty. The MOH (ministry of health) hospital sits crumbling inside a barb-wire maze, broken windows and rust stained plaster walls with murals about how flies transmit shigella from feces to food. A new sign announced that Baylor is going to be building a new pediatric wing. The outpatient department (OPD) had a large sleeping area for the kids who used to do the night commute.

The people of Kitgum just stare at us. (granted, we are coated orange with dust and look like we’re sporting bad fake tans) The kids don’t even break into the universal, ‘Hey Mazungu, How’re you?’ Maybe it’s just my imagination, but looking into the eyes of the people, you get the feeling that something bad has happened here. Many bad things. Maybe not even past tense.

We check into the New Loyima guest house next to the UWA (Uganda Wildlife Authority—the agency that maintains the parks and collects the park fees) office. Initially Roger and I were booked into the same room, with one small bed, which would have been pretty uncomfortable and, according to rule 4 of the rules posted on the wall, ‘strickly prohibited.’ Fortunately the management relented and gave us each our own room. I was so happy not to be sharing a bed with Roger that I gave him the room with the toilet.

The next morning we found the sign on the outskirts of town pointing ‘Kidepo Valley National Park 134km’ and headed into Karamoja—Uganda’s wild wild east. The road took us through rolling hills and plains and a minor mountain pass (a perfect place for the ambush that never happened). Some of the fields were verdant green, some sun-dried yellow, and some still smoldering from fires set to clear them. Dust, smoke and mist hung in a filmy layer in the valleys. Girls in flower print dresses hacked at dried grass with pangas (machetes), tied the grass into conical bundles the girth of your average rugby player, and carried the bundles, balanced on heads, back to their villages.

Villagers put new thatch on their roofs in Rom, or Orom, presumably while heeding the nearby sign warning them not to pick up grenades or step on landmines. I try to calculate the number of thatch bundles the girls would need to carry for one roof. My geo-spatial mathematic skills fail me as we bump off along the roadway—at least nineteen or twenty.

The women in the karamoja, as do women all over Uganda, carry their babes on their backs in a wrap, but, as I haven’t seen yet, they also use a half of a dried gourd to shade the baby’s face. Depending on the size of the gourd, it either looks like they have a giant beetle on their back, or a baby wearing an ill-fitting bike helmet.

The UWA ranger manning the gate seems happy to see us. He doesn’t get many visitors. We unload in a cloud of dust and take in the park as Jack gets out to chat and take care of our entrance fees (Ugandan National Parks have fairly steep entrance fees—25-50$/day for foreigners—one likes to hope that some of the money goes to protecting the animals of the parks and supporting the local tribes that were kicked off the land). To the north of us stretches Kidepo valley, some 1400 square kilometer of lush green river valley, golden grasslands and purple hills. To the northeast hangs Mount Morungole just in front of the Kenyan border and to the northwest, shivering slightly in the haze, the slightly larger Mount Lutoke and the Sudan. The Kidepo and the Narus rivers only run a few days every year, but leave behind enough in the way of mud and watering holes to support a diverse animal population (even a few hardy crocs). Kidepo is the only national park in Uganda with the cheetah and the ostrich; the only park with the aardwolf, the bat eared fox and the caracal; and the only park where you can find zebras, giraffes and elephants together.

Kidepo was established in 1964 in the early hours of the first Obote administration (there weren’t 2 Obotes, just one guy who managed to get elected despotic dictator at two different points in Uganda’s short history—two points separated by the Amin administration and a couple of other botched presidencies…). The Ik people were forced from their land in an act that resulted in mass starvation and death for the tribe. I whisper a small prayer of thanks to the Ik for their sacrifice that has left this pristine valley for us to wander in.

Our campsite lies on a grassy knoll fronted by a large rock outcropping on which to sit and watch the gentle meandering of the elephants and water buffalo in the valley below. The Lion King fans in our camp promptly christen the campsite Pride Rock. In one of the two shelters in the campsite we find lion hair and the smell of cat pee. We will be the only campers in Kidepo during our three-night stay. At night, sitting by a dying fire under the glowing swath of the milky-way, we will be serenaded by the distant roar of lions triangulating in the dark.

Like little kids giddy with visions of Christmas presents, we unload the van’s roof rack so we can pop the top and start safari-ing in earnest. I had a dream in kitgum of a cheetah flashing across the grassland, startling a herd of zebra into flight. It was, unfortunately only a dream. There may be a cheetah in kidepo, but he didn’t find it in his heart to sprint across open ground in front us. And even the zebras were a little hard to find (Cara says there were only 6 zebras in the park, I counted 12-13, I have one picture that shows nine of them, and I’m pretty sure I never got all of them into one picture, I guess I’m going to have to do a stripe count to win this argument).

To protect us from the wild animals, UWA assigned us a ranger whose name we couldn’t pronounce. Roger called him Ethel. Jack called him Neville. I chose Nevus. Nevus carried an AK-47, which we can only hope had an empty banana clip. Mostly he dozed in the front seat of the van or stared methodically into the ditch. When we did spot game, he would nod his head and impart some profound bit of zoological wisdom, ‘that’s a giraffe, it has a long neck.'

The highlight of the Nevus experience came when he took us out on a ‘game walk,’ of which 90% of the route was covered by dried grass six feet or higher. In other words, we walked for several hours without being able to see anything other than grass and the muddy clothes of the camper in front of us. And, had there been lions or tigers or bears in the grass, they could have pretty much picked us off one by one. At one point, with his uncanny woodcraft skills, Nevus walked us almost onto the back of a sleeping water buffalo (given there are no hippos in kidepo, the buffalo would statistically be the most dangerous animal in the park, and the main reason that nevus was even given a rifle). Unfortunately, the dark olive color of his uniform made it impossible to tell whether he peed himself or not. The look on his face would suggest so.

During our 3 days in kidepo we saw only one other safari vehicle out in the park. Once. (It was the tricked out Land Rover from the posh fly-in Apoko lodge--$350 per person per night, with not nearly the view of pride rock) This would be a big contrast from Queen Elizabeth park where it wouldn’t be uncommon for 6 or 7 safari vehicles to converge on a lion kill, or, I’m told, the Serengeti, where 15 or 20 Land Rovers might gather for a leopard sighting. But being out there alone meant we had to rely solely on our own spotting abilities, and, as I mentioned, Nevus wasn’t much help. Jack had an eagle eye, but he also had to concentrate on keeping the van on the road and the passengers on the roof from flying into the ditches. So our first two days we saw lots of elephants and buffalo and oribis (super fast tiny antelopes slightly taller than a golden retriever), but, except for a few side-striped jackals hanging around park headquarters, we struck out in the predator department.

We had been warned that there would be no beverages in Kidepo. So we were overjoyed to find that the canteen at park headquarters would sell us cold beer (a steal at 2000 shillings). One evening, while we were sitting around the parking lot savoring a cold Nile Special and an orange savanna sunset, a van marked Blessed Safaris pulled up and unloaded an obese man of European descent and of at least six decades and a young Ugandan woman whose legal age of consent could certainly have been questioned from where we sat. They checked into one of the bandas (huts) at park HQ and we never saw them out in the park. The markings on the side of van advertised: ‘safaris, gorilla tracking, camping, rwenzori hiking, and wedding arrangements.’ We were thinking of adding sex tourism onto their list of specialties, but there was not one magic marker among us. Maybe this trip came under the wedding arrangement category.

With the dawn of the 3rd day, we pointed the van north and headed into the far reaches of the park in search of our cheetah. According to Nevus, who may or may not have once seen a cheetah, this was where the cheetahs prowled. The ostriches too. Nevus said we might see ostriches if we got there by nine… or noon… or something like that.

Roger, a serious birder, wasn’t interested in spotting the cheetah. He was after bigger game: the karamoja apalis. A warbler found only in this little isolated part of the world. We, being helpful safari companions, offered to help him look for it. ‘Just what does a karamoja apalis look like?’ We asked.
‘It looks just like the grey apalis except that it is a slightly lighter grey and it has a patch of white on the wings.’
‘Okayyy.’
The karamoja apalis is only four or five inches long. Much harder to spot than a cheetah.

We left lush grasslands of the Narus valley and climbed up into a sandy scrub terrain. The grass was shorter and sparser and it looked like the perfect track for a cheetah to hit 70kph on. But it was not to be. We did spot a few stray ostriches strutting through the brush, but the big flock (do ostriches have flocks?) was hot-footing it into the Sudanese distance. The termites packed the sand into surrealistic seven foot funnel topped castles. The sandy expanse also proved to be prime tsetse fly habitat (the female tsetse fly prefers a loose sandy soil to lay her single egg into). The tsetse fly is a voracious blood-sucker that has adapted to the decrease in the game population by learning to chase safari vehicles. Unlike the mosquito which stealthily sneaks a sip of blood, the tsetse fly slams its proboscis through clothing and skin in a painful bite. The tsetse fly also brings the possibility of an added bonus: African trypanosomiasis (sleeping sickness). Jack assured us that the tsetse flies in Uganda are ‘disease free’ as he drove the van at breakneck speed trying to blow the flies out of the vehicle, all the while slapping at a fly that had gone up his pant leg. Given that Uganda has had at least two outbreaks of sleeping sickness in the past decade, and that trypanosomiasis is one of those diseases where the illness and the treatment both carry high mortality and morbidity, I wasn’t feeling like taking any chances as I hunkered in the back protecting myself from attack.

We drove all the way to Sudan looking for the elusive cheetah. To no avail.

But we did get to see the Kanatarok hot spings—a pint-sized burble of sulfuric hot water leading to a long swatch of green grass in an otherwise dry expanse. And, with the permission of the small contingent of UPDF soldiers guarding the frontier, we made a brief foray into the Sudan. Unfortunately, there were no Sudanese immigration officials at the border to stamp our passports.

And, as we wove our weary way back to pride rock, Jack stopped the van and quietly pointed out the three male lions lying under a tree. One by one, the boys strutted just out of camera range and lay down in the tall grass occasionally raising a regally maned head to check on our progress. I am told it is very rare for 3 adult male lions to hang out together—which begs the question, could this be a gay pride?

Later, after our evening game drive and another cold beer and warm sunset, on the road back to camp, we saw one, then two of the big males on the prowl. At one point one of our lions crouched in the grass about 20 meters from the van and roared. I don’t have words to describe it. I swear it shook the van. It was a grunt/roar/snarl rolled into one that boomed across the grass and echoed in the hills. And then across the darkness, one of the other lions answered back. I could just imagine being an oribi shaking in the grass, he hears a lion on one side, then the other, he bolts for clear territory—into the waiting jaws of the third lion.

Sitting on top of the van in a savanna lit only by stars listening to our lions roar, it was nothing less than the safari making moment.

for more kidepo pictures click here

Eviction Notice

2010-01-31T23:45:00.000-08:00

January 30th

Eviction Notice

The rumors have been circulating for a while:
There’s a cardiologist coming from India to start the new IHK Heart Centre. (I’m going to refrain from commenting on the wisdom of putting a ‘heart center’ and ‘cath lab’ in a hospital with a barely functioning museum piece for its main x-ray and an emergency department that doesn’t consistently have oxygen, let alone an EKG machine, in its main resuscitation room.) The new cardiologist has a family and is going to need a house… Ian is thinking about giving him ours… blah… blah…

But IHK pretty much runs on gossip and rumors, so I figured that when the time came to actually make a decision, Ian would have the courtesy to come and tell me about what he was thinking. Apparently not.

On Thursday, Dorothy, a second or third tier administrator from Human Resources finds her way to the closet I call an office (which I share with Justine, senior sister for OPD and Linda, team leader for emergency) and nervously sits down.

A bit of background. The house I live in with two other volunteers (Helen who manages the IMF which is the funding for the charitable work at IHK, and Cara who heads the physiotherapy department) is rented by the hospital. Before the volunteers lived here, Ian’s adopted daughter Rose (see much earlier post July 09 about Rose’s walk) lived here when she was clinical manager for the hospital, before she went to Yale to pursue a PhD. The house is furnished with Rose’s belongings. Rose left her stuff in Helen’s care. But ultimately the house is under IHK (Ian’s) control. It is a lovely sprawling 4 bedroom house, probably pre-independence era on a big lot (mostly left wild and unfinished and a place for Wilburforce to disappear into and come back out with a jack fruit or mango or spare auto parts), fenced and gated and within walking distance to the hospital. But it has failing plumbing and electrical and crumbling structure. In other words, it’s the perfect house for volunteers but you probably wouldn’t want to live here.

So Dorothy starts this long preamble about the new cardiologist coming. And his big family. And how hard it is to find a house in Muyenga (It’s not hard to find houses in Muyenga—you just have to be ready to outbid the American Embassy which is in the process of moving its staff to this, the perceived safer, side of town. And the new cardiologist, as part of his deal, is going to get a car, so he really doesn’t need to live within walking distance of the hospital). And therefore, it seems, well, that is to say, Ian has decided, that the only possible suitable place in all of Kampala for the new cardiologist to live just happens to be the house I’m living in.

I have to move out the first week of April.

But apparently Dorothy told Cara we’re moving sooner?

The suggested living alternatives are not nearly as appealing as my present digs. Small rooms in smallish apartments. With single women as roommates.

Another bit of background. In Uganda, if a man and woman spend the night under the same roof, they are assumed to have had sexual relations. Even in Kampala. Nancy wasn’t particularly happy when IHK moved me into a house with two women, but at least in my current living situation the neighbors (and even the girls in HR have asked the question openly) have to guess as to which one I’m sleeping with. (Just for the record. I’m not sleeping with either or my housemates.)

It’s all so very complicated.

And to complicate things more. To our usual Friday night, end of the week, south side volunteer, beer and bitch session at Fuego, Sally (not a volunteer, niece of Ian’s business partner in the construction business and here as a sales agent for Ian’s new housing project… did I just say housing project, hmmm.) brings the new cardiologist.

Well, he’s not really a cardiologist, he’s a cardiac anesthetist. (who knows, maybe anesthetists do cardiac catheterization in Kerala?) His name is Prasandan and he seems to be a very modest, likeable, smart guy. It sounds like he has a critical care background as well—which is good, maybe while he’s building the new heart center he can work on improving the mortality rate in the ICU.

So we all went out to the Coconut Shack. For Indian. And Sally is rambling on about how good the Indian food is here in Kampala. And Prasandan is poking about his aloo gobi like something died in it. And someone asks Prasandan where he’s going to live. And he says something about a nice house in Muyenga that’s coming vacant soon…

Another Kampala weekend...

2010-01-25T01:29:00.000-08:00

Sunday morning… January 24th…

Two weeks have escaped me again. My seven-month anniversary in Uganda has come and gone in a whoosh of imaginary candles.

This morning I awoke, as is my Sunday usual, to the sound of emphatic Christianity. ‘Praise him… Prraaisse himm…. PRAISE HIM…” (and you hungover pagans behind the wall, this means you too!) Although I did stagger in about 0330 this morning (story to follow… or precede… somewhere… maybe), I am actually not hungover. But I could make serious use of another good hour of undisturbed snoozing.

Stacey spent the night in our guest room. She is hungover. She assures me that our church is not nearly as obnoxious as the one near her house. ‘Hardly noticed them,’ she said. ‘Almost soothing, really.’ We set about planning the next kampala vso cluster fundraiser: Battle of the Obnoxious Ministerial Bombasts. We are quite sure we could fill a large venue with volunteers and expats. Nearly everyone we know has a horror story of Sunday morning torture. Judging could be done with a decibel meter and a panel to assess the quality of the rant. The revenue from rotten vegetable sales alone could roof a couple of schools.

So I dig out a pair of shorts and go for a run.

One of my buddies is waiting for me at the bottom of Tank Hill (the large hill near our house crowned with water tanks). Moses is an aspiring boxer (if I had to hazard a guess, somewhere between the fly and the flea weight category). As I drag my sweaty hypoglycemic carcass up the hill he shadow boxes circles around me in an elaborate dance, as he tells me how I should sponsor his career and take him to Las Vegas, and we could make millions. I contemplate kicking off one of his kneecaps and dropping as one perspiring mass onto his chest, but instead I put on what passes (at my age and fitness level) for a burst of speed. He doesn’t stop dancing, but at least I make him breathe hard enough to cease with the banter.

I run down through the gravel pits and into the flats of Bukasa and Namuwongo. On one stretch as I pick my way through the back streets back to Kironde road, I notice a gentleman peeing into the ditch. Taking a short call (elimination here is divided into short calls and long drops, I’ll let you work that our for yourselves) on the unprotected verge of a busy street is perfectly acceptable here—and taking a long drop not that unusual either. As I run up the road I think he may have a prostate issue as he seems to be making an inordinately long time of it. But no, he’s masturbating. He smiles at me as I slog past.

I guess we all have our own ways of worship on a Sunday morning.

Friday. January 22nd

Three Belgian medical students doing an elective rotation in Rwanda are visiting Queen Elizabeth Park. Their driver makes a stop at one of the crater lakes. He pulls the van to the side of the road that runs along the rim of the crater. And misjudges the slope and stability of the shoulder. And the van rolls down the hill into the crater. One of the students says she lost track of the rotations at seven. Fortunately the lake is much receded.

Later Friday

At the Centenary Park (it is unclear to me which centenary the park celebrates—independence was in 1963. Maybe the centenary of 100 years of being a slightly underenthusiastic part of the British Empire in its heyday?) We, however, are celebrating the new gentler, kinder, happier VSO Kampala Cluster—monthly Friday night gatherings: less whinging, more drinking. It is also graduation night in Kampala, so there are 4 parties within earshot, each with a speaker system larger than the space your average kampala family of 8 sleeps in. Needless to say, conversation is difficult, and they are charging 4000 shillings for beer (robbery, out and out highway robbery), so mostly we are milling around.

Modified phone log:

2130h: (loud music and giggling in the background) ‘Hello, Robert, its Ian, there’s three Belgian girls in a traffic accident out of Kadongo. One of them has a vertebral fracture. The Belgian embassy wants to fly them from Kasese to Nairobi. Can you do it?’
‘Tonight?’ (trying to calculate time for complete metabolism of two 500cc Nile Specials at 5.4% ethanol by volume)
‘No, in the morning.’
‘Are we flying the helicopter?’
‘No, the Belgians are arranging a plane.’
(against better judgment) ‘Sure, no problem.’
‘Good. I’ll give you the number of the guy from the Belgian embassy.’ (side conversation with someone who actually understands the workings of a blackberry) ‘uh yeah, I’ll text it to you.’

2140h: I call Bart, first secretary of the Belgian consul (later, when impatient with the fueling process he will be self-promoted to deputy ambassador). Once again I have forgotten to purchase airtime for my phone (most of the phones here are pay as you go, and you have to purchase little cards from the airtime shops and enter the code numbers to keep your ability to phone out—you can still receive calls when you have no airtime), but I figure I have a few minutes left.
(loud music and giggling in the background)
I’m trying to keep the conversation brief while trying to find a less than deafening corner of the park to hide in. He’s trying to give me minute details. Finally we agree that he will pick me and my gear up at the hospital about 11am.
‘Good. I’ll give you the number of the doctor in Kadongo.’ (side conversation with someone about the workings of his blackberry) ‘uh. Yeah. I’ll text it to you.’

2150h: I call the doctor in kadongo. He can’t hear me. ‘(slighltly incredulous tone) Are you in a bar, doctor?’
My phone runs out of airtime and the call ends.

2155h: He calls me back. Maybe slightly irate. Says his phone is almost out of airtime. We agree that I will call him in the morning to reassess the status of his patients.

0030h: Tom from IHK transport/ambulance wakes me up with a call to reiterate all of the information in the above conversations.

Saturday morning.

I wander into the hospital and start scrounging for equipment. One of the patients reportedly has an unstable cervical spine fracture. I grab the only spine board and the only two stiff neck collars in the entire IHK complex. Both of the collars are size regular and dirty (in the states, we would consider these single use items). I hope she has a regular size neck. I choose the cleaner of the two. I also manage to put together a few straps, a pad for the board, and a folding stretcher.

One of the nurses grabs me and says my patient is here. I had thought my patient was in Kasese, but she explains that an ambulance has just arrived from Jinja with a drowning victim. Okay, she has my interest.

In the ‘trauma room’ is an asian man involved in a camping accident that had something to do with a barbeque and a tent. Apparently he ran and jumped in the lake to put out the flames. The rescuers who fished him out of the lake decided that they had saved him from drowning and pronounced it so. My ambulance team stuck with the story. His lungs were clear and his oxygenation and ventilation intact, but he did have burns to maybe 30% of his body surface. We admitted him to our plastic surgeon. (in the states at a good burn center his prognosis would be excellent, here, well, we can always hope for the best).

Bart picks me up in the Belgian Consulate’s Prado edition Landcruiser and we make a quick stop by VSO to pick up my passport (VSO has been hanging on to my passport for the better part of 6 months in an ongoing, as yet unsuccessful, effort to get me a 1 year work permit/multiple entry visa). I am hoping that this jaunt into Kenya doesn’t result in me being forced to purchase yet another temporary single entry ($50) visa. Bart assures me he will handle it.

I was expecting that we could drive to the hangar of the chartered aircraft, load my gear, and be off in a matter of minutes. But that, it turns out, would have been just silly.

Imagine yourself in a line at airport security. You are already late for your flight to Addis (or Amsterdam, wherever), and then you notice that the people in front of you are trying to thread a folding stretcher and a spine board (not even to mention the medi-bag with the scalpel, scissors and oxygen tank) through the x-ray machine… Imagine your impatience as the security team decides they want to stop the flow of traffic through the only functioning check point in an international airport so that they can go through a medical bag that contains just about every device that a potential terrorist would want to carry onto a plane—if the plane were headed somewhere other than Kasese.

But, surprisingly enough, we manage to clear security a few milliseconds before the several hundred people behind us explode into a frenzied riot of exasperation. And we find the twin turbo prop Eagle Air plane the Belgians have chartered. And I have an interesting conversation with their engineer (Vlad) about how I’m going to secure a stretcher to the floor of the aircraft (Vlad ties the stretcher down to 4 disparate points in the plane, making it impossible to walk around and still allowing the stretcher the latitude to leave the floor by a good eighteen inches in the possibility of turbulence—I make him leave me a wrench so that I can remove 4 sets of seatbelts, and, screwing the anchor bolts for the belts into the holes in the floor from the removed seats, manage to secure the stretcher.)

Modified Flight Log:

1400h: take off for Kasese an hour and a half behind schedule. Spend the entire flight securing the stretcher and making plans for securing spine board to stretcher.

1445h: land in Kasese. Meet and examine patient. Look at x-rays—some subluxation of c4 on c5—might be a unilateral jumped facet, could be a normal, hard to tell as x-rays are crap (but, in the defense of the hospital in kadongo, no worse than I would have gotten at IHK). Fortunately the patient has full strength and sensation in her hands and feet. As we like to say in the business: she is neurologically intact. For someone who has suffered a potential cervical spine injury, this is a good thing. Load patient in plane and make her as comfortable as one can be while strapped to a board in a stiff collar (fortunately, the tiny hospital in Kadongo had a pediatric stiff collar to fit her tiny neck).

1545h: take off for Nairobi after a long wait for Ugandan immigration to come and stamp an exit stamp in the Belgian girls’ passports. Spend an anxious 2 ½ hours wondering if the spine immobilization is adequate to keep the turbulence and impact of landing from paralyzing the patient. During the flight, the patient’s two friends decide that instead of getting off in Nairobi, they are going to fly back to Kampala. Bart’s hair starts to go gray.

1815: land at Nairobi’s commuter airport. Wait for ambulance that was supposed to meet us on the tarmac.

1830h: communicate with ambulance. They were waiting on the tarmac at the main airport.

1845: ambulance arrives. Transfer patient to ambulance. Examine patient. Patient can still move fingers and toes. Relax sphincter tone for first time in four hours.

1900: pilot announces we have to take off. It is getting dark and if we don’t take off immediately, Eagle Air will have to pay extra to have the runway lights turned on.

1905: land at the main Nairobi airport. Pilot explains that in his hurry to take off before having to pay for the lights he made the command decision to refuel at the main airport (where the lights are free). Because the airport is quite busy, though, we are directed to a taxiway out in the cargo zone, closer to Tanzania than Nairobi.

2000: waiting for fuel truck.

2100: still waiting for fuel truck.

2200: fuel truck arrives. Long discussion with pilot. Apparently the fuel guys can’t accept cash at night. Ugandans don’t carry credit cards. (Unless they’re shopping at the gift shop at the Sheraton, they really have no place to use them) The pilot wants to use my credit card. In the interest of getting the plane the heck off the ground, I think about it. Hmmm… even if Visa security did approve a purchase in Africa for a 1000 liters of Grade A jet fuel (at 67 cents a liter, in case you’re wondering), would I really want the number of my credit card floating around a runway in Kenya in the middle of the night? Uhhh. No.

2230: two remaining Belgian girls change minds, again. Want to get off plane and go stay with friend who has just texted to say she’s not going to get a CT scan until Monday. Bart’s bruxism is definitely getting worse. He makes a few phone calls. It won’t be happening.

2245h: pilot somehow solves payment issue. Fuel guy puts rickety ladder into bed of pickup and balances there putting 200 liters of fuel into left wing tank. Bart gets up into pick-up to steady rickety ladder so that we don’t wind up with our second cervical spine injury of the night.

2330h: finished refueling. Take off for Entebbe.

0005: flying over Lake Victoria. Come to the realization that all of the pouches under the seats are devoid of life vests. Look around for the life raft. Nope.

0030: flying over Lake Victoria at 10000 feet in an unpressurized, unheated plane. Freezing my heinie off. Look for the overhead bins to see if there might be a blanket. There are no overhead bins. No blankets either. And, according to the pilot, Vlad never fixed the heater, because 'why would you need a heater in Africa?' Why indeed. Continue shivering for remainder of flight.

0130h: land at Entebbe. Taxi to spot a good half kilometer from terminal. Walk to the terminal and get a luggage cart. Push cart back to plane. Precariously load a spine board and stretcher onto a cart designed to hold a suitcase. Carefully push gear through doors of terminal into immigration area. Lone officer is sleeping. Push on through. The customs officer looks at me suspiciously.
‘Did you clear immigration?’
I tell the truth. ‘Yep, just passed right on through.’
‘Do you have anything to declare?’
I’m standing there with a luggage cart that has a seven foot long spine board extending off the front like a diving board and is otherwise heaped with medical crap. It is very difficult for me to pass up a straight line like this. But I do. ‘Nope, not a thing.’

0230h: drive Entebbe to Kampala. Unload Bart and the girls at the Belgian embassy. The Belgian ambassador is going to put the girls up at his residence. Ask yourself: If I got into trouble in a foreign land, even during business hours, let alone at 2 in the freakin’ morning, would my country’s ambassador offer to put me up? (speaking from experience, if you are American, I can tell you that your answer would be no) One point for Belgium.

0330h: Moses, the driver for the Belgian embassy, drives me back to the hospital to unload the gear, and then drives me home.

Re-Entry

2010-01-13T00:58:00.000-08:00

a few pictures from dubai

January 12th

Sixteen hours is a long time on a plane. Three weeks seems like a long time for a trip home for the holidays.

It seemed like I had just recovered from the upper respiratory infection I caught on my flight home (or was it the hangover from the 2nd annual west coast vodka and latke party) and I was just reaching the point of taking warm tap water for granted and then suddenly I was once again strapped into seat 37c of the Emirate 777 in the section of the plane reserved for screaming babies and tubercular coughing fits.

The holidays were a blur. I would like to say I reconnected with all of my family and friends, but that would be a lie. Mostly I concentrated on reconnecting with Nancy. Everybody else pretty much had to come find me in Noe Valley. We did manage a little road trip (the only kind of roadtrip available to you when the family vehicle is now a mini cooper) to Yosemite in search or our own little piece of the white Christmas everybody else in the northern hemisphere was wallowing in. And I did work a few night shifts in the ER at Seton—just to show my face and temporarily overcome the lurking anxiety that a year long sabbatical in the third world might ruin me for ‘modern medicine.’ (those of you in America will be happy to know that I can still burn through your healthcare tax dollars with the best of them…)

And then suddenly I’m kissing Nancy goodbye at SFO (she was actually getting on a plane to NYC the day before I left) and watching the aircraft safety video. I will say that flying steerage on Emirates is slightly better than some of the other airlines I’ve flown recently. The seats are more comfy and the added 19mm of legroom goes a long way to warding off those pesky DVTs and the entertainment system has the widest screens and most baffling array of controls in the air today. In the 16 hours from San Francisco to Dubai I managed to read half of The Girl with the Dragon Tattoo by Steig Larsson and watch 5 or 6 movies—even if I did fall asleep for at least 250 of the 500 Days of Summer.

Another nice thing about Emirates is the free hotel room (and buffet dinner/breakfast) that comes with a layover of 8 to 23 hours (and a ticket price over a $1000). So while I was checking into the Millennium Airport Hotel—at 8pm when my internal clock was saying 8am after a night of a few fitful dozes—I noticed a sign for the ‘Dubai City Lights’ tour. How could I resist?

The Dubai City Lights tour consisted mostly of 90 minutes of freeway driving in the frigidly air-conditioned van with occasional stops for our driver, Hassan, to poke me awake and offer me the opportunity to make photographs of yet another shopping mall or hotel built ‘in the traditional style’—ie like a sheik’s palace. For those of you who haven’t been to Dubai lately, the city planners are, if appearances don’t lie, on crack. Aside from building artificial islands shaped like palm trees and huge indoor ski slopes, there are so many skyscrapers under construction that they have more foreign construction workers (many from south asia who reportedly get paid less than $10/day) than citizens.

Oh yeah, and they’re broke.

Highlights included the Burg al Arab hotel (the ‘world’s only 7 star hotel’), described by Sam Wollaston in the Guardian as "...fabulous, hideous, and the very pinnacle of tackiness—like Vegas after a serious, no-expense-spared, sheik-over", and the Burg Khalifa (formerly the Burg Dubai—recently named after the Abu Dhabi sheik and president who bailed out the Dubai economy) the new tallest tower/building in the world—more than twice as high as the Empire State Building and 40% higher than the Taipei 101 (formerly the world’s tallest). The Guardian has labeled the new tower “a bleak symbol of Dubai's era of bling.”

It was hard to really take in the height of this giant needle in the middle of the night, standing in the entry of yet another shopping mall and surrounded by palm trees wrapped in christmas lights. It wasn’t until we were sitting on the tarmac at Dubai International a few miles away that I came to appreciate just exactly how tall a building that rises nearly a kilometer above the desert floor is. Pretty effing tall. As we did a fly-by from a safe distance I wondered if, like the pyramids, Dubai will be some archeological tourist site a thousand years from now…

And then about 8 hours and one stop in Adis Adiba later, I was standing in the Visa line at Entebbe (I still don’t have a work visa yet). Joseph said that Christmas in Kampala was quiet—‘everybody left.’ I’m not sure if he meant the kampalites or the VSOers on whom his taxi business depends. At the very least, there weren’t any riots.

And then about a day later, after wandering around the hospital in a daze and the faintest pretense of coming to work, I’m sitting in the private garden of the Ugandan Parliament (one of the hashers had booked it for the Monday hash), recovering from a mad run around city center, drinking a beer with Julian (dirty dick) and David (federo—prince of Buganda) and it dawns on me. I’m back in Kampala. Again.

Happy Holidays

2009-12-25T17:43:00.000-08:00

December 25th

Merry Christmas.

Those of you still in Kampala will know that I have proven myself unworthy as one not to be counted among the hardcore volunteers. I have flaked out and gone home (to San Francisco) for the holidays to snuggle Nancy, and to throw slobbery tennis balls for my increasingly obsessive labarador retriever (Bailey), and to wrap (and unwrap) presents, and to decorate trees and cookies, and to listen to one of the longest playlists of Christmas music ever compliled on iTunes, and to indulge myself in long warm showers where I can actually open my mouth, and to generally be amazed at just how good food and wine can taste.

With Nancy’s permission. Chances are good I’ll be back in Kampala in January. Until then, here’s wishing you and yours a holiday season full of joy and delight.

on a sad note

2009-12-17T21:22:00.000-08:00

December 17th

On a sad note. According to today’s New Vision, 5 people died in a bus ‘accident’ when the night bus from Kampala to Kisoro struck some large rocks on the Mbarara-Kabale road at 3am Wednesday near Ntungamo. The rocks had been placed there by the men who then entered the flipped bus and robbed the dying and injured people.

Among the dead was Moses Munezero, clinical officer from the IMC Lira clinic, on his way home to Kisoro for the holidays. Moses had been on leave from the Lira clinic during my recent visit, so I had not met him, but his loss has left a cloud of sadness over the hospital, particularly in the IMC/IMF offices where this is the second death in less than a year (Judy, one of the nurses from the Jinja clinic died of a ruptured ectopic pregnancy in April).

“In this Christmas period, we expect a lot of robbers targeting vehicles moving at night. Drivers need to move with a security person to ensure the safety of the passengers,” The Ntungamo police boss is quoted as saying.

It is unclear what the security person would have been able to accomplish as the bus drove up on the rocks. Merry Christmas.

New Vision Article

more adventures with the Ugandan legal system

2009-12-17T21:21:00.000-08:00

December 15th

I managed to get my wallet stolen over the weekend. I won’t mention the name of the club, because I would hate to give them bad publicity (but it’s spelled I-G-U-A-N-A). In their defense, they do have a sign up over the bar saying to be on the lookout for pickpockets—right next to the sign saying that effective Dec. 1st they will be ‘improving’ their drink prices (raising the price of a bottle of beer to 3500/=, outrageous, absolutely outrageous, this simply will not stand).

I had read the sign and moved my wallet to a front pocket where, if you know me, I usually keep my hand. But apparently I removed my hand from the pocket long enough to carry a few beers through the crowded bar, and, in my concentration not to spill the beverages, failed to notice the wallet lift itself out of the pocket. Fortunately I had just purchased a round of beer, and, also fortunately, I had enough loose change in my other pocket to cover the bota home.

There wasn’t much in the wallet aside from my VSO ID, the atm card for my Ugandan bank account, and enough cash to have purchased maybe another round of beer. So not a huge loss. But, given the vagaries of the Ugandan banking bureaucracy, a whole new world of hassle.

Naturally you have to go to the bank. No phone-in cancellations of your card. Then, at the bank you have to write them a letter telling them how you carelessly lost the bank’s property and begging them to forgive you and block the future use of the card. But in order to get them to actually cancel the card and issue you a new one, you have to go to the police station, file a police report, and bring a copy of the report back to the bank. You try to reason with the nice lady at the desk. What difference is a note from the police going to make in this whole process? And the nice lady says, ‘try and look at it from the bank’s perspective, if we didn’t make you get a letter from the police, then anyone could just get a replacement card anytime.’ It is hard to argue with logic like that.

So you make your way to the nearest police station—nearest to your house (at the bottom of the hill in Kabalagala). As you enter the station you see several dozen men milling about. The only activity you can detect is two men supervising a shirtless young man who appears to be mopping the muddy cement floor of the police station with his shirt. You brace yourself for what could be a long session and ask where the queue starts—only to find that they are all police officers and ready to help you. But really you should have gone to the police station nearest the Iguana. But after a little whinging and hand-ringing, the nice police officer agrees to take the police report even though it really really isn’t his job. Provided you are willing to ‘facilitate him a little something.’

So 15000 shillings later he hands you the form for a police report. You reach for your pen and he says no. ‘Photocopy.’ He directs you to the shop across the street with the sign ‘Fotcopi’ and tells you to make 10 copies. Ten? Yes, ten. And 5000 shillings and another 30 minutes later you return with the 10 copies. Of which he takes two and painstakingly staples them together over a piece of well-used carbon paper that he unfolds out of his jacket pocket. And then he proceeds to ask you a host of seemingly irrelevant questions (what is VSO, how much do they pay you as a volunteer, what do you think of Arsenal’s chance at the premiership?) while carefully printing your name on the form.

‘What did the man look like who stole your wallet?’ You try to explain that if you had been paying enough attention to see who took your wallet, you probably wouldn’t have to be having this discussion… But finally he gets to the bottom of the form and signs it. You sign it. He takes it over to another officer who signs it and stamps it. He carefully picks the staples apart, retrieves the precious piece of carbon paper, hands you your copy and shakes your hand. You have a little trouble understanding what he is saying, but the jist of it sounds like he is thanking you for losing your wallet and making a Ugandan child’s Christmas a little brighter.

And you take your copy of the police report back to the bank. And the nice lady at the bank tells you they only make the replacement cards on Tuesday.

back to gulu

2009-12-17T20:45:00.000-08:00

December 12th

Yet another trip to Gulu with a side trip to Lira

As I was fighting car-sickness in the back of the ambulance last Friday, one of the thoughts that kept crossing my mind was that on Monday I was going to get to turn around and do the whole thing over again. At least this time we did it in a Land Cruiser and the driver wasn’t bent on setting the land speed record.

Alison and I headed to the IMC clinics in Lira and Gulu to do a little teaching to the staff there… Irene from the recently dissolved IMC clinical directorate went along. Steven from pharmacy was supposed to join us, but apparently he didn’t ask proper permission from his boss, and his participation was cancelled at the last minute. (as such, I got to spend some of my time in Lira and Gulu checking out the pharmacies and auditing their records)

The road north crosses the Nile at Karuma. I wanted to stop and take some pictures, but Satchi, our driver, said that it was illegal to take pictures from the bridge (despite there being not a single sign to suggest this) and that the soldiers hiding in the woods would jump out and confiscate my camera or at least demand a healthy bribe. I suppose the bridge, as the only significant road link between northern and southern Uganda, has some strategic value, but I’m thinking that the GPS guided smart bomb dropped from 30000 feet isn’t really going to care what the view of the Karuma falls as seen from the bridge is going to look like.

At least the baboons sitting on the guardrails didn’t try to charge me for taking their picture.

Lira is a rabbit warren of shacks and old colonial buildings laid out along paths that were once probably wild animal tracks. Lira has tripled in size in the last decade or so, and the lack of community planning shows. The clinic in Lira is tiny and staffed by the usual up-country clinic contingent: a doctor, a clinical officer, 2 nurses, a lab tech, front desk/customer service representative, a security guard, a cleaner and a cook. The pharmacy, where I was to spend several hours trying to make sense of the medication record keeping (3 different books and an excel spread sheet with no correlation whatsoever between them), is the size of a coat closet.

While in Lira, we paid a visit to the Charis Health center, a 2 year old facility built by the UK charity, Fields of Life. Charis is a bit off the beaten path, but then, most things in Lira are. It is set on a nice lot, although parking seemed a little skimpy for the size of the clinic—but ours was the only vehicle there. The medical center consists of a spacious and empty waiting room, 3 consultation rooms, an emergency room (being used for staff meals and to store the donated ultrasound machine and EKG machines), 4 6-bed inpatient wards (with 3 patients), a labor and delivery area, office space and a lab. The senior medical person on duty was the lab tech (he said that the clinical officer who was supposed to be on duty was in Kampala on training, but proudly admitted that he was the one seeing patients that day) who was happy to show us around the clinic, and, when Irene wound him up a little while we toured L and D, allude to the fact that he had delivered babies (and might be able to do a C-section if he really had to). Fortunately he didn’t have many patients this particular day. I think he assumed we were potential donors, so he made a big point of showing the ‘room for expansion’ out back and suggested it would be a good place for a theatre (OR). We asked him if he was planning on expanding his practice to include major surgery, he just smiled.

What Charis amounts to then, is one of the nicest and best equipped health centers in Lira, and a horribly understaffed and underutilized resource. And the reason? NGOs like to build things. But sticking around to run them gets messy. So it’s better to cut the ribbon, shake a few hands, get the picture of the happy children on the opening day, and then get the hell out. Fields of Life mostly builds schools. Their website says that there are 34000 students attending schools built by Fields of Life, and I have no reason to doubt them. Their website doesn’t say how many patients are being cared for at Charis Health Center.

Gulu, like Lira, has also tripled in population in recent history. But at least it has grown in sort of a grid, and some of the streets have drainage gutters (even if they are full of trash and sewage and are located where one might expect a sidewalk to be).

Most of Gulu and Lira’s growth comes in the way of IDPs (internally displaced people) from the rural north battlegrounds of the civil war between the UPDF (Uganda’s army) and the LRA (Joseph Kony’s Lord’s Resistance Army). All in all there were over 1.5 million IDPs from the North. Gulu is where the ‘night walkers’—the 15000 rural children that would walk in from the villages each night so as not to be kidnapped by the LRA—walked to. Now that Joseph Kony is somewhere hiding out in the Democratic Republic of Congo, and Gulu is thought to be fairly safe, NGOs have flooded in. You cannot spit in Gulu without hitting a sign with an acronym on it. (my favorite acronym of the trip was SLAP—serving the least advantaged people) Nor can you cross the street without looking both ways for a speeding white SUV with some NGO logo plastered on the door and the trendy ‘no weapons’ (an ak47 in a red circle with a line through it) sticker in the window.

Our clinic at Gulu is a nice facility, with living quarters on the floor above. The Gulu staff come from all over Uganda (and Rwanda) and they work and live together roughly 24/7... so, naturally they have developed deep seated contempt for their co-workers. Fortunately, this was Irene’s problem. And one that a deep cleansing breath and a group hug wasn’t going to cure. We will see how my suggestion to pay them more and make them find their own accommodation will go over…

another trip to gulu

2009-12-11T04:13:00.000-08:00

December 6th

Ambulance ride to Gulu, and back.

My second trip to Gulu (a month or two back I flew on the helicopter) and I stayed for even fewer minutes than the first.

Friday morning, the sounds of the Soroti brass band still ringing in my ears, I show up at IHK. As it typical, whenever I have been gone for more than 15 or 20 minutes, Justine (senior sister in OPD) greets me with a smile and, ‘doctor, you’ve been lost.’

‘Yes, Justine, you have no idea how lost I’ve been….’

Technically, I am still excused from work by VSO for conclusion of the IVD (International volunteer day) festivities: a cocktail party at the Imperial Royale Hotel and the Volunteer of the Year Awards (VOYA). Surprisingly enough, I won’t be getting the VOYA this year. It will be going to an UNDP volunteer who goes by the moniker of ‘the Bushman’ who managed to design mud huts using nothing but a laptop and Microsoft excel! (A feat which, apparently, has brought the mud hut into the 21st century. I don’t know why they didn’t think of using an excel spreadsheet before.)

I pop my head in the ambulance/transport office to talk to Tom about a series of ambulance protocols we’ve been trying to put in place. Emma, one of my doctors is on the phone. With Gulu Independent Hospital. They have young man who crashed his motorcycle the night before. They want him to come down to IHK for a CT scan. He’s ‘stable.’ Glasgow coma scale of 13. Sure, we agree, send an ambulance with a nurse. I set a meeting with Tom and go on with my day.

A couple hours later I run into Tom again, talking nervously with Moses, one of the drivers. Apparently Gulu just called. The patient is getting worse. GCS 10. Gulu Independent is going to put him in their ambulance and head south to meet our ambulance heading north. I think out loud, ‘well, if our rig left 2 hours ago, they should be half way to Gulu now…’ Tom and Moses smile and nod, our ambulance is still in the driveway…

A few minutes later, I’m strapped into the front seat and we are driving like bats out of hell across town to the Gulu Road north. Flopping about the back of the rig, trying to take a nap, is another OPD nurse named Justine.

The ride to Gulu was 3 hours and 45 minutes of adrenaline rush and the metal on metal smell of disk brakes on their last legs. Naturally we did not see the Gulu Independent ambulance on the road. When I was finally able to locate the physician caring for the patient (who had been left in the ICU with 20 family members but no medical personnel to speak of), I was told that the patient ‘was too unstable to transport in an ambulance.’ Well thank goodness I had been planning on teleporting him back to Kampala.

GCS 3. (the Glasgow Coma Scale is a 15 point scale developed in Scotland as a predictor of morbidity in head injury based on a few simple brain function—you get 3 points just for showing up…)

As horrifying as the ride up to Gulu was(and as horrifying as was the reception at Gulu Indepenent), the ride home was exponentially more frightening. For one thing, I did much of it riding backwards attending to the last rites of my patient, while being thrown side to side like the scarecrow and the flying monkeys. When I did force myself to look forward (in a desperate effort not to hurl), what I saw through the doorway into the drivers’ compartment looked like a video game based on Death Race 2000:

Winding red-brown road threading its potholed surface through electric green foliage to the sound track of warbling siren and blaring horns. Occasionally the foliage would disappear and roadside trading centers garishly painted in the puce of Zain or the yellowgold of MTN or the sky blue of Uganda Telecom would flash by. The back ends (and occasionally the front grills) of buses and trucks and matatus would loom large and deadly on the view screen and then disappear. Targets would fly by on the periphery: motorcycles carrying 30 live chickens, tall thin men on tall thin black bicycles, women carrying jerry cans on their head, children carrying jerry cans on their heads, women carrying children and jerry cans, a baboon, (a baboon? Sitting on a guardrail), a baboon carrying a baby, two men pushing a bicycle with a coffin balanced atop, matatus disgorging floods of people, six foot high bags of charcoal on the side of the road...

The boy’s auntie rode with us, holding his hand. I had told her we would be very lucky if the patient was alive when we reached Kampala. He made it to Kampala. And got his CT scan. He was declared brain dead and taken off life support 2 days later.

VSO Roadtrip to Soroti

2009-12-06T20:35:00.001-08:00

December 4th

VSO Roadtrip to Soroti

December 2nd was international volunteer day. Or some such sort of event. About a week or so before I received an email from Daniel at VSO saying they were looking for 10 volunteers to take a bus trip to Soroti to take part in the festivities—which were to include tree planting, a march down mainstreet, and some media interviews to encourage international volunteering. I had mixed feelings on the invitation. On one hand, I haven’t been to Soroti yet (Soroti lies about due north of Kampala about 15km from the south shores of Lake Kyoga, but to reach it you have to drive northeast to Mbale and Mt. Elgon and then hook northwest for a couple more hours) and I try not to miss any opportunities to check out new places in Uganda. (The Bradt guide for Uganda doesn’t say much about Soroti except that the only thing to do in Soroti is to climb the large rock that looms over the center of town—sounds pretty good to me. We would also be driving fairly close to Sipi falls, so we had hope that we might persuade the busdriver to take a diversion.) But, as one of my fellow volunteers commented, the VSO program office would ‘have trouble organizing a piss-off in a brewery,’ so it would be likely that a fair amount of milling about aimlessly would be written into the agenda. True to form, the email said the bus would depart at 11am so we could make the radio interviews at 5pm, and we left Kampala at nearly 2pm and got into Soroti about 8pm.

On the bus: Geoff and Sabrina from Kamwenge; Hazel, Stacy and myself from Kampala. Agnes and Amelia from Kabale. Peter, one of the Kenyan volunteers. Wilson and Dunstan and several other returned Ugandan volunteers. And Grace, Rose, Harriet and several other members of the VSO program office staff. (Benon, the VSO Uganda country director, drove one of the VSO SUVs up to Soroti, despite empty seats on the bus, thus effectively negating all of the carbon offsets of our entire tree planting exercise)

On International Volunteer Day (IVD), after a suitable interval of sitting about the hotel, we went to Independence Park near town and watched the brass band warm up the crowd while we waited for the organizers to go buy hoes and shovels and watering cans… This years IVD had the theme of ‘saving the environment’ and ‘combating global warming.’ VSO Uganda, aside from a few volunteers working in wildlife conservation, does not have any ongoing projects involved in saving the environment from global warming. (VSO international does list environmental conservation as one of their core programs—so all emails from VSO do say ‘please don’t print this email unless you really have to’ at the bottom). UNDP, the other major group of volunteers attending, also doesn’t have any ongoing environmental projects in Uganda—unless you count the environmental impact of their large fleet of white SUVs.

But we got to listen to a speech from the district chairman about how he expects Uganda will stop global warming in its tracks given the success Uganda has had fighting HIV/AIDS… ‘it used to be that AIDS was a terrible disease, but now it is just like getting a cold, you take the drugs and you get better…’ (which may be why, after years of the HIV incidence falling—from nearly 20% down to about 7%--the incidence in Uganda is starting to creep back up.)

And we got to plant seedlings in Independence Park and in the mayor’s garden. Using a hoe with a metal blade precariously attached to a peeled stick, I managed to dig 20-30 holes and get blisters on my hands. It gave me newfound respect for the women I see every day wielding their hoes, turning over their fields one clump of dirt at a time. All together we planted 200 and something seedlings. I asked the man from the mayor’s office when we could expect rain. He said he hoped in April or May. (He mentioned quietly that, yes, it would have been better if we could have planted the trees a few months ago at the beginning of rainy season, but, then, it wasn’t IVD a few months ago, the time was not right for gesturing and speeches.) I don’t think things bode well for our little trees.

The next morning I jogged into town and climbed the rock. The nice soldier on top, once he finished putting his trousers on, told me that I wasn’t supposed to be up there. But he didn’t point his AK47 at me and he politely accepted my excuse that I wasn’t carrying any money in my running shorts to give him.

Rose, a little miffed that she had to ride the bus back with the volunteers, instead of in the luxury of Benon’s vehicle, nixed the side trip to Sipi falls.

I was waiting for my eggs at breakfast when the busdriver came and told me that ‘everybody was waiting’ for me on the bus and that I should come. It was 0855 and we had planned to leave at 9am. I told him that I’d be on the bus at 9… (those damned mzungus, always making you wait!)

November 2009

2009-12-05T04:32:00.001-08:00

November 4th

Another month has disappeared here.
Just got back from a week in the Netherlands with Nancy. Nancy had the annual IADMS meeting in the Hague and I got to sleep in a real bed and take real baths and showers and eat good food (with the exception of a couple of IAMDS buffet functions…) for a week. The Dutch, it seems, drink cheap south African wine, so the wine was the same. And Heinekin v. Nile Special… got to say they both rank firmly in the bottom 50th percentile of the world’s beers, but I’d have to give the nod to the Nile Special (at about a buck for 500ml) on the cost differential. Nancy and I had a very lovely belated anniversary celebration in a wonderful little inn outside of Amsterdam in the village of Broecke in Waterland. She liked the necklace.

Not too much has changed in the week I was gone. Carol, the doctor I had conned into being ‘team leader’ for the CME was transferred to one of the clinics… so I have to start all over again for that. Ian has been letting it be known (but not to my face) that he’s disappointed about the job I’ve been doing with the fun run… not feeling too bad about that. (apparently he’s miffed because I haven’t been spending my free time out at the lugogo mall signing up runners—but he seems to overlook the fact that I got the main corporate sponsor to double their contribution this year so that even if no one shows up to run, Hope Ward will still make twice as much money as last year). And Bob from lab came to the morning doctors’ meeting to rant about the fact that some of us don’t trust the lab results… apparently someone on the medical staff has been recommending to patient’s to get their labs done somewhere else (not me, I wouldn’t know where else to send them, but, even I notice that the lab values can oft times be hard to believe)… So Bob was haranguing the doctors not to voice their lack of confidence in the lab to the patients (apparently its okay not to trust the lab, just not okay to let your patients know about it). I tried to suggest that maybe instead of telling us to shut up, maybe the better approach would be to get some stricter quality control going in the laboratory… Nope, got shouted down on that one.

My roommates are off on safari, so I have the ranch to myself for a few days. Me and wilburforce the scary night guard.

November 5th

There were a trio of scroungy looking guys hanging at the compound gate when I got home from work last night. Grace, our housekeeper, wasn’t letting them in, so naturally I feared they were up to no good. But it was worse than that. They were musicians. Turns out last week, while I was up in the low country, my roommates signed up for drum lessons… and this week they are gone on safari… but a couple of the other volunteers straggled in on Ugandan time and by 6pm or so we had a little drum circle going (actually it was more of a drum semicircle).

Rhythm (along with musicality and talent with ball sports) was not something I was imprinted with genetically or picked up in early childhood or adolescence..

The African drums are hollowed out tree trunks with some dead animal skin stretched over the cavity. You beat on them with your hands. The edges of the drum head give the best reverberation (thonk) while the center gives off a more muffled beat (thunk). You want to smack the drum such that your hand kind of bounces off the drum, unless you want to punctuate your drumming with the flatter beat of your hand deadening the drum head. The drumming, traditionally, at least, has to do with the dances of the various tribes. Jonathan, who is a teacher during the day, in between swigs from the gourd in his pocket, told us how the 56 tribes of Uganda originated from the 5 main ethnic groups, and how the dancing evolved among the different groups. But naturally I forgot all that. I did remember the names to a couple of the dances, the Elongay, amagongway, oowingay and the Robert. (I think they made the Robert up just to make fun of my complete arrhythmia) As far as I can remember from the stories, all of the dancing basically comes down to proving how strong you are (and it sounds as if they gauge strength along the lines of endurance) so that the pretty young women (and, more importantly, their crusty old aunties) will be impressed and think that you would be an appropriate mate.

Fortunately I didn’t have to dance.

But, despite, my obvious lack of talent at the activity, I will say that it was quite cathartic. And the crazy drunk guy that lives over the back fence enjoyed it, he was clapping along and shouting encouragement (along with his usual ‘I love you mami.”). And for a good hour or two, we added our own blend of noise pollution to the neighborhood—drowning out the church down the hill with the microphoned hallelujahs. My hands were sore this morning.

November 6th

Tough day today. Dangerous medical missions.

Had to go to the malls. And try to convince shop owners that they should sully their bulletin boards and windows with posters advertising the upcoming Hope Ward (the charity wing of our hospital) fun run. Reminded me of being back in boy scouts about a million years ago trying to ‘sell’ jamboree tickets or some other sort of embarrassing shit. Fortunately, instead of being one of a host of skinny snot-nosed white kids lost in the trailer park selling useless crap, now I have the distinction of being a mazungu with a title… so at least the shop owners would talk to me (it must be important if IHK is sending around a doctor to hang posters—right?). But, for the most part, none of them really want to get stuck a week from now trying to get baked on masking tape goo off their glass… But I did manage to get a few of them stuck up and a couple of promises to do so when they found the proper adhesive…

Additionally, I had to line up volunteers to go to the malls and register runners. Our community outreach (the Touch Namuwongo Project—namuwongo is the slum off the foot of our hospital and the TNP provides free care to the people there as well as HIV/TB/STD screening and outreach in the schools) relies on community volunteers, so I had a number to choose from, but somehow I am supposed to gauge how honest they’ll be in a position where they need to collect money… And then I was left to negotiate how much they would need to be paid to ‘volunteer’… After some pretty intense haggling we settled on 10000/= plus an extra 2000/= for transport (6 dollars a day, 3x as much as the $2/day that 75% of Uganda survives on, but a little low for living in Kampala)… Jemimah, from TNP, laughed at me and said I got robbed… sigh… so I got to go down to the MTN shops and settle our team in to register runners.

And the day wasn’t over. Remember that I don’t have car, so I’m out with one of the ambulance drivers, because apparently I’m the only one at the hospital with this special expertise at poster hanging and table and chair setting up. So then I have to go to the MTN warehouse to pick up the tee-shirts. Because they aren’t going to release them to just anybody. I must say, at the very least, it was educational just to see what 600 tee shirts looks like (3 large bags weighing about 50-60 pounds each—in case you’re wondering). Naturally we are already behind the curve in getting the hope ward logo added onto the MTN tee-shirts, so we had to express the shirts to Tony the tee-shirt guy, and then I had to beg him to do a few of them tonight so the ‘volunteers’ can wear the shirts tomorrow. Which means that I’m going to get to spend at least part of my day off schlepping around to malls again. Whoo hooo. Wonder how many of the posters will still be in evidence.

November 16th

The ants invaded our bathroom over the weekend. It was horrific.

Living in Africa you get used to the fact that small creatures (ants, cockroaches, mice) share your kitchen. If you leave food out, you expect that it will be eaten, or at least swarming with insects by the time you get back. And it’s a good way to tell which of your housemates does a poor job washing the dishes—because if traces of food are left on a plate in the drying rack there will be a small horde of microants chomping away at it in the morning…

But the bathroom?

I should note that rainy season is still going on. Part of the global warming thing. There was no spring rainy season this year, so now the fall season is lingering on, turning everything to mud and washing away huge chunks of the road network. So apparently one or more of the ant colonies near the back of the house flooded and they decided to take refuge in our bathroom.
On Sunday morning there was a tiny trickle of the little warriors marching up the wall and on Sunday night the tub was so covered with them you could barely see porcelain… they also swarmed the toilet, the sink, and completely overwhelmed my toothbrush…
Fortunately these little guys are only a millimeter or two long, so we weren’t quite talking a Lennington vs. the ants situation, but my toothbrush had to go…
And, probably choosing a large white slipperly surface with a drain and a hand shower probably wasn’t the correct evolutionary choice to make as far as taking refuge from the flood….

November 17th

Despite all the signs pointing to doom and despair, the ‘fun run’ went off relatively smoothly. I showed up as I was told, sharp at 5am, otherwise, ‘security’ wouldn’t let me in. At 5am I was the only one there except for a few sleeping security guards. I just don’t learn.

But by 7, the essential truck with the sound system had pulled up, and the runners were marshaled around to the correct places and by 0730 we were on the road.

We had about 300 registered runners (about twice as many as last year) and a number of unregistered ones (apparently some people take the meaning of charity fun run to mean that its free).

I took 3 phone calls while out doing the 10k: one from our ambulance crew, one from Jemimah from hope ward (she was late), and one from Medi (my registration volunteer—he doesn’t really call me, he just ‘flashes’ me—calls and hangs up, calls and hangs up, until I get pissed off enough to call him back—most Ugandans have at least 2 phones… but no (prepaid) airtime, so they can receive calls, but not actually make them) Fortunately I started off pretty slow. So I was still able to get enough breath to talk on the phone.

The course started out roughly downhill for 2k then flat for 5k and then uphill for 3k. What’s wrong with this picture? Still, because of the slow start and the phone calls, I was able to pass people all through the race and this boosted my morale. For those of you who are into 10k times, I ran it in 47 minutes and change. Or, roughly, the same pace I ran my first marathon in 34 years ago…

I had managed to persuade one of the stores at Lugogo Mall (Game) to donate some gift certificates for prizes. Because we didn’t have official timing, or numbers, or even know who had paid their donation or not, we decided to give the prizes randomly (best looking shorts, sweatiest tee shirt, last finisher during the awards ceremony) as opposed by finish order. Mistake. Apparently the concept of ‘fun’ run and ‘everybody is a winner’ does not sit well with the Ugandan running populace. There clearly had to be a winner. But I was out running, so I had no idea who it was. One fierce looking gentleman was in my face and demanding a prize and, when it was not forthcoming, telling me that I had ‘cheated him’. I noticed that, unlike almost of the runners he was not wearing the official 'I am running for Hope' tee-shirt. But he did have one in his bag. I wound up having to pay him 80000 shillings to keep him from ruining the 'fun-run' atmosphere.

Given the early start, we were pretty much wrapped up by 10am. So I and my fellow Vso volunteers (I managed to get vso to sponsor a ‘corporate team’) went to La Foret and had the only breakfast available there (beer and chips). La Foret is a scroungy old hotel from the colonial era that is slowly being renovated by a Dr. Apollo (who also has his clinic on the grounds, and, unbeknownst to us, also rents the place out to a church congregation on Sundays).

So we are lounging at the pool with our beers. One of my housemates, Cara, an Australian physio, is doing laps. And this large group of people filter in wearing Sunday go to meeting suits and dresses. They sing a little, pray a little, rant a little (fortunately, unlike the church down the hill from our house, they didn’t bring a PA system), sing a little more. And then they stand at the edge of the pool looking nervously at Cara doing the butterfly leg of her individual medley… until Cara finally finishes up her laps and gets out of the pool. Then they wade fully clothed into the pool—to hold a baptism for a few newly converted sheep… I guess they didn’t read the sign behind them that read ‘all bathers must shower and wear proper swimming costume before entering pool’

November 19th

As part of my ongoing education into all things Ugandan, yesterday I had the privilege and honor to spend a day observing the Ugandan court system…

Now, as an emergency physician in the states, it’s not that uncommon to get a subpoena from the local prosecutor demanding your presence in court as a witness to some sort of evil or stupid thing that people do to each other. But here in Uganda things work a little differently. I was coming out of the morning cme meeting when Joel, Jackie’s assistant at the clinical directorate grabs me and says I need to go to Mpigi and testify at an attempted murder trial. The victim was stabbed in the abdomen with a steak knife by a friend in an incident that involved the over use of alcohol. I saw him ever-so briefly on his way to the OR, such that I didn’t even leave a note in his chart. I mentioned to Joel that probably the court would want the testimony of Dr. Ben the surgeon, or Dr. Michael the medical officer that actually provided his care… but Joel said no, that Patricia had asked for me. Patricia (it turns out I know her from the hash, and from some salacious locally circulating gossip) is the manager of the IMG’s construction company (and owner of a dress shop in kabalagala) and the sister of the man who was stabbed…
It takes us some time to find the medical record. This should not be a surprise given that our medical records consist of green 4 x 6 note cards, stapled together and lie around the registration area in huge piles. Her brother is called Emmanuel. She calls me while we are searching and tells me that I don’t need the chart and that I need to be in Mpigi in a half an hour (as it turns out the medical record was not much help—the medical officer’s note suggested that the wound was in the right upper quadrant, the surgeon’s note didn’t note a location, while my recollection—and the patient’s—had it on the left flank). I ask Joel where Mpigi is. He says ‘on the other side of town.’

Mpigi is actually almost 30km west of Kampala. It is its own district (roughly the same geopolitical unit as an American state). By the time I arrange a driver and we fight cross town traffic and make it to the Mpigi district court, it is 2 hours later.

The courtroom is a large concrete space with a high ceiling, open windows and two aisles of six or seven creaky wooden pews. Where we got to sit for another two hours while people chatted in lugandan and I smiled and nodded and put the occasional bullungi and kale out there. (fine, or okay).
And then a line of eight sullen looking young men and two young women filed in accompanied by a very large woman in combat boots and the beige uniform of the national police. I thought maybe the jury, but no, these were the defendants.

I’ll just note here briefly that typically, when I am forced to testify, I have managed to make the prosecutor think that I am so overworked that I might just go postal at any moment, so when I do have to testify they usually pick a time for my testimony where I don’t have to sit around a lot.

I’ll also note here, that because the justice system works so slowly at home, I rarely get subpoenaed to testify about something that I actually remember, whereas Emmanuel’s wound still hasn’t healed.

And then a couple of lawyers wander in. The prosecutor, a young woman with highlighted hair extensions and a tight blue suit, and the public defender (?), a slight man with a shaved head and a shiny green pinstriped suit a few sizes larger than its occupant. And they chatted for awhile. Patricia went up and talked to them and pointed at me. And we waited some more. And then we stood up. And then the Honorable Lady Justice Elizabeth Musoke came in.

Unfortunately, the stabbing case was not first on the docket. The rape case was.

The honorable lady justice sat at a slightly elevated table with the two lawyers facing her. To her right was a uniformed bailiff and the court clerk. The judge and the lawyers would grunt questions to the court clerk who would translate the questions and answers to the witnesses. I don’t pretend to understand everything that went down, because my lugandan is weak and my hearing is pretty poor and the sound of the shirtless man sweeping the lawn with a handbroom under the watchful eye of a stout woman in a webbing belted beige dress toting an AK47 with the butt broken/sawed off it was the loudest thing I could hear.

The defendant (the accused, he was called) stood in a box to the judge’s left—a young man of 18 or 19 in a blue checked shirt with an angry scowl fixed on his face and his eyes fixed on the girl standing in the box to the judge’s right. The plaintiff (the victim, as she was referred to in court), wore her school girl’s uniform—a pressed white shirt with emblem and a tan skirt. Mostly she looked at the rail she held tightly to.

‘and then what happened?’
‘mumble’
‘speak louder.’
‘mumble’
‘you must speak louder’
‘the accused used me’
‘tell the court how he used you’

I won’t bore you (or enrage you) with the details. Suffice it to say it was pretty painful to watch the lawyers and the court clerk berate the underage girl and make her recite in fairly anatomic detail the event in question in front of a tittering audience.

I will point out a few interesting bits of the proceedings that I might not have otherwise considered:

Quite a bit of the testimony (from her family and his) centered on exactly how old they were. Her family testified that she was 16 and that they had known the boy for over 20 years. Whereas his family insisted that they were both 18. Very few Ugandans have birth certificates, or even documents to prove their ages. It makes proving statutory rape kind of problematic.

The defense attorney also spent quite a bit of time questioning the girl about her bicycle. How often did she ride it? What kind of seat does it have? Because, apparently, everybody knows that young women can often break their hymens riding bicycles.

And then there was the question to the girl’s father about what he did after he found out about the rape. Did he go to the police? Well, no, it appears he first went to the young man’s family with an inquiry about the young man’s intentions—was he going to marry her? Was he ready to pay the bride price? I guess when he refused, that’s when it became rape.

The honorable lady justice scheduled her ruling in the case (no jury at this level in the justice system) for the following week. The stabbing case was postponed as well. Stay tuned.

November 20th

Phone log:

17:45 call in. (just home from work, Ben and Rachel coming over to cook us a Ugandan dinner) Ian: ‘Robert, are ye in the hospital?’ Two Belgian police officers were involved in a roll over north of Masindi. They’ll be flying in by police helicopter about 7pm. They have head injuries and one of them has a ‘dislocated shoulder’ ‘Can ye handle a dislocated shoulder Robert?’ So much for dinner plans.

17:46 call out. To IHK ambulance to have them give me a heads up when the helicopter is landing.

17:48 call in. from IHK ambulance (moses), our helicopter just left for Tanzania. I explain that its going to be a police helicopter. He says he’ll look into it.

17:50 call in. yep. A police helicopter is coming.

18:08 call in. nope. The police helicopter doesn’t fly at night. They’ll be coming by ambulance from Masindi. They’ll be here about 9p. I ask that they call me when the patients get there.

20:15 call in. ambulance still hasn’t left masindi. Eta 11pm) Reiterate request that I be called when the patient gets there. (rush dinner, excuse self early to go take nap—could be a long night

22:06 call in. from Ian. ‘Robert, they’re bringin’ ‘em down from masindi by ambulance…’ ETA 1am. ‘I gave y’er number to the supreme chief inspector of police, he’s a good guy, that’s okay, isn’t it?’
‘you’ll be there to meet the ambulance, won’ t you?’

(still trying to take a nap)

22:34 call in. from the supreme grand chief inspector of police. Just wanted to make sure the number ian gave him was correct. It is. He thinks the ambulance will be here about 1am. I thank him for this piece of information. He goes on about head injuries and broken bones and unstable patients. I reassure him that the men will be okay (because I know that if these men were seriously injured they will be long dead before they reach IHK).

(woken from early dream sleep)

23:02 call in from IHK ambulance. The ambulance has just left masindi. Eta 2am. I again repeat my request to be called when the patient gets there (ok, maybe a bit testy this time). Reset alarm for 2am.

(woken from sound sleep)

01:00 call in from supreme inspector ‘I am at the hospital. Where can I find you?’ I explain that, slacker that I am, I am still in bed. I ask is the ambulance from masindi there yet? No it is not. I explain that I live quite close and that a driver from the hospital will come pick me up when the patient gets there.

01:15 call in from chief inspector. He really thinks I should come and be at the hospital to meet the ambulance. I ask him to talk to his policemen on the ambulance and give me a call when the vehicle reaches the outskirts of town.

01:30 call in from chief inspector. ‘I have it on good authority that the ambulance will arrive at 2am’ sigh. I tell him I’m on my way in.

01:31 call out to IHK ambulance asking for a driver to come pick me up

01:32 call out to the driver

01:50 call out to wake up the driver who hasn’t come to pick me yet

2am—I arrive at hospital.

3am—2 ambulances arrive at hospital. Each with a single patient (in doing so they have removed 100% of the functional ambulances from the masindi district as well as maybe a tenth of the medical personnel, who, in hopes of a big payout from the foreign power, choke the ambulances). None of the medical personnel on the ambulances, by the way, know how release the wheeled gurneys from the locked down position in the ambulances (in their defense the lock down mechanism was one I have never seen before and couldn’t figure out either—but, then, it wasn’t my ambulance), so, in the end, the Belgians had to get up and walk into the hospital (thus effectively ruling out the diagnoses of hemorrhagic shock, lower extremity fractures, serious head injuries and the need for 2 ambulances).

6am—finally get the xrays confirming that the only injuries are a broken rib and a broken collar bone in one and a third degree acromioclavicular separation in the other. Get them checked into the hospital and curl up at desk for a nap.

At least now I have the chief of the Ugandan national police’s mobile number on speed dial—might come in handy some time. You never know.

November 23rd

Sunday the 22nd was the 6th running of the Kampala International marathon. About 500 people started the marathon and about 200 finished under 6 hours when they pulled the time clock and went home… I think many of the registrants felt chose to continue with the 10km route 5km into the race and were disqualified. About 1500 people were entered in the half marathon, while 16400 were entered in the 10km race and there were thought to be another 4000 ‘rogue’ runners in the 10km as well…

No, I did not run the marathon. I flirted with the idea of running the half, but IAA (IHK’s insurance arm) signed me up for the corporate team for the 10km, plus I had told the red cross I would provide backup for the medical tent (and I figured that I wouldn’t be much good to them if I was flat on my back with a saline drip…). So I ran the 10km. The same 10km as the week before. Just with twenty thousand more people on it.

Each of the mobile phone providers in Uganda have their own particular color: Zain is purple, Warid is blue, Orange is, well, orange and the color of MTN, the marathon’s corporate sponsor (who still haven’t coughed up the donation for Hope Ward), is yellow gold. Sunday, the streets of Kampala were awash with yellow-gold. Most of the 20000 runners were wearing their race t-shirt as were all of the course volunteers. It was fun for me to see this huge river of yellow in front of me (as well as the massive tsunami of gold behind me trying to run me down) out on the course—until my breathing got so ragged that my vision became blurry. I wore a blue shirt. As if being white wasn’t enough to make me stand out.

Aside from the sight of the yellow ‘nile’, the fact that they had 20000 runners in a race with a scant fraction of that number of officials and volunteers was problematic at best and downright scary in reality. The race start was on the same narrow 2 lane street as the week before. I managed to maneuver myself somewhat near the front of the bunch when they were lining up in the holding area, but before we were done ‘holding’ Brownian motion and general mayhem had put me back a few thousand spots. Then there was a sprint from the holding area about 200 meters to the line where I tried not to be trampled and I lost another 1000 places as I ran smack into the thousands in front of me with the weight of 10000 behind me driving me forward. Suddenly it became hot and smelly and difficult to take a full breath. At times the pressure actually took my feet from the ground. I thought about the Liverpool football fans being crushed against the fence at Sheffield in 89 and wondered if this was what it felt like. Fortunately, there wasn’t a fence between me and the start line, just a few beleaguered race officials (at least one of whom was curled in a ball on the ground still when I made it to the line) who rapidly decided to fire the starters pistol and run for their lives. For what seemed like ten minutes but what was probably a minute or two we shuffled forward like some sort of thundering amoeba. Inching forward with tremendous pressure behind. And finally, as the runners in front gradually broke from shuffle to trot the force from behind suddenly became unopposed and a few runners near me were thrown to the pavement.

By the end of the first kilometer I could finally run free and gradually pick my way through the pack. Given the dead sprint down the first 2-3 kilometres, most of the race I spent gradually passing thousands of runners (which is much more heartening than having thousands pass you as per my experience at Boston in 89…). The cheering as I went by almost invariably went like this: ‘blah blah blah mzungu blah blah…ha ha ha ha’ At which point the two or three guys ahead of me would look back in fear and put on a burst of speed. (So I think in lugandan the fans were saying don’t look now but there is a big fat white guy behind you) One gentleman in very short shorts and very tall stripey socks repeated the sprint process at least ten times before he finally dropped into a walk on the hill. ‘you shame me mzungu’ he muttered as I jogged by.

The actual marathon was won by a trio of Kenyans in about 2:18. Not only was the course hot and hilly, but they also had to contend with thousands of the 10km walkers in their way for the last 2.5km of the run. The half was won by a Tanzanian who managed to lose the local Ugandan favorite in the horde of fun-runners in a sprint to the finish in 1:03. My time was not nearly so competitive, but was a few minutes faster than the week before, so the training program appears to be paying off.

Fortunately there were no major resuscitations in the medical tent. Aside from a few dramatic, fling yourself to the ground finishers, most of the injured were security guards and race officials. Near the middle of the packs’ finish, the rumor went out that there were not enough of the coveted MTN water bottles (cheesy yellowgold plastic bike bottles, of course) to go around. The race officials were trying to trade the bottles for the ‘disposable’ timing chips tied to peoples’ shoes, but they couldn’t get the chips off fast enough and the crowd make a move for the bottles—a couple of volunteers and security guards tried to stop them and things didn’t go well for them.

But by noon everything was under control and it was time to hang out at the kampala hash house harriers tent and test the properties of nile special as a recovery drink.

The hashers were fairly impressed with my run. Parasite (I know most of these folks by their hash names, Parasite got his because when he started hashing he was mooching heavily off an expat girlfriend), fresh from his 1:15 in the half, summed it all up: ‘given your age… and given your weight… and given you don’t train… and (wave hand in front of Rob’s physique) given your body type… you should be very happy running a 43 minute 10k.’ (!)

A couple of related links:

http://www.newvision.co.ug/D/8/12/702026
http://www.monitor.co.ug/artman/publish/sports/Kampala_marathon_The_good_bad_and_ugly_95040.shtml

November 24th

Update on the trial…

I spent almost all of Monday with Patricia schlepping to Mpigi and back once more on the stabbing thing. Travelling with Patricia gave me even more insight into the Ugandan justice system.

For one thing, it wasn’t a rape case I was observing, it was a defilement case. The judge still hasn’t ruled.

It turns out, that, except in high profile cases (http://www.monitor.co.ug/artman/publish/news/Shock_as_Gen_Kazini_is_murdered_94417.shtml for instance), the burden of seeking justice falls on the victim or the victim’s family. After the stabbing, Patricia’s family went to the stabber’s family to ask for apology and restitution for Emmanuel’s 1.6M shilling hospital bill, but apparently they were rebuffed and the defendant went into hiding at his sisters. So Patricia had to find out where the boy was and bribe the police to go arrest him. She had to ‘facilitate’ the arrest by paying for their gas, their lunch, their airtime (prepaid mobile calls), etc… She then had to ‘facilitate’ the witnesses to come forward and make statements and facilitate the clerk in the printing of the documents for the trial.

Yesterday she had to pick up the two arresting officers and drive them to the court house, but not until we stopped at the mpigi dry cleaners and Patricia had to pay for one of them to get his go-to-court suit back from the cleaners. They reminded her that they would need facilitation for lunch, and then the one with the suit extorted another 10000 shillings from her saying he needed a bota back into town to get the fingerprint cards which, after pocketing the money without so much as a webale nnyo (thank you very much), miraculously appeared in his pocket…

(I should note, that I love the use of the word facilitation as it is used in Uganda for a payoff or bribe or a perk that you need to give in order to get someone to do their job. Partly I derive pleasure from this use because much of the last 4 days of pre-departure training I had from the VSO in Ottawa was based on participatory facilitation and how to be a good facilitator… and I’m sure that this may be one of the VSO—and other similar organizations—lasting impact on Uganda and the developing world: the gift of the word facilitation.)

After waiting around for another 3-4 hours, I did get to give testimony. I got to go stand in the little booth. That’s when things kind of got off on the wrong foot. The bailiff looks at me and says, ‘church.’ I say, ‘excuse me?’
He says, ‘what church do you belong to?’ You can see where this is going, I didn’t feel that my typical response of ‘recovering catholic’ would be appropriate, and I didn’t think that secular humanist would fly, so...
‘I don’t belong to any church.’
Stunned silence on the bench and in the courtroom. Patricia is pretending to look at something in her purse.
Finally
‘Do you believe in God or Allah?’
tough question. ‘Uhhh… yes?’
more silence
‘Will you swear on the bible or the Koran?’
‘Either is fine your honor.’
‘Pick up the bible.’ There are 2 books on the rail. Neither of which have any words on the cover. I choose the paperback.

It turns out that shortly into my testimony, the defense attorney decides that they need to talk to the surgeon. Not me. Patricia is a bit miffed. She knows that it will take many more shillings to facilitate the surgeon…

October 2009

2009-12-05T04:29:00.000-08:00

October 1st

Last weekend was the gorilla gala.

Gorillas are big business in Uganda (and Rwanda). A 3 or 4 hour excursion into the mountains on the Uganda-Rwanda-congo border for a 30” visit with the endangered mountain gorillas costs $500 for the permit (that’s not including your travel and lodging and the change of underpants). Some of that money actually is used to protect the gorilla and the habitat and to support the communities whose land has been taken away to continue protecting the gorilla. And some of that money goes for the minister of tourism’s brand new range rover…

In any case the gorilla gala was contrived to launch the new friend a gorilla website (www.friendagorilla.org). For those of you who can’t fly to Uganda and walk into the woods to pester the ‘habituated’ gorillas, you can now buy a gorilla friend online and put that gorillas face on your facebook page and your gorilla friend will send you periodic emails (‘had some really good shoots and leaves yesterday, still can’t get rid of the @#$%^ing tourists’) and you can check on his gps coordinates…

To add substance to the event they even recruited a couple of minor Hollywood celebrities to go check out the gorillas and grace the gala with their charm. Jason Biggs was the headliner and Brenda Wu (from Buffy the vampire killer, I’m told) and her boyfriend who is so minor his name escapes me also showed up… Initially I thought, ‘well that’s nice, the Hollywood types are supporting the wildlife efforts.’ But then Donna, one of the vso volunteers, who works at UWA (Uganda wildlife authority) told me that UWA got a grant from USAID to pay for these characters to come to Uganda and see the gorillas… So you will be happy to know that your tax dollars paid for a filthy rich American actor, known worldwide for a scene in which he masturbates into an apple pie, to come and participate in gorilla tourism.

So that about catches me up to date.
Tonight I am catching the night bus to Nairobi to participate in the Naivasha relays with some of the Kampala Hash harriers… No, I have no idea what I’ve gotten myself into this time.

October 6th

Report on the Naivasha relays long weekend trip to Nairobi: bus time—27 hours; sleep—only in 5-20 minute intervals; kilometers run—11; energy replacement drink—warm tusker beer; wildlife spotted from the bus—flamingos, zebra, impala; SVUs stuck in the mud—17.

So the Naivasha relay covers about 100km of inhospitable terrain between Nairobi and Lake Naivasha in legs of 5-6km. Most of it is Masai land (the Masai, like their cattle, have been fenced in), dry and rock and dusty with sad looking cows scrabbling for the bits of vegetation. Some of the legs of the relay were so rocky that the herd of support vehicles made such slow progress that they were overtaken by the runners. And at one point we crossed a plain covered in 6 inches of fine as flour dust unable to see more than a foot in front of the bumper of the 4WD. Watching the runners approach through the shimmering heat waves in clouds of dust was like a scene out of some post-apocalyptic epic.

For some inexplicable reason, dirty dick (his hash name) our team leader, put me in the second seed. So I got to run with several Kenyans and a Ugandan capable of running 30 min 10ks over impossibly rocky tracks. Needless to say, I didn’t see too much of them. Fortunately there was one older Kenyan in the bunch, maybe in his 40s or 50s. Unfortunately, even though he walked the uphills, he still managed to sprint by me in the end, much to the delight of the crowd.

The Kenyans were all pretty much mad (mad, in the UK sense, as in crazy, not angry). We arrived in Nairobi about 10am after the bus ride (many of team kampala, sipping on pints of waragi for the road). The Kenyans had already started drinking. The night before the relays there was dinner and dancing at the Impala club (the Nairobi hash travels with their own DJ, so nothing is accomplished without the accompaniment of ground shaking bass and afrofusion/eighties disco/hip-hop music). The hardcore hashers (myself, and the top Ugandan and Kenyan teams, not included) stayed up til 5am and then got on the bus.

As would be expected, the start was late, even though the race director said it was imperative that we made it over the hills before the afternoon rains came. Naturally, the rains came just as we hit the bottom of the hills… and the dust turned to mud and the SUVs, most with bald tires, driven by people who had been running and drinking all day, turned into lethal weapons.

One by one, the vehicles (ranging from full on land rovers to little rav4s) went screaming up the hill with tires spinning and mud flying, and, one by one, they got stuck in ditches… The masai people wandered out and stood by the fences and watched and smiled. Our driver (we were in a 4WD matatu, also with bald tires) walked over and talked to the old masai man leaning on his stick, wrapped in a red tartan like cotton blanket. ‘he says that in an hour, the rain will stop, in two hours we will be able to drive up the hill.’

But we got out. And got covered in mud pushing land cruisers piloted by drunk men whose idea of finesse is gunning the motor and flipping the steering wheel back an forth out of ditches, only to have them go into another ditch. And as soon as we got one vehicle to the top, another 2 would come and get stuck…

And in one hour the rain stopped.

And in two, the road was dry (albeit permanently scarred by the ruts we had just created). And our driver took his matatu to the top without spinning his wheels once.

So they had to cut the relay short. But there was no reason to cancel the post-relay party. We drove to captain crawdads lakeside resort on Lk Naivasha. (in the last decade, lk Naivasha has gone from being a mazungu resort haven and wildlife sanctuary to being part of the booming flower agribusiness—as you drive into the crater, all you can see are miles of huge plastic sheeted greenhouses. All those roses getting shipped to Europe drink a lot of water, and the lake is on the run—captain crawdads lakeside resort is now almost a kilometer from the lake). And, shockingly, there was more beer (at least it was cold). And we got to hear from each and every driver ‘yeah, I had it all under control, I would have made it up just fine if X hadn’t gotten stuck in front of me…’ it’s the same the world over.

The DJ didn’t stop the music until 3pm the next day.

Somewhere in the endless stream of tuskers, I’m chatting with a very inebriated but still quite articulate young man reminiscing about his days at Boston College. Topics change and we talk about Liverpool football, and then the recent unrest of the baganda. And he says something like, ‘well, (pres) Musaveni was right, my brother (the kabaka, king of the Buganda, Ron Mutebe) isn’t a private citizen, he can’t just go where he likes.’ Turns out I was drinking with Prince David, the kabaka’s little brother, bugandan royalty.

And I got a hash name from the Kenyans: kigelo (sp) home village of Obama’s dad (I guess they haven’t run with many Americans). The Kenyan hashers were quite gracious to me—given that I was running with dirty dick, peeping dick, roughrider, vodka, loose comer and sad term…

And then we got back on the bus. The road from Nairobi to the border is under construction. So the first six hours consisted of accelerate, brake, swerve, rumble, swerve, accelerate, repeat… Dirty dick and the prince had achieved alcoholic coma. Somewhere out in the wasteland the bus blew a tire. There was an explosion under the bus and the cabin filled with dust. Dick and the prince didn’t stir. There have been reports of armed bandits robbing buses, so I went about the process of hiding my camera and my passport. But the bandits never came. And an hour later the driver and the conductor had changed the tire, and 4 hours later we were at the border. And dirty dick is asking, ‘so, how was your sleep?’

Highpoint of the weekend: I’m running somewhere out in the plain. Spindly thorn trees are just getting buds from the fall rains, a few disgruntled cows are milling about in the wavy heat, the runners ahead of me are just puffs of dust on the horizon and the sweep car hasn’t caught me yet. Movement catches my eye on the left. 3 giraffe, two adults and a young one, come up out of the scrub and cross the road less than 50 feet in front of me. I stop. They trot off across the desert and disappear in the haze and dust.

0ctober 7th

Monday at the hash, Ian says something like, ‘Robert, MTN is putting on a 10k run to benefit Hope Ward… you interested?’ Since I was standing there in my running shorts and a sweat soaked tee shirt that says ‘end child sacrifice’ I kind of figured he meant, was I interested in running it… so I said, ‘sure’.

Yesterday he pops his head into my office and says ‘we’ve got a meeting with X (name I don’t recognize) at MTN at 10:30 tomorrow. I’ll pick you up at 10’

MTN, in case your wondering, is a south African phone company that has put more phones in the hands of Africans than all other companies combined. They are a major sponsor of the world cup in south Africa coming up in 2010. They are sponsoring the Kampala marathon on 22 Nov and have graciously allowed us to use the 10k a couple weeks before as a fund raiser for Hope Ward(and as a dress rehearsal for their volunteers who put on the marathon). Hope ward, in case I haven’t mentioned it, is the charity ward at IHK.

So today he picks me up, we drive across town to MTN tower. We get frisked, my laptop gets impounded, we’re ushered upstairs to a board room with no less than 20 Mtn executives in it, and the gist of the 15 minute meeting was that the run is on the 15th and there will be another meeting next week to figure out the logistics…
MTN, by the way, is where IHK gets it internet. Internet which, by the way, has been down all day today. Now we know why, all their workforce is planning a 10km run…

And Ian says..’so, Robert, you want to take the lead on this one?’

Cholera has come to kampala… there have been 10 cases so far in Namuwongo (the slum below our hospital) and 2 fatalities. The 2 people died in the taxi park trying to get across town to Mulago. I suspect that there passing was not without a large amount of transmission of the vibrio bacteria…

We are setting up a tent in the yard to stabilize cholera patients from the slum and are setting up an ambulance to transfer them to the cholera ward at mulago.

Most of the cafeteria workers here at the hospital live in Namuwongo. I don’t think I’ll be eating lunch here for a while. Life in the time of cholera.
_________________________________________________________

October 11th

Wilberforce told me the rainy season would be over the end of September.

I’m sitting here on what passes for our veranda looking out at the gray clouds gathering on the other side of the wall. There’s a rumbling of electrical activity in the cloud bank, but no flashes to speak of. The church down the hill has finally stopped with the megaphoned hallelujahs.

Spent the weekend in wakeso. The suburb/village I described in an earlier passage where we went to hear Dr. Jose Chameleon, uganda’s biggest pop star. (incidentally, Dr. Jose has gone international, we saw posters for his gigs when we were in Kenya). Wakeso is, among other things, also the home of the Peace Corps training/indoctrination center. At some point, Liam and some of the peace corps kids floated this idea that a friendly little football (that’s soccer if you live in the states) game between peace corps and vso would be a good idea… yeah. Right.

So this weekend, 13 uber fit young peace corpses showed up in matching soccer jerseys with the peace corps logos (your tax dollars at work) and soccer cleats (or, as the brits would call them, footie boots). And 10 hung over, old, out of shape vso volunteers in sneakers and blue tee shirts… We were holding our own for the first half of the first half (partly ‘cause the pool lifeguard we pulled over to play on our team was actually a pretty talented striker). And then it started to rain…

And the field turned into a muddy swamp, and suddenly cleats seemed like a pretty good idea…

Because its Sunday, Wilberforce, our usual askari (gate boy) is out, and the weekend askari gets up from a perch under a tree and runs to the back yard and runs back with a pile of laundry that has been hanging on the line since Friday (through at least 2 rain storms) and hands it too me and runs back to the back yard, presumably for the rest of the laundry.

And the skies open up. I can’t begin to describe the water that can fall here in a few minutes. By the time he returns, he is soaked to the skin and the laundry needs drying again. I don’t have the heart to tell him to hang it back on the line. There is a bare dirt patch about twenty feet from where I sit. The dirt turns to mud. And I have to move because the rainfall is splattering me with this seemingly impossibly distant mud.

Over the wall, a 30-40 foot palm tree becomes top heavy such that the waterlogged roots will no longer support it. The arc of the trunk shortens its radius, the lean picks up momentum, and the tree crashes behind the wall, beyond my sight.

October 12th

Woke at 3am to my phone going off… pretty much nothing good can come from a phone call at 3am. It was from Tom Kyobe, team leader of transport and ambulance service. They are sending a helicopter to Gulu for a medevac. Can I be on it? At 8am? (when I usually am already at the hospital) Sure, Tom, I’ll be there. Let me just lie in bed awake for a few hours wondering what I’m flying for, so I’ll be at my very best…

The morning newspaper, The New Vision, gave me a hint… there was a picture of Professor Osengo Latigo, leader of the opposition in parliament, in the ‘ICU’ at Gulu Independent hospital about 150 miles north of Kampala (a 5-6 hour bus ride). At 3am the morning before, he, his driver, and a female college student reportedly named Inocent, collided with a bus. His driver and the young woman were killed.

As I think I mentioned, for most of my first 3 months here, we have been without a pilot for the helicopter we keep on the back lawn here at IHK (the helicopter belongs to a Kenyan company, everet helicopters, the owner is a FOI—friend of Ian). But the FOI has recently assigned a pilot to Kampala and they’ve been busy trying to drum up some business for what is otherwise just a huge misrepresentation (as I think I’ve mentioned—the insurance arm of IHK is known as IAA—international air ambulance—but one of the many things that IAA medical cover will not buy you is any kind of air evacuation, and especially not a ride in the chopper). Last weekend Dave, the pilot, ex British Army, flew the bride and groom into a wedding… if you browse my gallery you will see one picture of the helicopter getting ready to fly 3 people in gorilla suits to the gorilla gala… Needless to say, Dave has been looking forward to some real flying.

So. After waiting around for GPS coordinates of the football field they wanted us to land in, and not receiving them. And after receiving a briefing from the doctor in Gulu who assured us that Latigo was ‘out of danger’ and would be able to ‘walk to the helicopter and sit in a seat.’ We took off at about 9am… and flew through the dusty haze that is the Kampala skyline and into the north country. We flew over Wobulenzi, one of the villages we walked through on Roses walk…

Our route took us over the scattered villages ringing Kampala and into the forested plains with great swaths of grassland running through them—probably the remnants of even greater rivers than the Nile off to our east, flowing out of Lake Vic at Jinja. We flew over the western end of Lake Kyoga where the Victoria Nile makes a rest stop before exiting and heading for Murchison Falls and Lake Albert. The morning sky was nearly cloudless, letting the sun reflect on the serpentine Victoria Nile at the beginning of its 4000 mile journey across the top of Africa to the Mediterranean.

And by 10am we were flying over a landscape chopped into a green chessboard of rectangular plots. Every few fields were centered by a brown spot of tamped earth sporting 3-4 circular thatched roofed huts. And at 10:30am we were lining up to land at Gulu International Airport…

The gulu airport maintenance crew—3 shirtless young men wielding pangas (machetes) with the tips bent at 45deg angles stopped their sisysphisean (sp) task of cutting the grass alongside the landing strip to watch us land.

Naturally, the ambulance wasn’t waiting there for our arrival as had been communicated. And, as you probably have guessed, professor latigo wasn’t able to walk, or even sit. There were no stretchers to be found in Gulu. And, given our preflight briefing, we didn’t bring one. So, after reconfiguring the seating of the helicopter, and after physically throwing a number of photographers and gawkers off the helicopter, we managed to position the professor on a mattress on the floor of the chopper.

http://www.monitor.co.ug/artman/publish/news/Prof_Latigo_survives_death_new_92824.shtml

http://www.newvision.co.ug/D/8/12/697677

October 13th

Happy to report that the professor and his wife (if not the 3 pieces of luggage they wanted flown down—apparently they thought they were flying business class…) made it safely to Kampala and onto the front page of the New Vision. (See links above.) As we were flying back, the thought crossed my mind, does Musaveni consider this man enough of a political threat to knock down an unarmed helicopter and have it declared an accident? So, in addition to scanning the patient’s sat monitor and respi rate during the flight, I kept a lookout for RPGs and green helicopters. Apparently, however, Musaveni isn’t running that scared. But, talking to Dave the pilot later, he was having the same thoughts as I. He said, ‘yeah, I figured if they were going to try anything it would have been over the lake…’

The professor is doing fine, by the way. I wouldn’t go so far as to say he is ‘out of danger’ (‘cuz I don’t think he’s going to be out of danger until he gets out of politics or joins Musaveni’s National Resistance Movement party).

I thought the press coverage of the whole incident quite interesting… Aside from the fact that I managed to get my pic on the front page of Uganda’s two main newspapers wearing an aloha shirt. And one of the papers called my a pilot and the other noted me as one of the paramedics… But I mean, if this had been an American politician, the emphasis on the event would have been: who was the dead girl in the car and what was she doing out at 3am with a middle aged married politician? But apparently the Ugandans don’t think that way. The only quote from the dead girl’s family was something like ‘we thank god that prof latigo was not more seriously injured…’

October 15th

Went out to Mulago today to tour the ‘cholera ward’…

So far the outbreak has stayed at the outbreak stage and not progressed to an epidemic. Thank god for that. We have seen a few more cases and have gotten them stabilized and transferred to mulago. So no more deaths in the taxi park. A good thing. As far as I know I haven’t managed to contract it yet. Also a good thing. Alison, who lives down near Namuwongo and has three children who play with the slum kids and can’t keep their mouths shut in the shower, has been fighting with VSO to get her kids vaccinated. There is a cholera vaccine (oral, two doses a week apart, about 85-90% effective with immunity for a year or two, but too expensive—about $25 a dose—for routine use in Africa), but VSO didn’t want to pay for it.

Cholera is a nasty disease. You can basically poop and vomit yourself to death in a small number of hours. With proper treatment (fluids, antibiotics) the mortality is less than 5%, but without treatment, much higher…

The cholera ‘ward’ of mulago hospital is actually a collection of semi permanent tents in a field down below the hospital. Fenced in with barbed wire. Most of the tents bear the logo of various aid agencies. Kind of telling is that the cholera ward, a disease noted for profound diarrhea, of the national referral hospital, does not have one flush toilet… (It does, however, have a number of cots with holes in them and buckets underneath—I’ll leave that to your imagination)

I had tagged onto a bus from IHK with 10-12 of our first year nursing students (if the shit really hits the fan, so to speak, they will be manning our ‘cholera camp’). They are basically just kids, happy to get out of class and go on a field trip. But they hadn’t expected to be greeted by the senior sister (most of the qualified nurses here are still called sister, even in the non-missionary hospitals) in charge of the ward, who, in my assessment, is a nasty piece of work. So, in addition to the tour of their facilities, I got to watch the senior sister bully the nursing students and call them stupid because they didn’t know the proper ratio of sugar to salt in oral rehydration solution (neither did she, actually, the WHO (world health org.) has recommended hypotonic rehydration solution (ORS)in cholera for at least the last 5 years, but, frankly the lady scared the piss out of me, so I wasn’t about to tell her that she was wrong—although it was a moot point, since they had boxes of the WHO ORS that you mix with the enclosed scoop in the can, so nobody has to measure out salt and sugar…).
She also seemed to think she was dealing with the ebola virus instead of cholera (which is, as I’ve mentioned, a nasty bug, but still a bacteria that needs to get into your digestive tract to make you sick), so she had the little nursing students whipped up into a froth of hysteria by the end of the visit.

All in all, the cholera ward is clean, well ventilated, and all the buckets (each patient gets 2) are getting emptied expeditiously. The patients seemed well cared for, and since the site is funded by USAID and DFID, they can receive antibiotics and IV fluids at no cost, unlike patients up the hill in the main hospital

October 18th

Stacy drove us out to lugogo mall yesterday. Stacey is one of the UK VSO volunteers. She is nursing director at one of the other hospitals—Case, not related to Case Western. Case has been trying to suck up to VSO to get more volunteers, so they treat Stacey pretty well. I’ve had to write multiple emails and hunt down personnel in far corners of IHK just to get a chair for my office and a key to my desk drawer, whereas Case gave Stacey a car…. Stacey got in a disagreement with the hospital’s managing the director a week or so ago, so they fired him…

Anyway. Out to lugogo. I needed to shop for an anniversary gift. (yep. Spending another anniversary out of the country. Yeah, I know, I suck. But… will be meeting Nancy in Amsterdam next week, so hopefully that will sort of count… Nancy has her IADMS (intntl assoc of dance med and science) meeting in The Hague, so I’m going to meet her in the Netherlands and continue my quest for the VSO record for being the volunteer with most days out of country in one year…)

There is an African craft shop at lugogo (there are African craft shops everywhere in Africa, mostly with the same stuff… as well as several large craft markets, also with the same stuff…. Lots of carved animals, paper beads, authentic masai cloth made from acrylic, boatloads of carved salad utinsels, and piles of garish shirts and batiques (sp)… put your order in now) that sells more upscale African jewelry, so I found a sufficiently chunky ethnic looking necklace. The shopladies couldn’t tell me which region of Africa it is characteristic of, but its nice enough looking. I hope she likes it…

Also at lugogo is a coffee shop where you can order the mammoth cappuccino for 4000/=. Unlike at the Itaiian gelateria where you order a cappuccino and they use the Italian espresso machine to heat the water to mix with the Nescafe instant and pour a little warm milk on top… And there is a Game (kind of the Kenyan equivalent of Target) and Shoprite (the South African Safeway).

On the way home Stacey went to make a U-turn across the median on Jinja road and got a bit too close to the truck that was doing the same thing, but got caught with his nose too far into traffic and had to back up suddenly—performing some after market modifications on the plastic bumper and grill of Stacey’s Toyota corso…
The guy driving the truck got out and started screaming… Being the only guy in the car, well, the only guy in the car not counting Paolo, but that’s a long story… anyway I had to get out of the car and do the screaming from out side.

I haven’t taken the official Ugandan driving test (slipping a 50000 shilling note to the DMV official without his supervisor seeing you), so I don’t really know who exactly is at fault when both vehicles are making an illegal U-turn, but I do know that in Uganda, no one ever puts their car in reverse for anybody, so I figured we had the moral high ground. His vehicle wasn’t damaged. I’m screaming at him, flapping what’s left of the bumper, telling him that we have 2 injured women in the car… He’s telling me I owe him money, I’m telling him why don’t we both drive down to the police station, he offers 20k, I demand 200k, we settle on 75k, the money changes hands, and we drive off.

No, I have no idea what 75000 shillings worth of body work will get you in Kampala. Stacey gives me a hard time about being a weak bargainer. I ask her if she’s going to give the money to the guys at the hospital to fix her car. ‘No.’

October 18th

The church down the hill wakes me at nine… God must be hard of hearing in Uganda, ‘cause all the preachers have sound systems that can chip concrete…
‘alelu…Alelu…ALLELU….ALLeLUGAH!!!’ (sp) and then a painful mix of lugandan and English shouting, some offkey singing, more shouting… I’m lying in bed (okay, so I was at the Iguana til almost 3, so I might be just a wee bit hung over) praying for a power cut and trying to put the incessant noise out of my head and then it happens, the power goes out, there is a god, and the church goes from being an oppressive pounding to a dull irritation…

but I still can’t go back to sleep. So I go for a run.

I stagger up the mud track (Lubwamma close) that we live on up to Kironde road and uphill til I hit Tank Hill (Muyenga) Rd. Up Tank Hill, turning onto Yusef Mutuvi Dr., the road that actually goes up to the water tanks, I run by Ian’s house and the US ambassador’s residence to the guarded gates at the top (I don’t know who lives there). On top you have a lovely view of Murchison bay (Lake Victoria) and the hills south and west of Kampala—a lovely view if you’re not panting so hard so that your head shakes and the sweat obscures it…

Heading down the hill, SW on tank hill road, I make my way past café roma and my previous little bungalow. About a kilometer down the road, the ritzy suburb peters out into a series of shacks housing small shops and large families selling airtime, cold beer, warm juice and the green bananas for matooke. And the paved road turns to dust and winds around the quarry and gravel pit from which comes the rock of which so much of Kampala is built. The rock is blown off the walls of the quarry using dynamite. But the several large machines for crushing the big rocks into little rocks sit idle. Some of them are obviously rusted in a fixed position. Instead, people come take the rocks in homemade wheelbarrows and make their own little piles around the site.

Around the piles, entire families gather, using hammers (or pieces of metal tied to sticks or other big rocks) to bash the big rocks into little rocks and the little rocks into smaller rocks and so forth until gravel or sand is achieved. No one wears eye protection. I tried to ask a couple of kids pushing a wheelbarrow full of sand what the would get paid for it, but they just laughed at me. But I suppose its one way to have some family Sunday togetherness and earn a few extra shillings along the way.

I run down the hill away from the clunking of metal against stone. Down to Bukasa road which is where the city ends and the slum begins. Large stucco houses look out over a sea of tin roofs to see the Luzeero prison on a hill in the distance. The city has been moving through the slums with a mandate to tear down any ‘house’ that doesn’t have its own pit latrine… pit latrines that, during the rainy season, fill with water and comingle with the water supply… hmmm. Realistically, every shack in Namuwongo has a pit latrine, it just depends on how many other shacks you have to walk around or through to get to it. Either way it stinks. And the KCC is using the cholera mandate to knock down houses closest to the road (easier to do, better resale potential) as opposed to the shacks down in the swamp. Hmmm.

I run past a group of boys ripping open garbage bags. Most people deal with their own trash here—food scraps to the animals or garden, bottles back to the shop for deposit refund, paper and plastic burned at the corner of their lot to send an acrid black smoke into their neighbors windows. But some of the affluent subscribe to the ‘BINS’ service and put their garbage on the corner in conspicuous bags. Naturally the trash of the wealthy is a treasure in itself in Namuwongo. Two bony urchins in cinched up shorts fight over a rubber band they both spotted. It reaches the limits of its elasticity and breaks. Both the boys scream.

On bukasa road I run past the bota stages and past the chapatti and rolex stands and past 4 or 5 huts that advertise nursery schools and daycare… I run past boys pushing bicycles loaded with impossibly balanced huge bags of charcoal or 3 huge bunches of green bananas… I run past a group of shirtless men digging a ditch… I run along a trail of chewed up and spit out sugarcane…
And I run past ‘neighbors pub—the company of cultured folk (once a hang out of Dr. Richard and Dr. Pete, but now somewhat abandoned by the expat crowd due to a mosquito problem) and to the corner of St. Barnabas road where I can see the shining grey and white of the IHK. I don’t run up to IHK, but I cut into the backroads, past the Rank Inn and up past a small field of banana trees and up a steep tarmacked hill back to kironde road and home. It takes me an hour.

Time for some coffee and a bath.

October 22nd

I was up on IPD2 (inpatient dept 2nd floor—where most of the sick people who have escaped the ICU are) talking to one of the doctors about the CME (another thing Ian dropped in my lap—seeing I’m one of the few senior doctors that bothers to show up for the 8am M,W,TH sessions). I have convinced Dr. Carol that she wants to the coordinator.

One of the patients’ family members comes to the desk and says something in Lugandan that I don’t catch. Carol asks me, ‘do you want to go see t patient?’
she hands me her stethoscope. I ask her who the patient is and what they’ve got, but she doesn’t answer and I follow her behind curtain number 6 where there is a dead lady. Carol freezes there and starts to cry. I ask her whats wrong and she mumbles ‘HCC (hepatocellular carcinoma—not a readily obvious acronym to me at that time) and palliative’ So I assume that we aren’t calling a code and I listen to her chest for a heartbeat and, as expected, there is none. OK, all well and good. Then a woman sticks her head in the curtain and asks what is wrong. I tell her the patient has passed on. ‘Is she dead?’ ‘Yes, she’s dead.’ And then all hell breaks loose. The patient has many children and at least 6 of them throw themselves to the floor, wailing at the top of their lungs and tugging out their hair extensions.

Carol has disappeared. The nursing staff is amazingly absent. All of the other patients and their families are surrounding me and yelling questions at me about a patient I have never seen before. ‘what did she die from?’ did she have swine flu?’ ‘why did you just let her die?’ Finally the security guard for the ward comes to see what is the problem that the mazungu doctor has caused—with his help I manage to get the 3 or 4 ululating women off the floor and into an empty private room, and manage to find the patient’s chart. Metastatic liver cancer with pneumonia and sepsis. Her vital signs on the morning round (the last vital signs that had been done) were not compatible with life—something about temp(in C)>BP didn’t bode well... But apparently no one fully explained to the family that she was going to die…
Or what the word palliative means…

I am told that the wailing is a healthy part of the grieving process and I couldn’t agree more (and I’ve certainly seen similar demonstrations by some subsets of our population back home), but, given that death is not uncommon here (even at IHK, sadly enough), and given that I would have thought the family would have been a little prepared for the event, I guess I was a little taken aback by the demonstration. And why did all the nursing and medical staff choose this precise moment to disappear?

Sigh… I guess we’ll have to schedule a CME session on end of life care.

September 2009

2009-12-05T04:26:00.001-08:00

September 1, 2009

Have a lot of lectures this week… yesterday put on an ACLS practical for the doctors. Went pretty well. Almost got a couple of them engaged with the whole ‘mock code’ concept… got off to a rocky start, though. Had booked to have it in the trauma room. But the trauma room was locked. And the night nurse with the key (the only key, as it turns out—back to the big box of unlabeled keys) had taken it home—to the other side of town. I could only laugh.

Today Alison and I went out to Mukono (halfway out the jinja road) to the IMC clinic at the RVZ flower farm. Rehima is the clinical officer (roughly the equivalent of a nurse practitioner, maybe) who runs it, and simon is her nurse. Very bright, inquisitive, fun people. Of course my lecture was on basic emergency care. So I tried to limit it to pretty basic stuff and pretty basic interventions.. like oxygen… oh except they don’t have oxygen… or a bag valve mask…. Oh, except they don’t have one of those either. Here they are, in the middle of nowhere, 15 miles from the mukono hospital, and they have no basic emergency equipment. At all. Okay, she did have one vial of epinephrine. I told her not to use it all in one place… So I don’t know if my lecture enlightened them, scared them, or just depressed them. (we are working on standardizing the emergency response equipment of all our outlying clinics, so maybe I will have to go back and repeat the lecture in 6 months when they actually have the stuff….

Tomorrow, lecture at KPC…

September 24th

Somehow most of another month has slipped past me.

In my defense, I have been away from the computer for 2 and a half weeks.

One of those weeks was spent on the chianti highway in Tuscany with Nancy. It definitely did not suck. Its nice when the most important decision of your day hinges on which beautiful little hilltown you are going to have your 3 hour lunch in…. enough said (this is private stuff, folks).

Those of you who were tuned to the BBC for the 5 minutes on September 11th when they showed the riots in Kampala know that while I was in Italy there was shooting and mayhem in my adopted city. Armed youths stormed the city center and burned police stations, stopped traffic and turned over matatus. The police fled and the army was called in. 20-30 people were killed and another 80-100 injured. 300+ people were arrested. The city center was pretty much closed for 2 days and the boda drivers were charging 10000 – 20000 shillings to take people home (1000% rate hike). A couple of the volunteers were stranded, but no one I know was hurt. IHK got one patient—an expat reporter—so we were guaranteed our fair share of media attention.

It all came down kind of like this…

Uganda, like all African countries is composed of several kingdoms. Each kingdom is made up of a number of tribes. In Uganda’s case, the traditional kingdoms were manipulated by the British during the colonial days and abolished by Obote during the early years of independence. Yoweri Musaveni, Uganda’s current president (since 1986) allowed the traditional kingdoms and their leaders to re-establish during the 90s. 3 of the 4 major kingdoms, Buganda, Bunyori and Toro were allowed legal recognition, but the Ankole kingdom was not. While the traditional monarchs were recognized, they don’t have any political power, although they do have a tremendous amount of popular support, especially within their traditional kingdom (except for the Ankole, who, apparently, could really care less if they have a king or not).

The kingdom surrounding Kampala is Buganda… so already you can see that the other kingdoms might be a little testy having to live in a country that was (mis)named after an opposing kingdom. The monarch of the Baganda (people of Buganda) is the Kabaka. The current kabaka was invited to speak at a youth ceremony an hour or two outside of Kampala in Kayunga—an area with many Buganda people, but maybe not necessarily within his rightful kingdom. If I understand it correctly, one of the local clan leaders (from the Mengo clan?) demanded that the kabaka ask permission to visit the area, and the Kabaka wasn’t ready to stoop so low as to ask permission of a mere clan leader. So there were clashes between the kabaka’s advance party and the Mengo students and the kabaka appealed for police or military assistance and apparently Musaveni told him that he couldn’t go. This was a big slap in the face to the monarch and his supporters. Kings aren’t supposed to have to ask permission to travel within their kingdom (perceived or otherwise), so a few supporters of the kabaka descended on downtown Kampala to protest and were quickly joined by some of the tens of thousands of unemployed or underemployed youths that occupy city center. And a well meaning protest rapidly descended into looting and pillaging and tipping over of matatus and burning police stations. The police forces were caught mostly off guard, and for the most part, ran for the hills. But a few of private security guards and some of the police fired their weapons randomly in the air to dissuade the rioters and, unfortunately, killed or injured bystanders who had come out onto the first and second story balconies to watch the fun. Shortly thereafter, the military moved in with armored vehicles and restored order.

A few of my fellow volunteers got cut off on the wrong side of town and had to hole up in a hotel, but no VSOers were hurt.

Apparently the peace corps had some sort of warning from the American embassy that things were going to blow. The 80 or so peace corps volunteers in the area were put on lock-down and evacuation plans were drawn up. VSO didn’t even send me a text. (and neither did the US embassy to which I’d recently gone through the trouble of registering with).

By the time I flew in on Sunday, all the mess had been cleaned up. Entebbe road was moving along nicely… Joseph, my driver, said that the city had been ‘busy’ but it was better now. In 2011, Musaveni comes up for re-election again. I think I will plan to be gone by then.

September 29th

Still reminiscing here… will let you know when I make it back to the present.
So after I skulked back into the country from italy, I caught a few hours of sleep and got up and caught the post bus to Mbarara. The post bus leaves the downtown post office at 8am with the mail. (there are actually a number of post buses… surprisingly enough, I caught the one to Mbarara). The post bus is generally thought to be one of the safer forms of overland travel in Uganda (where some of the other bus companies have the nickname ‘flying coffins’). Apparently the mail is more valuable than the people who sent it. On the bus as we passed lk mburo I had my first real wildlife spotting: 3 zebras were grazing with a herd of ankole cattle (the real big horns) on the verge of the highway. I nudged my seatmate and said ‘look, zebras.’ He looked at me as if I’d just asked him to pull my finger.

Even though I was headed southwest and downhill, Mbarara is considered ‘up-country’. Alison and Al and the kids (amy, zoe, bella, in case I haven’t introduced them) had spent the weekend leopard spotting at Lake Mburo and they met me in mbarara where Alison and I had arranged to do a clinic visit and some teaching at our clinic there. We had dinner with the VSO contingent at the Mbarara University of Science and Technology (motto: succeed we must…) and stayed at the lakeside hotel and resort (with its own manmade mosquito breeding pond) and woke to the army sealing off the hotel and unloading the bomb sniffing Alsatians for Pres. Musaveni’s surprise visit to the west country.

Spent a night perched on the edge of the great rift valley at kingfisher lodge…
The night was made interesting by the fist sized rhino beetles that apparently had it out for the lamp inside my screened window. The beetles would take to wing (making the sound of a piper super cub on short final—really, the first time I heard the noise, I had to look out the window for a small aircraft) and then smash into my window. And then you’d hear this smack like a crumpled beer can going into an empty trash can as they fell back to the walk. In the morning, I found 3 of these mini dinosaurs lying on their backs on the gravel. They can fly, but they can’t roll over. There’s a lesson in that somewhere.

From Mrarara we headed west to Bushenyi and then turned north into the great rift valley and Queen Elizabeth Park. Named, surprisingly enough, for the Queen, when she visited in 1952, QENP covers over 2000 km2 of the rift valley and protects the kazenga channel as it weaves between lake Edward and lake albert. For our first day we went on a nature walk with a ranger carrying a ak47 in the maramugambo forest. We saw vervet monkeys and baboons.

That afternoon we went on the channel cruise out of mweya and were entertained by hundreds of hippos, thousands of buffalo, a multitude of water birds, 3 small crocodiles and 2 elephants.

We had dinner at the tembo canteen overlooking the channel and, as if to be expected waited 2 hours for our food to be delivered until it was good and dark. Walking back up the road (300-400 yds at most), Alison’s eldest, Amy starts pestering us ‘what if there’s a lion out here, shouldn’t we have an armed ranger with us?’ We’re telling her that there would never be lions this close to the hostel with all these people around… Then one of the tour guides screeches to a stop in his land rover and basically demands we get into the car… ‘what are you doing in the dark, with children on the road, don’t you know there’s lions here?

We get into the vehicle. Amy says she told us so. I’m still thinking, yeah, right, lions and tigers and bears, oh my…

Until about 3am when I wake from my dream about hippos to what sounds suspiciously like a roar. Still, I’m thinking, right, I roll back over. I wake up about 15” later to more of a muttering and purring. So I pull up the mossie net and creep to the window. At the hedge, maybe 30ft away, some animal is moving… hmmm…. Can’t quite make it out. Lion? Nah. Back to sleep. Then there really is an MGM lion sort of roar. I sneak back to the window and the king of the jungle has a female lion pinned to the ground about 15ft from my window. Oops, sorry leo, did not mean to be snoopy….

The 2 lions came back one more time and I managed a rather dark looking pic, (didn’t feel like keeping my arm out the window too long futzing with the camera…)
I didn’t tell amy about it in the a.m. because I knew it would make here insufferable, but she heard about it from the other guests on my side of the building.

Alison and I went to visit the clinic in Kasese at the colbalt mine there…

Sep 30th

…continuing on. Caught the bus back from fort portal on Saturday. the post bus wasn’t an option as we didn’t get into town until mid afternoon. Sat next to a very nice, but very large woman in a red suit carrying a brief case, a knock off channel handbag, and two live chickens…

didn’t drive back with al and Alison ‘cuz (aside from the fact that if I heard one more rousing chorus of ‘my bonnie lies over the ocean’ I was going to have to choke some body) I’d promised to visit (vso volunteer) Chris and Maggie in Masindi, and even though Masindi is closer to fort portal than kampala, you can’t really get there from there, so I needed to catch the Sunday am bus to masindi so I could make rounds with chris (a gp from uk) on Monday…

alison said, ‘well, what time is the bus scheduled to leave? We’ll drop you then.’ I had to chuckle. Aside from the post bus, buses in Uganda leave when they are full, not according to any known timetable. So you crawl aboard a hot stinky bus and wait for your fellow passengers. Maybe an hour, maybe two. And then, after every square centimeter of seating space is crowded with flesh, then the bus pulls out of the bus park… and drives to the petrol station to fill up with diesel… (that is called tight cash flow)

for the ride up to masindi I got to sit next to the raving drunk man in his best Sunday go-to-church suit. Apparently he goes to the service where they serve waragi afterwards instead of donuts.

Chris is working at masindi district hospital. Districts would be the equivalent of US states in Uganda. The masindi district is home to about a half a million people. So the district hospital would be the main referral hospital for that district. I wanted to get a feel for hospitals out of kampala…

Masindi district hospital is a grim place. Built by the brits in the 50s. 3 long low-slung buildings each containing 2 open wards with 20-30 beds each. An operating ‘theatre’ from the 50s where they still use ether as an anesthetic. An xray machine from the 50s that doesn’t get used much, not because its probably a radiation hazard, but because they don’t have any film for it. Only one of the wards has running water, except that it wasn’t running that week. There are no flush toilets. Its not that much different looking than the mission hospital I visited in kiwoko a few months back except at kiwoko there was a slight sense of hope and at masindi there is nothing but despair.

I did rounds with Chris on Monday. About half of the patients in the hospital have hiv and TB.

One thing you have to learn about practicing medicine in Uganda is to listen. The patient whispers to the clinical officer who translates and whispers to Chris who whispers to me—this in a long concrete barracks with 30 other patients each with at least one or two family members who are laughing, crying or shrieking as the case may be. I suppose the whispering is the only form of confidentiality available to them.

Most of the patients who were on antibiotics were on Gentamicin (an older antibiotic that we don’t use too much of in the states anymore because it can be toxic if you don’t keep a close watch on the blood levels). To my inquiry, Chris replied that’s what the ministry (of health) sent us this month. Some months they don’t get any antibiotics… Typically the doctor will write the name of the antibiotics that he thinks the patient ought to be on on a scrap of paper and the family will go across the street to the private pharmacy and purchase it along with an IV set and bring it back… that is, if they have the money for it. If they don’t have the money for it, or if they don’t have a family member, then they get gentamicin. If the hospital has gentamicin.

And, no, the lab at masindi hospital isn’t able to check blood levels of gentamicin.

We visited the pharmacy at the hospital. They had just gotten a pallet of co-artem (one of the newer, combined, treatments for malaria). They hadn’t had any drugs for malaria for a few weeks. Malaria is a big problem in masindi. The pharmacist was in the process of telling one of the subdistrict health centers that he didn’t have enough co-artem to send them. All of the boxes of co-artem are marked ‘this medicine donated by X drug company, NOT FOR SALE’ Not too surprisingly, most of the medications for sale at the pharmacy across the road, which is owned by the hospital superintendent and run by the same pharmacist, bear the same markings on the box… hmmm….

Chris is burned out. I sit with him in his clinic for an afternoon, telling patient after patient that he has nothing to offer them. He has a stare like a concrete wall. We are driving out to visit with the community volunteers and a 2 women come in on the back of a bota. The one riding side saddle practically falls off the back into the dust of the parking lot and delivers a baby. Chris glances over, tells the driver to keep going.
Part of me wishes I was in masindi fighting the good fight with Chris… but part of me sees the price that he’s paid and is glad that I’m in kampala where things aren’t so grim. And where I can get a decent pizza and my choice of antibiotics.
Somewhere a couple of months ago I wrote about Chris and Pam’s community volunteer project in the miirya subdistrict of masindi. We drove out and met with the volunteers and talked about malaria and mosquito nets. It was the first time I saw Chris smile all day.

August 2009

2009-12-05T04:03:00.000-08:00

August 1st

Cannot believe it’s august already.
Went out to fuego’s for a beer to celebrate. Have switched to Club beer as opposed to the better tasting and slightly more alcoholic Nile specials. Have found that the clubs (in a reasonable amount) don’t give the hangover of the niles—the niles must have a secret ingredient not on the label (sterno or ethylene glycol or something)
Fuego’s has a lovely garden to sit in with an open fire pit and a 70s music soundtrack. How can you argue with that?

After that wandered down to kabalagala for Chinese food at 7th heaven (or something like that). You have to wonder about a place that has a 103 item menu and the kitchen the size of a portopotty. But, my fellow vsos said this was the Chinese place to beat on the south side of town… I think we ordered six different entrees and, surprisingly enough, they all came out looking like sweet and sour pork. None of us, mind you, ordered sweet and sour anything… but, I will say, it was pretty tasty sweet and sour pork…

August 2nd
Washed my underwear today. Mukwaye doesn’t do underwear. It is good to know that even in this land of cheap labor, money can’t buy you everything. But just the simple act of hand washing a few pairs of underwear makes you realize how much work it is to stay clean in this land of dust and dirt (and no running water, at least at my house at the moment). So doubly more impressed when I do my Sunday morning run down through the slums and see the women walking with their 5 or 6 children to church each dressed in a perfectly white and clean and pressed shirt.

Went down to movie night at Al and Alison’s. Richard’s wife Pat was supposed to give a lecture on Friday (but was canceled at the very last minute because the director decided she needed to address the group instead) so she took the ngo’s computer projector home. Watched a pirated copy of ‘state of play’ replete with soundtrack footage of someone in the audience talking back to russel crowe and slurping on their soda.

Alison had cute story. Standing on the corner with her 3 daughters (amy7, zoe5, bella almost 3). One of the Bota drivers stops and asks what country they’re from. Alison says England. The driver gives her a look and asks: ‘don’t they teach family planning in your country?’

August 3rd

Still no running water. Getting a little stinky around my house. Use the shower in my office after the hash tonight. The pipes haven’t been used in a while, so the water came out rusty and choked with debris. Sigh.

The hash was good. Out at the dateline guest house in luzira (southwestern suburb on the way to port bell—where the shipping traffic across lk Victoria comes in, also where the ganda kabaka, king of Uganda, use to keep his fleet of getaway canoes). Nice night for it. Good course they put up. Some of the nicest trash heaps I’ve run across in my day, some good hills, a nice sunset, out to the swamp canals and wound up sprinting through this village to the finish with all the children laughing at pointing at us (me… couldn’t tell if they were laughing at me for breathing like a freight train or laughing at the young black men for not being able to drop the mazungu). But couldn’t drink beer at the end as was coming in to work, so had to lay low during the drinking song part of the event. But they did have a nice stewed goat meat for dinner.

Speaking of the kabaka, the crown prince of Buganda (the traditional kingdom which involved most of southern Uganda when the Brits showed up and misnamed it Uganda because they were using Swahili translators and in Kiswahili, the Bu or Lu is just U) was at the hash tonight, getting warm beer poured on him by his royal subjects who would otherwise have to approach him crawling on their hands and knees with their eyes averted…

August 4th

Gave a lecture on trauma in the trauma room to the nurses today. Actually packed the room. Was a little surprised. Managed to get a little audience participation, but really had to work for it. Mostly just 20-25 pairs of eyes staring at me.

Went to great length to try to extol the benefits of keeping the trauma room prepared for the trauma patient at all times… will see how that takes. Justine, the head nurse (or, senior sister, as they like to say), didn’t make it.

But managed to draw them into an imaginary patient scenario (by physically dragging 5 of them out and around the trauma table and assigning them a letter in the abcd’s of trauma assessment) which seemed to go well and, at least the nurses whom I didn’t pick on, everyone seemed to get interested and show a little enthusiasm.

We will see how this translates into trauma care the next time….

August 13th

Let’s see… where was I?

Spent 5 days and 4 nights in Rwanda (except for a day trip across the border to the DRC)
Didn’t take the computer (can’t write without the macbook). Went to visit a few of the folks from the Liverpool course. Sat around and ate Indian food and drinking expensive beer (the cost of living is high in Kigali—beer is almost 2$ a bottle—and it only comes in small bottles, what kind of a country is this, anyway?) and bitched about our respective placements…

But otherwise Kigali is a beautiful city, aside from the high price of beer, smaller, cleaner, greener and more organized than kampala. Kigali cabdrivers actually stop at traffic signals and the botabota drivers (in Kigali they’re called motos) all wear helmets and have to carry a helmet for their passenger.

Stayed at the Hotel Mille Colline in the city center. Mostly ‘cause when I got to the Kigali airport (I chose the one hour flight over the 12 hour bus ride) I didn’t have any money (okay, a little disorganized ‘cause I worked the night before I caught the plane and I figured that, being neighbor countries I could exchange Ugandan shillings for Rwandan francs at the airport, but no, the Rwandans want nothing to do with the Ugandan currency) so I needed to stay at a place that took Visa and had a hotel airport shuttle. Unfortunately, the Mille Colline is in the process of a major renovation and there is early morning jackhammer work and the pool area is fenced off. Fortunately they did give me a good rate and the coffee at breakfast (not to mention a hot shower with real running water) made it all worthwhile. The Mille Colline is the hotel that was the basis for the move hotel Rwanda (but not the hotel filmed in the movie).

On Friday I wandered through the Nyabugogo market and then caught an impromptu hip hop concert in the taxi park.
Saturday I did the genocide tour… walked up to gisozo where the national genocide memorial sits overlooking the city. Pleasant grounds with a nice garden, but you kind of, initially, wonder why there are so many huge concrete slabs in the garden, until you come to the understanding that all the slabs are mass graves and that roughly a quarter of a million bodies are under there. Long black wall runs the length of it, with only about a tenth of it covered in names. If they knew the names of everyone buried there, the wall would be completely full of names…

Then caught a matatu out to Nyamata. The matatus in Rwanda go 4 to a row, as opposed to Uganda where its only 3. I think the Ugandans must have bigger butts. But you don’t want to be the last one on, ‘cause you wind up sitting on the little bar in between the real seat and the jump seat.

In Nyamata there is a Catholic church that has been left empty since the genocide. Several thousand people sought sanctuary in the church and were killed there. Blood stained piles of slashed clothing line the benches. The altar and the baptism fount have blood stains as well. Downstairs there are skulls and the coffin of a young woman who was raped and killed and thrown down the latrine. Legend has it that when she was pulled out of the latrine she was clean and dry (but apparently still dead).

Sunday I caught the bus to Gisenyi. Gisenyi is in the far NW corner of the country on Lake Kivu on the border with the DRC. Pav, one of the Liverpool gang, works in the DRC in Mweso.

The bus ride was very beautiful and painful at the same time. The Rwandan countryside is beautiful. Winding road through the foothills of the Virungas (volcanic mountain chain separating Rwanda and Uganda). Lovely terraced hillsides, nice little roadside villages and markets. Small children seemingly daring the bus to crush them…
Painful in that one of the previous passengers in the bus had thrown up. Someone had pointed it out to the driver, whose response was to take a mildewed rag and dip it in a bucket which must have contained urine and spread the vomit around a little bit. Unfortunately, as we went up into the mountains, the passengers all closed their windows (because everyone knows that cool air is going to give you a cold or the flu… not the nice man with the tubercular cough next to you), so the last half of the bus ride was a pretty trying olfactory challenge of vomitus, urine and mildew….

Gisenyi is a tired old colonial town on the banks of lake kivu… aside from the methane gas platform about a mile off shore, it could be a tropical town from the turn of the century anywhere…
Winding palm tree lined shore path with neglected houses, closed and dying hotels and banda bars… Bar Bikini tam tam, next to the fish market, seems to be the place in Gisenyi to watch the sun go down while you drink your Mutzig or Primus and gnaw on a tough but flavorful chunk of barbequed chicken.
The beach is nice enough, and the lake warm. Wasn’t able to get a straight story about the presence of schistosomiasis (so may have to pop some praziquantel), but was told that there would be no crocodiles or hippos…

Being the travel geek that I am, I did feel the necessity to walk across the border to the DRC to the city of Goma. Goma has a distinctly different feel. Dirtier, dustier, with almost no living vegetation. The people seem beat down and suspicious. I was the only muzungu walking on the streets. The UN is mounting their response to the conflict in the DRC (Dem. Republic of Congo, formerly Zaire) from Goma, so there were big cargo planes flying in/out and many armoured vehicles moving in convoys through the streets carrying Indian and indonesian troops.
In Rwanda the people speak a patois of French and English in addition to Rwandan, whereas in the DRC, only French and pidgin French. So I got to use what little French I could remember… Je ne comprende pas. Et Je n’ai pas d’argent….

Flew back to Kampala Tuesday night. (was fortunate enough to get a clean smelling and not totally packed bus) Joseph, my preferred cabbie, was only about an hour late in picking me up (and still had to stop in Kabalagala on his way into town to pick up dinner from ‘I feel like Chicken tonight.’)

Wednesday I gave part one of an ACLS type lecture to the medical officers and then that afternoon we headed out to the Ridar hotel in Seeta (east of Kampala on the jinja road) for the annual planning session for the health programme of the VSO… more on that later.

August 15th

The VSO Uganda PAP (programme area plan) Health session was interesting. Most of the health volunteers from around the country came in and gave reports on their placements. I did not need to give a report because my placement is so new and I am so obviously clueless. So the part where I got to hear from all of my fellow health volunteers was good for me. Even some of the ones in the kampala area, I guess I hadn’t really figured out what it was exactly they were doing. There is some interesting stuff going on out there.

Enjoyed the presentation by the volunteers in Masindi (NW of here, on the way to Murchison Falls Park) on their work putting together village health teams. But even there, working in the sub-district of Miireya, they ran out of money for their mosquito net program (they had committed to getting nets out to 5000 households) and there was no money from the VSO or the health district they were working in and so Pam (one of the volunteers) had to fly back to the UK and raise 15000 pounds from her family and friends in order to finish the project (I can just see you all changing your phone #s right now). From their follow up, the numbers suggest that they have decreased childhood malaria in the sub-district (in africa, aside from muzungus, almost all severe malaria happens in children—adults who live in malarious areas develop partial/temporary immunity to malaria) by 40%. So the project was a great success. And the MOH (ministry of health) officials have basically demanded that VSO ‘roll-out’ the project to the entire Masindi district…

But of course the MOH wasn’t going to commit any funds to the project, nor was VSO Uganda, so apparently Pam was supposed to go home and now raise 150k more…

Unfortunately, after the project reports, then came the small group sessions to work out the VSO Health PAP for the coming few years. And decide on the aims and objectives. (I always thoughts that aims were objectives, but, apparently, I am mistaken). Sigh.

I really really don’t want to sound too cynical here. Okay. But. The reality is that VSO is placing about 20-30 health related volunteers into Uganda in the coming years. None of these volunteers will be placed in the ministry of health or in any policy making position. Most will be placed in positions of minimal influence and with minimal if any control of finances or resources. So, maybe our aims and objectives should be kept in line with our influence—for instance: keep our volunteers healthy and well-fed, try to teach the health care providers we come in contact with the best way to practice medicine given the limited resources at hand, and try to show by example the value of health care workers and how compassionate care is possible even under less than ideal medical circumstances…
But, no. VSO Uganda’s health care aim is a little more grandiose: improve the health and quality of life of the disadvantaged people of Uganda. And the objectives: 1)increase the access to and quality of health care delivery in Uganda; 2) increase the recruitment and retention and quality of training of health care professionals in Uganda; and 3)improve the advocacy for health rights for the disadvantages, especially women and children.

All very admirable. Don’t get me wrong. But achievable? On the level we’re working at?

August 19th

Re: the above. I suppose what is important here is that I determine what my aims and objectives are here as I amble into my third month in Uganda. Hmmm.. will have to give that some thought. Maybe over a cold nile at the palm café.
And, even though, their aims may be a little beyond their means, they did take me to a nice hotel with a pool for a few days… I know, as donors, what you’re thinking… couldn’t those hotel and conference and banquet fees be better put to use buying mossie nets in masindi? Enquiring minds want to know. Well, just feel thankful I haven’t send this email list to the vso fundraising staff.

So I have moved into the ‘posh house’ as some of the other volunteers call it. The house actually belongs to Ian’s adopted daughter Rose (see prior) or the hospital, I’m not sure. But it’s a nice 4bdr 2.5ba house with thick walls and a cool interior. The house is off of kironde road and about 10-15” closer to the hospital than my last place. The walk is also nicer, mostly backroads with less traffic. Although, mostly dirt, so we’ll see how nasty they get in the rainy season. The house also has hot water and a refrigerator. It used to have an oven, but one of the previous volunteers set a fire in it… or something like that. Also included in the package is daily housekeeping from Grace and an askari (gatekeeper) named Wilberforce. I think I will be more comfortable here, and, since I now have roommates, I will be less able to continue my antisocial ways. Also, strangely enough, the hospital buys food for the house as well (nobody ever offered to buy me food at Sanyu’s place…). Now if I could just get them to stock the fridg with niles…

Went to Entebbe over the weekend. Aside from being the country’s only international airport and an international incident from the 70s to boot (do you remember what happened at Entebbe? There will be a quiz later), Entebbe is a sleepy little town on lake Victoria. Nicola, one of the English vso volunteers, had her birthday at the sailing club. Plans were to spend the afternoon sitting on the beach, but the rain came all day so we spent the afternoon huddled in the bar… and the extra water trashed some of the roadways, so our trip back took twice as long.
Apparently the much talked about fall rainy season that everyone feared wasn’t going to come due to global warning is here.

Okay. Pop quiz time. What day did the Entebbe raid take place?
Mulago hospital played a small role in the Entebbe incident. One of the hostages, a 75yo woman named Dora Bloch, was taken to Mulago with a presumed heart attack before the raid occurred. After the raid, Idi Amin’s soldiers came to the hospital and killed her and the doctors and nurses who tried to protect her.
Answer to pop quiz: July 4th, 1976.

August 25th

Don’t really know where august went….

This past weekend I played in a netball game on Saturday. One of the volunteers coaches a netball team and they have been getting their drawers blown off in all their games, so Becky thought that it would be a confidence builder for them to play a bunch of overweight old muzungus, many of whom had never played the game before…
Netball, in case you’re wondering, is a UK game played mostly by school girls which is probably most similar to being a cross between basketball and ultimate Frisbee…
It’s played on a basketball sized court, but the hoops at the ends have no nets and no backboards… you also cannot dribble the ball. And once you catch a pass, you can only pivot on the foot you landed first on… Additionally you have to stay a step away from your opponent when they are shooting. And, when you are shooting, your feet need to stay on the floor.
Weird. But we did accomplish our goal and get beaten badly by the team of schoolgirls. I was particularly embarrassed on numerous occasions by anna the 5 foot nothing barefoot girl guarding me…

Also, over the weekend. One of our volunteers had a syncopal episode and fell off the toilet and split his eyebrow open. He went to the IHK and was evaluated by one of my young doctors, had his eyebrow shaved (usually we don’t recommend doing this because in a fair number of people eyebrows don’t grow back), had some rather large gauge stitches put in in a random and haphazard fashion, had a blood count done of which his white count was slightly elevated as would be compatible with falling off a toilet in the middle of the night, so he was immediately diagnosed with bacteremia, but never once was the question asked why he passed out and struck his head… sigh… guess I have to put together a lecture on wound management and syncope…

Saturday night we went on a road trip out to wakeso where joanne and liam live. Joanne is the fund raiser I think I mentioned… her ngo still hasn’t paid their rent or their power bill… but anyway.
We were in wakeso because Dr. Jose Chameleon was playing at the wakeso recreation center. Dr. Jose, just in case you are one of the uninitiated, is Uganda’s premier pop star. You may have caught with worldwide smash ‘angelina’ which, surprisingly enough, is not available on iTunes…
First off, I should note that Uganda is a highly musical country. Little girls and boys sing in school. Young people are often singing as they carry their jerry cans of water home. Even Dr. Rose sings religious songs to herself as she plays solitaire on her computer… But. In the clubs of Uganda, instead of singing, or even karaoke, the favorite is lip-syncing or miming to other people’s music with a fake microphone…
So we filtered onto the recreation center grounds along with about a thousand other Ugandans and drank the new official drink of VSOUganda: waragi gin and fanta orange…
And we were expecting to have a few warm up acts before the great chameleon appeared, but instead we were treated to lip syncing kids prancing around on stage and a Ugandan comedy quartet complete with dwarf. Unfortunately they did their schtick mostly in lugandan, so much of the humor was lost on us, but, suffice it to say, I suspect very little of it would have been considered politically correct…
Finally, after midnight, Dr. Jose made an appearance on stage for exactly an hour. His voice sounded like it had been trashed by too much singing and cigarettes, and, although he was surrounded on stage by his entourage of folks dancing and waving a german flag (?) and road flares, his singing was accompanied by a drum machine and taped backup vocals…
Very camp. Probably would have been very annoying were it not for the waragi.

August 26th

Went for my first real ambulance ride in nearly 20 years. Lights and sirens, the whole works.
There was an industrial accident at one of the factories IAA (international air ambulance—the insurance arm of IHK, even though we really really don’t have an air ambulance—even if we had a pilot for the helicopter, its not really rigged out for patient transport) insures. In Jinja, about 75km down a busy 2 lane road from kampala. But, a first for me, before we could get on the road, we had to stop at the petrol station to put 12 liters of fuel in the ambulance. Yes, even the ambulances are kept with their fuel gauges on empty and only enough gas for the trip is put in… So we go screaming out of the ambulance bay with lights and sirens, up the hill in the middle of the road, rip around the corner to kibuli road and screech to a halt… in the petrol station.

Our ambulances at IHK are basically souped up matatus with the rear seats ripped out and a siren on top. Moses, my driver, was pretty stressed about the whole thing. Apparently they had asked for the helicopter and he had had to tell them the pilot wasn’t available, then they had demanded a plane (which would have been pretty silly given that the airstrip is half way to jinja and then they would have need another ambulance on the jinja end…) and he had had to tell them no on that one, too.
Anyway. It was a pretty wild ride. A real E ticket. (e-ticket Disneyland from the 70s, not e-ticket on an airline) Driving impossibly fast for the conditions down the middle of the road with botas, bicycles, matatus, and pedestrians diving into the ditch on both sides. On several occasions, with a truck on our left and another bearing down on us from the other lane, I looked for the lever to make the ambulance thinner (like on the night bus in harry potter), only to find that it hadn’t been installed first.
I probably would have enjoyed the ride a little bit more (aside from the very real threat of death and dismemberment) if I hadn’t picked up a bit of a stomach bug, and if the ambulance didn’t leak exhaust fumes into the passenger compartment…
As it was, I had to keep fairly focused on the road to keep from vomiting.
Jinja, in case you were wondering is where the headwaters of the Victoria Nile is, and looks like a nice little town, from what little of it I got to see… They run rafting trips down the Nile out of jinja, I’ve been meaning to get over and do a trip, but haven’t had a free weekend yet.
The patient had been caught in some sort of turbine apparatus and partially transected. I was never able to get a clear idea from the factory management exactly what happened. They pulled him out of the machine and brought him by truck to the MOH (ministry of health) hospital in jinja where he was pronounced dead on arrival. We arrived about 15 minutes later. In my rough assessment of his injuries, he wasn’t going to survive even under the best of conditions.

August 29th

Came down with my first gastro bug of my time in africa. Little bugger was probably a few weeks overdue. But nothing like hourly trips to the loo to remind you that maybe you’ve gotten a little lax in your eating and drinking habits… (I guess I may have to rethink the unidentified meat on a stick in kabalagala) can’t really moan too loud. At least I don’t have to haul the water to flush my toilet. At least I have a toilet.
By near the end of day on Thursday, I was pretty weak and feverish. So I visited the lab and got tested (negative) for malaria (maybe just a wee bit on the paranoid side—charles, the lab tech looks at me… ‘do you not sleep under a net?’... and looks at my slide… ‘you do not have malaria, but you do have neutrophilia… go home, take some antibiotics…and some painkillers… you’ll feel better’ ). So I took my lab techs advice.

July 2009

2009-12-05T03:58:00.000-08:00

My commute:

I walk to work. It takes about 30” at a brisk walk (and, if its hot out, which it usually is, arriving soaked in sweat) or 35-40” at an African saunter…

I start by walking up the back to tank hill (there are big water tanks on top) on tank hill (or muyenga, people call it either) road which is a fairly wide and paved road with a generous shoulder for the motorbikes to scream by inches from the pedestrians who fight for the last few millimeters of macadam.

In the morning I am joined by a large number of commuters as well as a few obese middle aged African men in jogging shoes (‘development’ has brought chronic diseases such as diabetes and hypertension to Africa), so I am glad to see that my ugandan colleagues are prescribing exercise to their patients… (I think prescribed, ‘cuz I don’t see much in the way of enjoyment in the eyes of the joggers)

Sensing a possible tired muzungu, the bota bota boys that don’t have a fare slow the down on the hill and offer me a ride into town: ‘hey, good morning, hello, we go to town?’ but, not having the courage to ride the back of the boda boda just yet, I just smile and wish them a good morning. The matatus zing by, already loaded with the 14 passenger limit that is upheld in Kampala as opposed to other African capitols.

Cresting tank hill I have some great views of kampala, as well as of the muyenga club and the hotel international. There is a smaller road that continues up to the tanks and some very large posh houses (one of them is Dr. Ians) as well as a few shacks that have ‘this is not for sale’ signs on them.

Also in the morning I get to witness the trucks picking up loads of private security guards. It would appear (to me) that the second largest industry in kampala (the first being the collection and disbursement of international development money by the various NGOs) is private security to protect the compounds of the NGOs from the people they are here to help. Every evening truck loads of thin young men (and a few women) in the paramilitary colors of their respective companies are unloaded at gates around the city. Some of them are handled rifles. A few are even handed a bullet for the ancient weapons. Every morning the trucks swing by to retrieve their charges. Some of the trucks have trailers full of snarling dogs. This evening as I walked home I passed a large pack of the falcon security boys in their midnight blue being led in kung fu exercises by a small asian man.

July 2

The rest of my commute…
Once I crest the road’s path over the shoulder of tank hill I pass the athletic club (?name) on the right and look down toward reste corner where, I’m told, there used to be reste corner hotel. But reste corner is home to VSO headquarters as well as the ever important Italian supermarket and gelateria where you can get really bad Italian wines for only 20000/= ($10), authentic prosciutto, and mango gelato that hits the spot after a hot dust walk up the hill.
You can also buy toilet paper, deodorant dishes and small appliances…
Rest corner turns to the left down into Kabalagala which, besides being fun to say, is a tight packed strip of bars, restaurants, internet cafes, and street food vendors—unknown meat on stick, yummy, and, my fav, Rolexes (greasy fresh cooked chapatti bread wrapped around an omelette for 600/=).
If you take a right off reste corner onto St. Barnabas road you wind steeply off the hill on a narrow potholed piece of asphalt fought viciously over by trucks, cars, motorcycles, bikes and the large number of pedestrians (myself included) silly enough to risk life and limb in the melee. Unfortunately, this is the road down to the hospital…

First Bota Bota ride today!
We were supposed to be at a meeting at 0730 at the KPC clinic across town… we were told there would be no way to take a car across town at that time in the morning because of what, in Kampala, they affectionately call the jam… so we were advised that we would need to take botas ‘cuz they can weave in and out of the ‘jam’. So we dutifully picked up the helmets VSO mandates and made phone contact with a couple of hand picked bota boys recommended by Irene who met us at neighbors pub in namuwongo near Alison’s house (having to get up at 0600 and skip breakfast to make the rendezvous).
Joseph and Jamal were waiting there for us. Allison rode side saddle in the manner of the kampala women whereas I chose to straddle the bike and hang on for dear life (but apparently it’s poor form to wrap your arms around the driver and scream like a little girl…)
Will have to say it’s actually kind of fun. And didn’t have to yell mpola (slow down) once… but did feel the proximity of my exposed shins to the other vehicles as we wove our way as we wove through traffic on bukasa, mukwono, and jinja roads…
Of course we got there late at 0740. And of course, we were nearly the first ones there. The rest of the people we were meeting with came in over the next hour, noting how bad the jam was.
Personally I find it refreshing how unapologetic they are about showing up late.
But, note to self, stop setting alarm clock.

July 4, 2009

Happy independence day. Had the unpleasant opportunity to visit the US embassy the other day… wanted to register with the embassy and try to get on the email list for the American expats… and maybe score an invite to the 4th of July party and fireworks at the embassy…

Since the bombings of the Kenya and Tanzania embassies, however, American missions abroad have become less like putting a friendly face on the USA abroad and more like fortified bunkers. They moved the embassy from downtown Kampala to a hill outside of town surrounded by multiple layers of barricades and armed guards. To even approach the embassy you have to get patted down by the Ugandan military police and then go through an airport like screening to get into the building and even then (as someone carrying a US passport, mind you—I’m sure if you’re not, you are subject to even further humiliation) the embassy staff addresses you through a window of bullet proof thickness via a speaker.

And she’ll tell you that you could’ve registered with the embassy on line (which is only half true—travel.state.gov is a piece of crap and when I tried to register online it never sent me an email confirmation).
And, as far as an invite to the fireworks. Yeah, forget it.

July 8th

Ian is proving an interesting boss.
He calls me periodically.
“Robert. I’m talking to some people who need a doctor to fly to Gabon and help medevac a patient to south Africa… “ “Robert, there’s a couple of guys from the British Army in my office… they’re planning a live-fire exercise in X jungle… they want to know what our trauma capabilities…” “ Robert, what do you know about swine flu… I want to you to organize our response…”

and as immediately as one crisis arises, his attention to the previous one evaporates, so when you present him with the swine flu protocol or talk about flying to Gabon a few hours later he looks at you with a blank face.

Am finally finishing up a two week orientation for the hospital… had a rescheduled appointment with the Navision guy from IT (Navision is the electronic medical record system that is soo bad they couldn’t even manage to sell it in the US…) at 0830, for which he never showed up (and didn’t return any phone calls, and nobody in IT knows where he is or how else to reach him… apparently being the only person in the system who understands this antiquated piece of shoddy software that they have pawned off on the third world puts him in a position of power…) But did manage to attend the multiple sessions on mission statement and customer service…hmmm.

The A and E (accident and emergency) ward seems like it will be a fun place to work, but am still in the process of deciding on and developing what that work will be. My thought was that I was going to help the doctors assigned to A and E develop their emergency medicine skills, but whenever I come down there to see patients they have a tendency to disappear… this may take some time.

Went bota-ing downtown last night to get some rather disappointing palak paneer at an Indian restaurant all the expats rave about and to meet some of the vso volunteers who are down from bwindi (sw Uganda, where the gorillas are). Went to the National theater, to see the percussion discussion Africa—kind of like a mix between a jazz quintet and 6 person traditional African drum band. Not too bad. Didn’t buy the cd. Didn’t feel the need to get up and dance and demonstrate my complete lack of rhythm.

July 9th

Went back downtown to the vso ‘cluster’ meeting… chaired by Marcel, a dutch volunteer who works improving the lives of the people imprisoned in Ugandan jails.

The cluster is supposed to represent volunteers located in the same general vicinity. Apparently the word cluster doesn’t carry some of the same military induced connotation that it enjoys in the US, at least in ER circles. Most of the volunteers in Uganda are located in Kampala (because, as I think I mentioned, the main industry in kampala is the generation and distribution of foreign aid, and this is what the majority of the volunteers are involved in), so we have a really big cluster—in more ways than one…

So 15-20 volunteers wander into the masala chaat house and order 15-20 pints of nile special… and the whinging begins. I guess I feel pretty lucky that my expectations are pretty low and so are those of my employer, so I don’t feel as if I was set up for failure, as a number of my colleagues seem to feel…

Joanne and Liam (English) were sent out to wakesa, which, I’m told, is a northwestern suburb of kampala (but apparently in the suburbs they have to haul their own water in jerry cans…). She is a fundraiser for a british medical charity at home and she volunteered to work here as a fundraiser to raise money for an ngo that works for people with disabilities. At least on paper. Joanne showed up at her posting to find an empty office… no phone, no computer, no internet, nothing. But they are very anxious for her raise some funds, so that they can buy some office equipment. The first order of business was her new boss asking her for a loan…

TimTim, from the phillipines was also quite distressed. Pretty much every third sentence out of his mouth was ‘they will cheat you.’ (the other two sentences, in case you were wondering, would have been asking for another beer and ‘the vso in Uganda does not care about us.’ Hmmm

Met a lovely irish couple. Jo (short for Josephine), a nurse who basically walked away from her assignment with a private orthopedic clinic to start working with the nurses at Kibuli (Ki is pronounced Chi here) Hospital which is the muslim funded mission hospital where things are apparently desperate. She’s asked me to come hang out in their OPD and teach their doctors manners… hmmm…

Her husband Larry, works in management for another NGO that works with hiv patients. He just scored them a 2.5M USAID grant which means that the NGO will be able to pay the salaries of its employees for another 2 years. Which I thought was a pretty big score. And should make him a hero where he works… but he has described it as a double edged sword. Now that their income is secure for another 2 years, he feels his coworkers are doing even less than before… and he’s a little miffed that he had to pay 30000/= (which isn’t that much money, but looks more impressive in ug. Shillings than pounds) in back fees on the ngo’s postoffice box, so that he could get his mail, because his boss (who reportedly drives a bmw) said that they didn’t have the money to pay the fees…

Jo and Larry were robbed at knifepoint in their apartment the other night. They swear that they feel this was a totally random event and have chosen to remain in their apartment.

July 11th

Today was Rose’s walk. Rose is Ian Clarke’s adopted daughter (he has a large number of ‘adopted’ African children—4-5 of them were here today). 20 years ago, an orphaned Rose walked away from the village of Bamunanika and walked 52km to the village of Kiwoko where the Ugandan church has a mission hospital and where the Clarkes were working in 1989. Rose has since gone on to nursing training in Uganda and in the states (she worked as a neurotrauma nurse at Baylor) and now she’s in a PhD of nursing program at Yale.

So today we walked the 52 kilometers (I think it was probably in the mid-forties, but in high sun and heavy dust, it was plenty) to raise money for the IHK nursing scholarship fund and to raise awareness about the ongoing practice of child sacrifice (apparently witch doctoring is still happening in Uganda and if you need really powerful magic then you’ll want something with some child parts in it).

Hannah from HR said she’d pick me up at 0450. I told her I’d walk to the hospital to meet the buses, but I think she thought I’d flake. So something completely startling happened… she came early. I would have been ready to go at 0450, really I would have. (but then, naturally, we got there before 5am and the buses that were supposed to take off at 0530 so we could get out there walking before it got hot, didn’t leave til almost 0630 once again, stop with the alarm clock stuff)

So it was my first trip out of kampala, and I was pretty excited (even if I slept through most of the drive up to Bamunanika).

We walked from Bamunanika to Wobulenzi, wobulenzi to Luwerro, and Luwerro to Kiwoko. The way from Wobulenzi to Luwerro is on one of the main N-S highways (the Gulu road), so it was hot, choked with diesel fumes and not a lot of scenery except the occasional roadkill. I jogged the middle section with an irish lady named Irene who, even half winded, was able to keep up both ends of the conversation. Her husband sean, hungover from a party at the irish embassy the night before (their embassy invites them to parties, Hilary, just to let you know), so he took it out on us by telling us we had 5 miles to go when really it was less than 2km.

The other 2 segments were packed red dust roads through little villages of mud huts and brick houses with children that would run out to the curb to wave “Bye” (because, apparently that is easier to get off than ‘good day, how are you?’), and buses and matatus and determined looking men and boys pushing bicycles loaded with impossibly big bags or charcoal or bundles of sticks and boys herding cows with horns 2-3’ across and motorcycles whipping by with entire families of 5 or 6 balanced on the limited seating and nonseating areas.

All in all, a nice walk. Wound up at the Kiwoko hospital where the nursing students sang and danced for us and we sat in the grass and had tea and chapati and cold stony ginger beer (it is, after all, a church compound). And I got a tee-shirt that says ‘End Child Sacrifice’. Won’t see too many of those in Noe Valley…

July 12th

Oh. Forgot to mention that some friends of Hannah gave me a ride home from kiwoko. Not exactly sure where they fit into the whole IHK/IMG/extended family of Ian bit, but they are apparently doing okay ‘cuz they’re driving a newish Toyota landcruiser and they live in Muyenga. So on the drive back home they stop (literally) to do a little shopping. They pull over at the luweero markets, which are all roadside and open air and roll down the window and yell and point at the vendors. I am told that there is no word for please in Lugandan. Its basically ssento meko (how much?) and mpa (pronounced oompah, which is give me) that.
Edith and Charles complained bitterly that ever since they got the new car the vendors in the market want to cheat them and charge them the mazungu price. So they have to haggle twice as hard and this slows down the roadside shopping experience. Edith did buy me a big bag of mangos for only 2000/=, however, for which, given my poor market skills, I probably would have come home with only two mangos.

Ugandan mangos, by the way, are pretty amazing. They pick them ripe from the trees and the kids will eat them peel and all. I could pretty much eat them until I’m sticky all over and have a pile of mango pits bigger than my head (and I have to spend the rest of the day in the potty).

Today Sanyu, my landlady, made matooke in the backyard, okay, actually Mukwaye, one of the servants, peeled the green bananas, wrapped them in banana leaves and steamed them over a charcoal brazier. Sanyu added salt and spices and mashed it up to its usual off yellow mush consistency. Maybe because it was fresh, but this was the best matooke I’ve ever had (the matooke they serve us at the hospital has started to cool and takes on the consistency of rubber cement left with the lid open).

July 13th

Caught a Bota after work across town to Ntinda for a run with the Kampala Hash House Harriers. Hashing is sort of a group run where the course is poorly marked with bizarre symbols and only really known to one or two of the crowd (the hash masters) and the goal seems to be trying to get people irreparably lost in an unknown part of town (not hard for me) and then gathering at the end to sing drinking songs and chug lukewarm club beer (actual warning label on club—‘don’t drink and walk home, you might fall into the road and block traffic’). Needless to say, I have found my people.

Hashing apparently is a worldwide phenomenon hitherto unknown to me. I’m told, by Jo and Larry (irish vsoers, see above) that typically hash clubs are made up of expats, but what makes the Kampala group special is that the bulk of the hashers (including the has master) are Ugandan.

Regardless of whether I was participating in a worldwide phenomenon, it was fun to get out and see another neighborhood of kampala and follow a papertrail (literally piles of shredded paper were used to mark the route) over hill, through swamp, through the back yards in the slums, across fields occupied by cows and strung with barb wire, across the grounds of a catholic school and winding up at the headquarters of the ASFU (acid survivors foundation of Uganda—now, coming from san Francisco, I was pretty sure this had something to do with Tim Leary and lsd, but actually here it is a form of domestic violence…) So I was running (and drinking) for a good cause, and have added another teeshirt to my collection: ‘Hashing to support victims of Acid violence’

July 14th

Walked to the corner store for a nile special (singular, as I don’t have a frig, I don’t have the luxury of purchasing 6-paks). I know you think all I write about is beer, but I feel pretty righteous about walking a half a mile for a cold beer. And I remembered to bring an empty with me. Some places won’t even sell you a beer without an empty and some will charge you 1000/= for a deposit on a beer that costs 1500/=… but it is one thing they do right here. Reuse, not recycle. Now if they could just figure out what to do with all the plastic water bottles—personally I think they need to start selling bottled water to the mazungus in glass bottles with the same deposit. I could probably walk 10 miles across kampala and put my foot on a flattened plastic water bottle for every step…

Reason for beer (okay, do you really need a reason?): I am supposedly here to help the IHK develop a trauma system which might, eventually, translate to better trauma care for greater kamplala and Uganda. I have been asking myself just how bad could trauma care be? Today I found out. It is bad. Really really really bad.

I stood in a trauma room choked with nurses and watched a man die. Granted, he had been hit by a speeding minivan packed with people, and his chances of survival were poor from the get-go. But he could have at least died with a functioning IV in place, or some oxygen, or connected to a heart monitor, or an airway tube, or a chest tube or two, or, how about this, some pain medicine to ease his suffering… but none of this happened. The larygoscope (the metal thingy you use to place an airway tube) was not in the crash cart (it turns out the dentist borrowed it), the monitor leads in the crash cart are for a different brand of monitor, the oxygen tank had been moved out of the room, and the nurses were more interested in restraining the patient (‘cause he and I were the only people in the room who knew he was dying) than putting in an intravenous.

I suppose that I should be glad that there is plenty of room for improvement, but when I tried to engage the medical officers and the nurses later about what had happened and what we could learn from it, I got nothing. Nothing but blank stares and what I perceived to be just a bit of attitude: You’re the great mazungu trauma doctor and you couldn’t save him—what do you expect us to do? And I guess that is the question. Sigh. I’ll have to figure out an answer for that.

Note to self. Don’t get injured here. IHK reportedly is Uganda’s best hospital.

July 18 and 19

This past weekend the kampala cluster did a public service project… obviously something planned well in advance of my arrival, but, according to rumor, apparently a bunch of vsoers were sitting around at a bar and someone said, ‘hey, all we ever do when we get together is drink beer and bitch about out placements, so why don’t we get together and do something constructive for a change?’

So Marcel and Nicola put together a project to paint the wards at the Mwanamugimu nutrition center at Mulago hospital (Mulago is Uganda’s state referral hospital and teaching hospital and mwanamugimu wards are where the malnourished kids are treated). They hired a local artist to sketch cartoons on the wall that we would paint, along with the walls, etc…

So 12-15 of us descended on the ward this weekend. They moved all the kids from ward 2 to ward 3 and we scraped and sanded and aerosolized all sorts of nastiness, not to mention uncovering several hordes of mice and roaches (the roaches are bigger than the mice) and then started to paint.

Kind of amusing watching 12-15 doctors, nurses, speech therapists, accountants, project managers, fundraisers, etc—none of who could paint a straight line on a wall to save there lives (and this is in a country whose greatest resource is cheap labor, where nurses work for $150/month—on the months where the government actually pays them and you can hire a ‘gate-boy’ for 24hours/day 6.5 days a week for roughly $25, so my guess is there are lots of guys/gals in kampala who can paint and would be happy to work for a pittance) while Stevie Wonder plays on the ipod doc, high on paint fumes, accompanied by the relentless crying of 20-30 starving children down the hall.
Fortunately I was able to keep my hyperactive sense of irony to myself.

I will say that I have done my fair share of painting (with various results) over the years of our home improvement fiascos—but I like using masking tape, and I prefer water based products… but the plan came with painting big swatches of color around the room with oil-based paint done over two days so that there wasn’t enough for the paints to dry so that masking tape could be applied without ripping off the fresh paint… and the project manager ‘thinned’ the paints with a bit too much terpentine… (also we were using donated paints… like pepto bismol pink, camo green, traffic stripe yellow and other soothing pediatric colors), so despite out best efforts there were drips and splashes everywhere (even the toilet seat came away with a swatch of cornflower flue—don’t ask me…)

When we got too high from fumes, we went and visited the ward and held the babies whose mothers were too sick (mostly hiv) to do so. The babies looked like little old men with wrinkled foreheads and huge, nonblinking, relentless eyes (and matchstick limbs). Then the nurses hit us up for money… We were told that the World Food program feeding supplements (soy products for the kids that can’t absorb milk) had run out and they weren’t due another shipment for a month)… I don’t know what to think of this… the administrator we talked to (he came through and told us not to use the blue paint next to the purple (duh)) said that that was not the truth, that there was plenty of food supplement… (but why do the kids look so sick? Why don’t they have feeding tubes? How can this be the country’s referral center for malnourished kids?)

Ch3

July 23

Have been working nights this week 8p-8a… just to change things up a little bit. And to see if the A&E is any more happening at night.
The jury is still out on that. What does happen in A&E at night is the mosquitoes come up from the namuwongo swamp and roam the hallways. And not just your average buzzy little black things. You swat one of the mossies here at IHK and invariably its full of partially digested blood. And you wonder, hmm… has this little anopheline been feeding on the malaria babies on the paediatric ward, or has she (boy mosquitoes don’t suck blood) been feeding off the HIV/TB patients on the Hope ward. (Or was it the one that bit me on the scalp last night while I was trying to catch a little zzzz time?) Either way, makes you think twice about swatting the little buggers. Tonight though, I’ve brought my secondary mosquito net just in case I want my nap to be undisturbed by some pathogenic insect.

Gave a lecture to DFID (the british development aid agency) and the staff of the British high commission. Managed to put together a 30 slide powerpoint prez in the middle of the night last night while fighting off mosquitoes and a really pushy Indian patient with an entourage of no less than 13 people (3 of them claimed advanced medical training… the patient had been on no less that 6 different antibiotics (2 of the intravenous) in the past 10days, none of them for more than 2 days… and, lo and behold, he was not getting any better, naturally when I tried to explain how antibiotic resistance develops and tried to get them to choose one antibiotic and stick with it they looked at me like I was the one on drugs)
Anyway, the topic was swine flu, a topic on which I have little of no expertise, but, in keeping with the general idea of powerpoint, that fact matters very little—I kept with my basic strategy of downloading lots of funny images from google image and putting in as few word slides as possible. It appears to have been well received, but not so well received as to encourage more lectures.

Tonights little fiasco was a women who’d been in the hospital for 10 days earlier in the month and had been given several conflicting but equally devastating neurosurgical diagnoses by the medical officers, but hadn’t seen the neurosurgeon…
Tonight she came in with a severe headache, proceeded to have a fit, and stopped breathing…. The nurse said, we’d better take her to the trauma room (given my previous experiences with the trauma room, you can imagine I was a bit reluctant to go back) Fortunately the dentist had been kind enough to return the laryngoscope, so I was able to intubate the patient. But the O2 tank was missing. The nurse went out to get the tank… And never came back…. After bagging the patient for what seemed like eternity, and pretty much exhausting my extensive collection of curse words, another nurse comes in. Not to help me with the only critical patient all night, mind you, but to remind me that my guy in room 3 with the sore hip is waiting for me to come and read his x-rays…

Manage to get the neurosurgeon Dr. Kirubwere (sp) on the phone. Says to get a CT scan and he’ll be right in (this is a miracle by the way, in the states if you call the neurosurgeon before the CT has been done all you’re gonna get is a chunk taken out of your butt). Unfortunately, they cannot find the key to the CT scanner room. I am not making this up. Dr. kirubwere, who unlike his western brainsurgeon colleagues has the patience of a saint, shows up about the same time that security finds the unlabeled key, out of a box of 300, that opens the door… So we put her on the CT table and my nurses disappear, again, and I find myself bagging this poor woman for another hour while the tech futzes with the scanner… and gets no images… so we go to the ICU, where, blessedly, Dr. Kirubwere takes over managing the patient, and, will miracles never cease, there is a ventilator and I can stop bagging…
Best thing about the whole experience—documentation—my note summarizing the entire encounter on a 4 x 6 notecard…. With a little space left over.

July 25th

Update on the unfortunate 37 yo woman above.
The reason that the tech was unable to get the CT scanner up and running the other night—the memory was full… The printer (the machine that puts the images onto film like they used to do at home before digital x-ray became the norm about 10 years ago) for the CT scanner doesn’t work and they haven’t bought the software package that would allow them to store the images on a CD, so they don’t dump any of the images…
Anyway, Dr. Kirubwere was finally able to get his CT 20 hours later: huge bleed. 24 hours later he took her to the OR to decompress… prognosis: poor. Had she gotten out of the country (she’s Chinese) 2 weeks ago, her chances would have been better.

So I finished a string of 4 -12 hour night shifts, Friday morning. So, after a little nap, I had Friday off to wander into town…
Caught a matatu (15 passenger minibus) into the downtown taxi park. Had to go into town to pick up a plane ticket. (some of my Liverpool trop med buddies are in Rwanda and the congo and are converging in Kigali in a couple of weekends, so thought I’d pop over). Rwandair Express is the only airline on the entebbe-kigali route—so I go to their website and book a flight, just like you’d do on alaskaair.com, etc, until you get to the part where you click on the purchase ticket button and it takes you to a screen that says—‘go to rwandair express office. Rwenzori courts, lumumbu avenue, kampala, pay for the ticket in US dollars.’ ..

So I wandered downtown and stopped at the Standard Chartered Bank (where, I’m told, I have an account, even though VSO has yet to deposit any of the living allowance promised me…) I thought I could cash some traveler’s checks to get the US dollars needed. I thought this because of the big sign that says “we accept American express travelers checks” above the teller booth. But, the teller tells me, no we don’t cash traveler’s checks. So I ask if I can deposit some of the checks into my account… No, I can’t deposit into the account because the account isn’t active yet. And the reason the account isn’t active yet? Because no one has deposited any money into it yet. I start to get a headache. The manager comes over to explain things to the silly mazungu who looks like he’s about to stroke out at the teller booth and is holding up the long line of nice people who actually know what they want. She kindly explains that my account is at the Lugogo branch (wherever the heck that is…) and that I will need to take at least 100000/= over there to fund the account….

Go to ATM, take 400000/= out of US acct. Go to forex bureau, change money back to USD, go to Rwandair and purchase ticket, and wander back down hill to old taxi park.

2 taxi parks in Kampala. Picture an area smaller than a safeway parking lot seething with a thousand minibuses moving as if by Brownian motion. Generally, if you want to go to the southwest of town you make your way to the SW corner of the old (south) park. The buses are all running, filling the space with diesel and gas exhaust fumes as they jockey for position. A conductor for each van is trying to load his van with the maximum number of passengers… by screaming out his route and hustling people into the van. I find one yelling kabalagala (which is the closest I can find to my place) which already has 10 or so people in it (score, it will be leaving soon) and crawl to the far back corner (people get in, grab the best seat available, then future passengers have to scramble over them..)

Our matatu takes off out of town, through the roundabouts and up the hill on nsambia road. Still full, the driver pulls over near one of the alleyways… the passengers look at each other as the conductor hops out and runs down the alley. (None of the passengers are getting off, so they start grumbling to the driver) The conductor comes running back carrying 2 plastic bags—the local gin (waragi) is sold in little 60cc bags called tot packs (or, given that the Ugandans like 2 syllables, totter packs). The conductor hands one to the driver who bites into it and starts sucking on it. I crawl over the people again and get out of the van. The conductor wants my full 500 shillings for the ride. I tell him that I don’t mind if he drinks gin on the job, but I won’t ride if the driver drinks with him… we settle on 200/=.

26 July

Had dinner last night with Conrad and his wife Katherine (sp). Conrad was in my trop med course in Liverpool. Conrad works for The Surgery, which is IHKs main competition (although they don’t pretend to be a hospital, they do have 6 overnight beds and 24 hr medical coverage). The surgery is where most of Kampala’s expats go for their first round of medical treatment before they get the hell out. It sounds like they are working poor Conrad pretty hard: 10-12 hours a day, 6-7 days week. He does say that they pay him by the hour, though, so I think he may be taking some extra hours to earn a few extra shillings.

He says that he’s been using the DTMH (tropical med diploma) stuff quite a bit. He says that in medical school in Kampala they tend to rush through the infectious diseases (which is mostly what trop med is)… just like in the states.

Katherine is also a physician. She works at an HIV/aids clinic out toward Entebbe. They have 2 kids, Matthew (18mos) and Joshua (3mos). They have a ‘house-girl’ who watches the kids during the day (and cooks and cleans). At night Katherine works on her MPH from Makerere university. The goal is to get hired by an NGO as a project manager—pays a lot better and better hours than doing clinical work…

Conrad and I reminisced about our trip to Snowdonia. A couple of the Norwegians took us hiking up ‘Bristly Ridge’ into a freezing rain storm. The Norwegians were decked out in full goretex ad hiking boots while Conrad and Simon and Rocky (from the tropics) were wearing varying degrees of unsuitable clothes… I remember looking back at Conrad, soaked to the skin, his non waterproof hood tight around his face with this look of amused disbelief on his face. I caught up with Hege and Hilde on a big rock which offered no shelter from the wind or the rain and offered the opportunity to fall to one’s death in 3 directions. I tactfully suggested it might be time to turn around.

Conrad fondly remembers the weekend as the time we took him into the mountains and tried to kill him. (we got back to the chalet and he shivered for a good 2 hours, then fell asleep, and woke briefly for dinner, but otherwise slept the rest of the night). He also remembered a berry crisp I made for dinner that night… We talked about if it would work with pineapple, mango, and jackfruit.

Conrad says that Mulago sent one of friends from med school to Italy to study emergency medicine. His friend came back with the task of organizing the emergency department… His friend worked at Mulago for a few weeks when he got back… then left the country for a better paying job in Botswana…
Conrad is going to get me a few contacts at Mulago.

July 28th

Monday night, hash night, was going to bota over, but Ian said he’d give me a lift, so hung out at the hospital until 5:40p (hashing starts at 6) waiting with Charlotte (another vso) and patricia (manager of ian’s construction co) who he also promised rides to. Ian screams up in his bmw x5. He had just driven cross town in traffic from a meeting with parliament about providing health insurance to parliament members and staff (the big new item this week in Uganda—aside from the famine in NE Uganda due to crop failure—is that the government purchased new 100,000,000/= ($50k) SUVs for the MPs… not too bad. Better for running the muzungus off tank hill road with…)
Ian drives like the Ugandans, except with a bigger, faster vehicle. Was kind of a fun ride, as things go, except the part where you’re begging whatever higher power you beg to that the little kids stay out from under his wheels.

But despite his best efforts we were 20 minutes late for the start. Couldn’t catch the running masses. Jogged up to the top of the hill with the radio towers and watched a great sunset. Jogged down and had a beer. In consolation Ian invited us to Rose’s birthday dinner at one of the nicer Italian restaurants in town. Ian, however, had a change of clothes… Rose and all of her friends are there dressed to the nines and I’m wearing a tee shirt and running shorts… I can just tell from the looks: ‘@#$%ing mazungus, you cannot take them anywhere.’

But it was a nice dinner. Had my first wine in a while and a very nice piece of tilapia completely buried in mushroom and cream sauce…

Ian had a couple of beers and became a little more voluble, went into a long tirade about all the medical aid etc that goes to mulago and doesn’t do anything ‘cuz the place isn’t organized well enough to accept it. Tactfully hinted he could probably get some of that aid if IHK was willing to provide more charity care. But then he counters with, “I’ve never asked for any of their help.” Okay then.

July 29th

Would swear I walked by a young man on tank hill road today who was wearing Justin’s boy scout uniform shirt from the early 70s, with the eagle scout badge sewn on. Troop 129. Similar bad haircut and black framed glasses as well, but of course this young man was black. Wanted to give him the secret boy scout handshake, but, of course, I’d forgotten it. Saluted him instead. Probably thought I was an idjit.

July 30th

Sanyu (my landlady)’s dad died this past week. He’s been sick since I moved in. First at a public hospital, then a private hospital, then in a private hospital in Nairobi. Sounds like diabetes, hypertension, and then stage 4 colon cancer to top it off…. Not good. Sounds like he had surgery for the colon ca and then never made it out of the ICU in Nairobi. One of the hardest things to learn about intensive care medicine is when to say goodbye. And I’m afraid, from my limited exposure, that they haven’t learned this in Africa. If the intensive care medicine works, then they are too happy to keep it going to think about turning it off… sanyu’s dad had been on dialysis and a ventilator for something like 3 weeks, she kept telling me she didn’t understand why he wasn’t getting better because he was ‘getting the best of care’. This is kind of the thing in africa, I’m afraid. Because they’ve had crap for health care for so long, they assume that all they have to do is get better care, and then they’ll live forever…

Anyway, as someone stressing about a sick relative and , now, in mourning, she hasn’t paid her water bill… so I am now without running water. Fortunately, mukwaye is kind enough to bring me a jerry can of water every couple of days, so that I can sort of bathe and wash dishes and flush the toilet… Not really sure exactly where sanyu is, or what her # is, but don’t think it would be too appropriate, at the moment, to call her up and say sanyu where’s the flippin’ water, so have been suffering in righteous silence.

June 2009

2009-12-05T03:55:00.000-08:00

Some first impressions of Uganda… 27 June

… the ICT1 (first week of in country training, of which I missed the first half because CUSO-VSO Canada insisted I take their skills in working in development (acronym SKWID…) before they’d fly me over here) is winding down and everyone is excited about getting started with there placements… also everyone is excited about moving out of the Lwewa training and conference center and into their new housing situation… but I have been informed that my housing isn’t ready yet, so I will be going to ‘temporary housing’, but as all the fresh new volunteers are hugging goodbye and heading off to various parts of Uganda, Rose (VSO program admin) pulls me aside and tells me that even my temporary housing isn’t ready yet. It’s being cleaned. I’ll be spending the night at the shalom guest house and ‘someone’ will be picking me up in the morning to take me to my temporary housing…

so I hang out all morning. But I don’t have an idea of who is supposed to be picking me up… and I couldn’t call them if I did, because I haven’t got my phone sorted yet. Finally at 2pm a beat up looking SUV rumbles up the drive and a kid who might be 15 gets out and starts loading my bags into back. He doesn’t speak much English, and my Lugandan stops at what’s your name (ggwe ani?, literally, who you?), but he doesn’t seem to recognize that as a question, or even a manifestation of his language…

we pull out of the shalom and head up the hill toward… oh, I don’t have a freakin clue, ‘cuz noone’s given me an indication as to where this temporary housing is going to be, somewhere away from town and from the hospital, but otherwise into uncharted territory as far as I’m concerned. About half way up the moderately steep hill, the SUV dies. Traffic backs up as the bota-botas swarm around both sides and the trucks behind start honking… the kid puts on the e-brake, gets out of the car, and runs off down the hill.

so I’m sitting in the passenger seat of a car stuck at the front of an ever growing line of pissed off drivers… some of them are putting their heads in the open window and screaming at me, others, more entrepreneurial, are trying get me to move my boatload of crap into their trucks and come with them, which is tempting, except that I have no idea where I’m going… meantime, I’m getting shouted at and not having much luck with my limited lugandan—wasuze otye ssebo (how did you sleep last night sir?) and the ever important oosela ssebo (I believe you are overcharging me, sir)…

about 30 minutes (I was keeping an eye on my watch, figuring I’d give the kid 30 minutes before I really started to freak out) later the kid comes back on the back of a boda-boda (motor cycle taxi and kampala’s leading cause of head trauma) holding 2 liter water bottles full of petrol. He empties the bottles into the tank (carefully discarding the plastic in to ditch) and, surprisingly enough, the car starts and we proceed up the hill…

28June

I’m staying in Muyenga, one of kampala’s many posh suburbs that dot the hilltops (Kampala, like rome and seattle was built on seven hills, but has expanded since then) while the slums fill the swampy valleys below. I’m staying in the guest house of a Ugandan family, or maybe the servants quarters (hope they don’t mind sleeping in the shed while I’m here). It’s a cute little place—one large room that doubles as bedroom and living room, a small bathroom with toilet and shower (but no sink, and no hot water), and a small kitchen with a two burner gas stove. I’d love to say there were cold beers in the fridg, but there isn’t one. All in all, pretty livable. Compared to some of the volunteers in the villages who have to haul their water from the communal pipe in jerry cans and have no electricity, it’s pretty posh. When I ask where the help is sleeping, my land lady Sanyu says, ‘you know, its africa, what can you do?’

Muyenga has many large white stuccoed houses with terra cotta roof tiles built to take in the views of the hills and Lake Victoria. Most of them have high walls strung with concertina wire or set with broken glass. My house, I think because Ugandans live there, doesn’t have any concertina wire, but the wall is still there. Many of these large white mansions behind high walls have tastefully small signs denoting one of the numerous NGOs that work in Uganda: Holland War Child, Danish Refugee Association, Save the Children… Makes you think about what Paul Collier said in the ‘Bottom Billion’ about aid not getting to the poorest of the poor because aid workers don’t want to go there. And wonder about your donations to X charity when they say that X% of your donations goes to work in the field—does that mean building a fortified mansion somewhere in the third world?

Went for a run this morning (Sunday) that, through my generally poor sense of direction, took me off the hill and down into the namuwongo slum. Don’t really know if this is advisable or not, but figured better on Sunday morning when they are putting on their best clothes and heading to church than on Saturday night. Didn’t really feel particularly threatening, everyone smiled at me and gave me the ‘stupid mazungu’ look. (mazungu is lugandan for single white man, bazungu would be plural, just like mantu would be man and bantu would be people) Maybe it was ‘cuz I was wearing a Liverpool FC shirt and they are all Arsenal fans. Figured I didn’t really have much on me worth chasing me down and mugging me for, but I suppose in a dollar a day economy, even a beat up pair of asics have some resale value.

29June

speaking of resale value… Dr. Hamsa (sp), one of the ‘young doctors’ (we would call them interns or 2nd year residents) that I met the other day is in the ICU this morning on a ventilator. Apparently he was mugged outside his house in Makerere, for his cell phone. Frontal epidural hematoma. At least he was able to get a CT scan and a burr hole. But doesn’t really look too good from my cursory glance. Makerere is across town from here, over near the university and the Mulago hospital(the large state run hospital in kampala). Apparently not as nice a neighborhood as Muyenga. The Ugandans assure me that violent robbery seldom happens in Kampala, and certainly never in my part of town, BUT, as they say with a shrug, ‘this is africa, sometimes things happen…’

cell/mobile phones are everywhere here, so you wouldn’t think that they’d be worth braining someone for (or maybe that is precisely why?). The other day in the market where a man in fairly beat up, dirty attire (which is unusual—most people here in kampala are dressed better than I am) was shoveling the bones and waste left by the fish sellers onto a rudimentary handmade wheelbarrow when a jazzy ringtone went off. The fishseller checked his phone then looked at me, while the fishgut shoveller wipes off his hands on his shirt and pulls a little nokia out of his pocket… my in-Uganda calls on MTN cost about 400 /- (Ugandan shillings) a minute, or about 20 cents… A third of Uganda survives on less than a dollar a day… So if you were living on a dollar a day (or even $8/day which is what my stipend works out to, and is what, I’m told, a doctor at mulago gets paid), would you be willing to spend 1/5 of your income on a minute of airtime?

Met Ian Clarke today (or Dr. Ian, as almost everyone in Kampala knows him). The man with the vision and energy behind the IHK (internatl hospital of kampala), as well as 13 Internatl Medical Clinics, the Internatl Medical foundation (the charitable arm, providing free care), the IAA (internatl air ambulance) which is actually kind of an hmo selling ‘subscriptions’ to employers, and a construction company (for building these things). Talking with a couple of our language teachers… they think Dr. Ian has gone over to the dark side (‘he used to be one of us, now all he thinks of is ’) also the Ugandans are already leery of the hmo thing ‘if you are on the subscription, they give you the cheaper drugs…’
Dr. Ian assures us that the hospital and its various subsidiaries are broke…(and to judge from his shabby dress and beat up Seiko watch, he may be telling the truth) he’s just returned from trip to china where he’s been looking at Chinese icu monitors and trying to find donors.

We’ll see.

another wakiso weekend

2009-12-05T03:44:00.000-08:00

November 29th

Wakiso for the weekend.

Jo and Liam are finishing up their placement and getting ready to launch on the travel portion of their year off. The Kavumba recreation center, the venue for the ill-fated Peace corps-VSO soccer game in October and the infamous Dr. Jose Chameleon concert in August, was hosting the grand gala opening of their swimming center (even though we have been swimming there for 4 months), and it seemed a good excuse to see Jo and Liam before they disappear.

On Friday, I had arranged a ride out to Wakiso with Alan and Alison, but on Saturday morning I got a text from Alison saying that Zoe was ‘squitty.’ I guess I wasn’t curious enough as to what squitty means in the UK medical vernacular to spend 50 shillings on a return text. I’ll leave it to your imagination. I took matatus out to Wakiso.

The head of the Ugandan National Swimming certification body was on hand to cut the ribbon and, as a treat, some members of the Ugandan National Team in Swimming were on hand for some exhibition races. Godfrey, the ribbon cutter, wanted to have his swimmers race our ‘team’ in a 200m medley relay. We joked that we’d be disqualified for using performance altering substances (the even was scheduled to kickoff at noon, but didn’t get underway until close to 4p, at which time we had already cracked a nile special or two). Then we realized he was serious. We politely begged off. But, I will say after watching them swim, it would not have been as big blow out as you might think (not, of course, because of my aqua-skills which focus primarily on staying alive in the water, but Jo and Liam actually can swim).

As an additional draw to the swim gala, Moses, the center’s director, offered dinner and a show. Dinner was a sharp stick with 3 or 4 large hunks of meat on it to roast on one of the several large fires out behind the pool. The show was Uganda’s own BeBe (pronounced baby) le Cool, who is either the most famous or second most famous pop singer in Uganda. I know, it sounds like you’ve heard this before.

The secret to searing your meat over an open flame (and making sure all the encysted tapeworms are fully sizzled), as we were shown the our highly amused hosts, is to get a good charred crust going and then remove it from the flames and nibble away the crust. And then return the meat to the fire and repeat the process.

The concert was much the same process. Stick with the crusty layer on top. At least now we understood the format: 4-5 hours of ‘warm up’ acts followed by a few songs by the headliner. And then end of show. No encores. As opposed to the Dr. Jose show where everybody mimed, however, last night, most of the opening acts actually sang into the microphone. Some of them shouldn’t have, but at least they tried. And the comedy act actually seemed funny (maybe my lugandan vocabulary is getting a little better—having picked up some gems like cabina kalungi, big fat ass (in a complimentary way), and banangay, which, I think, loosely translates as WTF?) even if they didn’t have dwarf.

So with a little help from the new official VSO Wakiso cocktail (mountain dew and waragi) we generally enjoyed the show. I particularly enjoyed the gluteal muscle control of the girl groups (I swear, this one woman could have done calligraphy with the pen clenched behind her back), but the crowd seemed to go more for the guys in askew yankee caps and large sunglasses doing tired hip hop renditions. Who is to explain taste? Certainly it was in short supply all around.

Bebe le cool made a brief appearance after the rain, much to the crowd’s delight. His anthem (be cool. Bebe cool is cool… blah blah. ) was a particular crowd favorite. I did not feel cheated when he cut his performance short.

I spent the night at the guest house on the recreation center property and was lulled off into waragi-aided slumber by the thudding bass of the all-night disco, also on the property. In the morning I wandered through the detritus and out to the gate. There were no botas to be had for the 2 miles of dirt road separating Kavumba from Wakiso, so I walked in a strangely Seattle-like mist falling from a cement colored sky.

I walked by traditional mud and stick huts with thatch roofs and brick houses with tin roofs. I walked by towers of mud bricks stacked into and fired as on-site kilns, ready for new construction. I walked by shells of huts overgrown with Spanish yellow oleander, the words ‘not for sale’ slowly disappearing with the disintegration of the bricks. I walked by children playing in yards—a baby being pushed over uneven ground in a wash basin, a boy pulling a toy car fashioned entirely from bits of trash, an urchin throwing rocks and twigs at the chickens and goats eating the vegetation in drainage ditch (invariably, the children see me a wave and shout, ‘Hi Mzungu, or Bye Mzungu.’) I walk by families on their way to church—the mothers with a baby or two in one arm and the other hand bunching the brightly printed floral fabric of her skirt to keep it out of the mud, the fathers similarly grasp a wad of dark cloth at their crotch in an attempt to keep their cuffs clean. (Do you ever wonder where that suit went? A little too shiny? The lapels too big? Maybe Ralph or Pierre decided that the ventless back was passé? Well. Some guy in Africa has your suit. It doesn’t fit him very well either. Remind me to go off on a tangent at some point and talk about how clothes donated to goodwill in America wind up for sale in Africa and have resulted in the demise of the African clothing industry…)
I walk by the Real Life church—a few walls, no roof, but a congregation already filling the floor. I walk past the True Life Church. ‘Worship God. Do not worship money.’ (just leave a little in the collection plate, please)

At the Wakiso taxi park I pick up a matatu back to Kampala. The minivan is nearly full, so we are underway in a few minutes. The windows have all been shut against the mist, so within a few minutes it is stifling within the vehicle. I dig deep for my travel zen as I watch the baby in the next seat regurgitate breast milk onto the church frock of the unsuspecting woman in front of me. Ugandan matatus are licensed for up to 14 passengers (its 18 in Rwanda with the same seat configuration), and the passengers tend to self-enforce the rules if the conductor tries to pick up a 15th, but children ride for free on their mother’s lap, so it is not unusual to see 3-4 infants in a matatu or even 16 year old boys sitting on their mother’s lap. Giles Foden, in The Last King of Scotland, describes a ride from Kampala to Mbarara in a matatu with ‘goats, chickens and what must have been nearly thirty human bodies—in a space meant for ten…’ Most matatu rides feel like this. (Foden unfortunately muddied the picture when 3 soldiers ‘climbed in’ to the matatu and ‘walked down the aisle’—matatus don’t have aisles… no one walks on a matatu, certainly not a fully packed one, you slide on your butt or crawl, and only with the assistance of several of your neighbors, and no one climbs in to a fully loaded matatu.)

The matatu from Wakiso eventually arrives and deposits me at the new taxi park. The persistent rains and the continual Brownian motion of the hundreds of minvans jockeying for position have churned the park to a muddy milk chocolate froth. Walking ankle deep in diarrheal soup, I try not to lose my shoes or my toes as I negotiate the tiny gaps between vehicles heading to the southeast end of the park (there is an unsignposted rule that vans parked to the southeast will be heading to the southeast part of town). ‘Ogende wa?’ I ask the conductors. ‘tugende mengo… tugende nsambya… tugende ggaba.’ Close enough, I can walk up the hill from kabalagala. I pick a seat in a nearly full bus. As we wait, we can take advantage of the commerce going on in the taxi park’s interstitial spaces—I could have my shoes resoled (or buy new ones), buy a new watch or one of several Obama tee shirts, or purchase meat on a stick or a rolex or a bag of groundnuts or a chunk of jack-fruit. A man approaches who appears to have slept in the taxi park (kind of like sleeping on the benches in the bus station, except for the part where there aren’t any benches). The right side of this body is covered in clotted mud. Naturally he’s headed in my direction. Either I can hold my seat (as is considered proper matatu etiquette) and let him crawl over me, or I can slide over so he can rest his muddy side against me. I brace for the worst. At the last moment, the conductor says something that I don’t quite catch that must have been the lugandan equivalent of show me the money. The mud man digs in his trousers but fails to find even a 100 shilling coin for the shortest ride possible. I feel relief. Then shame at my relief. For a second I think about handing him a 500 coin. But a woman in orange and brown print and a large shopping bag quickly grabs the seat and the conductor slams the door and we’re off. Tugende.