David's last post from Uganda

David:

I've been back in the UK now for almost a fortnight.  Time sure flies by.  However, I had one last post to share, and have only managed to complete it now...

11/6/10

Today I am to meet with Alison Cowan, a GP from England who has been working at the International Hospital, Kampala (IHK) for the last year.  She has very kindly offered to show me her work for the day, and so at 8.15am I find myself on the front terrace of the hospital. It's peaceful until the piercing cry of an inpatient child breaks the ambience.

Alison arrives in a whirlwind.  Very quickly I realise that she has an amazing passion for setting up decent sexual health services for the community around the hospital.  She makes me feel very welcome, and soon I'm observing, even making contributions to, a meeting with some clinicians involved with the community project, on developing a validated screening tool which can be used for chlamydia and other STI testing.  Currently patient concern centres on syphilis, and patients' understanding is subject to signfiicant myths so that even minor itches and other completely unrelated symptoms can instigate a strong belief in patients that they have the condition.

So many factors contribute to the awesome task of trying to improve sexual health.  Condom use is still heavily influenced by religious belief, social  propaganda and myths which are regularly upheld by local - and widely-received - media.  The double-whammy of trying to offer effective family planning with STI protection is no easy task. The additional task of tackling cervical cancer is yet another strand to this neglected component of community health care.

But Alison and her team have taken this challenge head-on.  With impressive support from her friends at home, she has managed to find funding and enthuse local clinicians in developing the services that they can offer.  Collaboration has been set up with UK experts, and a heavily evidence-based approach has been taken to target the service effectively to local people.

The meeting is productive, and at the end we have a plan on how to take forward the next stage of the project.  I am sorely tempted to cancel my flight back on Sunday so that I can stay and get involved - however stronger factors, mainly getting back to my fiancée Kelli, prevent any calls to KLM!

I sit in the STI clinic, again gaining more understanding of the scale of HIV/STI problems in Africa.  Patients and staff very helpfully conduct some  consultations in English, purely for my own benefit.

We then go to a school which Alison's husband, Alan, has been supporting in one of the slum areas of Kampala.  Their offer of running a meeting with parents of the schoolchildren, to teach on various aspects of health education, has been welcomed by the teachers, and today Alison and Alan are to explain more about what they intend to do.  For them it is an important step in building on the rapport they have with the teachers.  For me it is yet more proof that myths and beliefs regarding healthcare continue to present the biggest challenge in providing decent access to services, and an indication of just how important it is to engage local community leaders with any planning. And the appetite for such information is there.

Later we return to IHK, and Alison gives me a tour of its facilities. IHK is the international hospital, a rare opportunity in Uganda for modern medicine to be practised with the adequate backup and support. A philanthropic strand means that some profits from paying patients are reinvested in health services for the local community.  There are still some interesting differences however, such as when blood is required for transfusion.  When this happens, a call is  made on the tannoy and staff are requested to donate.  Apparently there is never a shortage of volunteers, from all levels of the hospital workforce, and
checks on HIV and hepatitis status are carried out before its timely infusion next door to the labs, in the emergency department or ICU.

Our tour continues through medical, surgical, obstetrics and paediatric wards, and I am grateful for the time that Alison takes to show me the facilities.  Once again, as hinted at in previous posts, I feel a sense of futility - I really am a doctor-tourist with little to contribute - but I hope that in some way this insight might be applied in whichever future healthcare setting I find myself in.  The scale of what IHK achieves is impressive.  The frustration is that so few Ugandans can expect healthcare to this level.

Alison and Alan have embarked on an impressive challenge, and now that they've been here for over a year, they've built up an interesting account of their experience - at their blog http://thecowansinkampala.blogspot.com.

Into the last quarter

Well we are starting to count the weeks (13) until we return home – we are due back in Edinburgh by 18th September. We are assessing what we can achieve before the end of our placements and what more of Uganda we can explore in the next three months.

We have had a frustrating six weeks at work relieved by a most welcome and enjoyable visit from our son, David. We are enjoying our stay here but as the time to return draws near we are increasingly thinking of resuming our lives at home and thinking of the things we have been missing – our friends and family, concerts and theatre, a good power supply and hot showers . We will miss the friendly Ugandan people, the warm temperatures and the bird life but the vulnerable lives, chaotic traffic belching black fumes, and crater-like pot holes we will be glad to leave behind. I think I will need to be careful to modify my driving behaviour – I’ve forgotten what “Give Way” means and learned to push my front bumper into any small gap with the potential to develop. After another encounter with the police last night I will have to avoid inappropriate reactions if stopped in the UK and keep my wallet in my pocket.

Although our placements have been successful and rewarding, the last 6 weeks at work have been hampered by a number frustrations. A computer virus knocked out network connections for a week and I am not sure if all PCs have completely recovered yet. Our power supply at work has been fragile with maybe up to 20 hours lost due to power failures. I don’t fully understand it but invertors (back up battery supply) seemingly require at least 180 volt supply to charge and the main supply seems to fall beneath this frequently. When the main supply fails the invertors can’t meet the demand while the generator kicks in and on one occasion the generator could not kick in until someone fetched the fuel. On top of this I discovered a faction at work who had changed data capture procedures without discussing the implications with me and jeopardising some of the work I was doing. I think this got resolved on Thursday. This all leads to the growing gap in Reach Out’s expectations of me and what I will achieve before September.

David has posted entries in our blog covering his time with us…….. As he remarks our stay at Katara Lodge, just outside Queen Elizabeth National Park, was exceptional.

I think it was the best place we have stayed in Uganda. The food was fantastic and the staff were wonderful - very attentive and fun with their cheeky banter. We can recommend a stay in you are traveling in this part of the world.

 Uganda kob - the country's national antelope.

 An encounter with a 12 foot python causing us to reassess the risk of going behind a bush!

Grey crowned crane - the emblem on Uganda's flag. 

We saw a good selection of game in the park 

but were disappointed with our chimp trekking in Kyambura Gorge. I think we disappointed our guide when we refused a tree trunk crossing over a 30/40 foot river allegedly hosting hippos (some people were eaten by a hippo in Lake Victoria near Kampala a couple of weeks back).

 

 This is the bridge we diverted to when we refused the log crossing!

We traveled down to spend one night at Ishasha Widerness Lodge near the Congo border but failed to find the famous tree climbing lions despite the efforts of our guide/driver.

A Day at Reach Out

David:

The call to yoga attracts gradually increasing numbers to the morning-sunlit compound of Reach Out Mbuya - the project where my parents have been working.  It has the feeling of a school assembly - collective gathering to state a common purpose, and in this case share some humour before the more serious aims of the day begin.  Us muzungus (white people) seek the shade of the tree, and this is good especially as we are about to commence the daily yoga workout - simple stretches to iron out the muscular crumples from the many African massages over the last few days.  "African massage" is a euphimism for the many potholes encountered on even short commutes across Kampala, and probably rates as one of the more traumatic types of massages to be had.

By now over fifty staff have joined the circle, and a few clients linger in the background.  They are very welcome to join in, but a deep respect for the work of Reach Out seems to prevent some of them from doing this.  They realise this is important time for Reach Out staff.  I am to see the benefits of this team spirit as the day progresses.  I am introduced to a warm welcome, and even "inducted" by way of a song and a prayer.  Humbling stuff indeed.  Humour punctuates the many intimations that people are keen to contribute.  The most chilling was when one staff member reported the death of her adult son.  He had achieved a great deal, and yet was to become yet another statistic of road deaths in Uganda.  I am to learn that this is an all too frequent occurrence; a reflection of the daily accidents that claim the future potential of Uganda in one tragic moment.

The staff break off to their individual departments.  Impressions are of a well-organised and committed project, with a quiet air of efficiency - certainly amongst clinical staff who get through up to ninety patients in a morning.  In a country where free healthcare doesn't come easily, it's so tempting to take the services for Reach Out for granted, and yet there is absolutely no sign of this from patients.  The operation affords dignity, time and personalised care, and this makes for frustration when the logistics of drug availability and referral options are not able to support the assessments of clinical staff. 

This is made apparent when I am asked to help in seeing a patient presenting with an acute asthma attack.  Fine - so we check respiratory rate, pulse, auscultate the chest and assess the case as moderate to severe asthma.  But the patient has no inhaler - they are much too expensive, her daughter explains.  The nebuliser, held at a satellite clinic, has been sent for by boda-boda - in Kampala traffic this will take at least an hour to arrive.  Oxygen isn't available, so a pulse oximeter - which isn't available either - wouldn't be much use anyway.  We sit the patient forward, encourage her adopt the most comfortable position, and hope for the best.  There are additional complications to her case - largely as a result of her HIV - and so the clinicians decide to start an IV infusion of some antibiotics and steroids... but we really need salbutamol. 

The rest of the day is a crash-course in HIV, and I begin to understand the wider ramifications of a disease about which I felt differently before coming here.  The challenge of education, correcting myths, and overcoming the high degree of corruption that continues to permeate every aspect of Ugandan society, makes me feel selfishly glad that this is "not my problem" once I get back to my GP registrar job in Kilmarnock.  Sorting out how my own training could be applied - including drilled-in concepts such as ICE , patient ideas, concerns and expectations - in such a clinical setting, becomes a headache; one which I have the luxury of having an easy escape from by means of KLM on Sunday.  I feel like a thought-tourist.  With guilty relief.  It's interesting to consider problems at a superficial level, think about "what I think needs to be done" and then return home without contributing any more than passing, and likely ineffective, comments. 

Thankfully, Reach Out does not have the same approach.  It has obviously developed with amazing speed, now overseeing the HIV and related treatments for more than three thousand clients.  Daily clinics, home visits, community adherence teams, moonlight testing teams (for prostitutes and lorry drivers), the children's brass band, and grandmother support in the form of a piggery, are supported by a backbone of administration, IT, marketing and finance.  For such an organisation to function in the context of regular power cuts, limited funding and slow internet is quite remarkable. 

The nebuliser eventually arrives for the patient with asthma.  She makes an acceptable recovery, and it's agreed she can return home. 

I leave with respect and admiration for the work of Reach Out, and the hope that such efforts are rewarded with ongoing success in addressing the massive problem of HIV in Africa.

Into the wilderness

David:


We're back.  And, rather surprisingly, alive. Our safari trip was, for the most part, a fantastic chance to see the wildlife that Uganda has to offer.  We met lions, elephants, lots of buffalo, two menacing pythons, hippos, a crocodile and numerous birds in different shapes and colours.  


We stayed for 3 nights at Katara Lodge - and we would highly recommend this to anyone thinking of heading to Queen Elizabeth Park.  Brilliant views over the savanna with sunsets and gin to match - in fact see the pics below for evidence.  It's well run by Pascal and his well-trained team, and easily worth the bumpy ride down the track to reach the oasis of wonderful service and ambience of calm.  Our fourth night was spent at Ishasha Camp - involving slightly more trepidation (staff have to accompany you back to your tent to fend off hippos and lions) but tasty biscuits.


The highlight was seeing the lions.  Nine of them, including cubs, lazed about with paws in the air all very chilled out, whilst all the wildlife around them kept a very close eye on their movements.  They really are the kings of the jungle.  Our driver Paul shared his enthusiasm for safari animals throughout and his skills allowed us to see so much over our trip.


Our experience of chimpanzee safari was unfortunately rather different.  We were taken down into a rainforested gorge.  Having descended the steep and muddy slope, we were then advised to watch where we put our feet and hands, as poisonous spiders and snakes were around.  There was also the risk of coming across hippos or lions, hence why our guide was carrying a gun to scare them off.  Unsure whether our guide was creating an air of suspense (gee, thanks) or actually giving us a realistic risk assessment, we opted for the optimistic view.  However soon we were faced with a 40 foot traverse commando-style across a log over the fast-flowing (and ?piranha/hippo/snake infested river) - but we required no assertiveness training to refuse.  Had we been confused for a team of SAS soldiers in Uganda for a survival exercise?


As a result of our (very collective) decision not to take such a risk, we had to take another path, which involved ducking and diving under and over fallen trees and through seriously boggy undergrowth.  Fine for Scotland, in fact really quite good fun.  However with the constant reminders of poisonous and dangerous animals, not such a walk in the park.  At one point when clambering over a particularly difficult section, our guide remarked quite seriously "be careful, last time we had an accident, it was a terrible situation".  'Nuff said.  


We still don't really know if there was much of an act going on.  However, given that we were in a proper proper rainforest, it didn't seem too far from the truth.  In the end we saw a baby chimp, not the community of chimps we were expecting to find.  However on getting back into our car, I just felt very lucky to be alive, and appreciated the sun-downers even more that evening.


Since returning home yesterday, we've been taking it easy in the hot and humid weather.  Tomorrow I visit Reach Out - it will be interesting to see what my folks have been up to all this time.  So far I get the impression that it's all been safari tours and sunset drinks, but tomorrow I expect that illusion to be shattered quite dramatically!

First impressions all over again...

David:

It's 7.30pm.  An excited Glaswegian shriek is heard in the mids of the arrivals area of Entebbe airport.  The locals don't quite know what to do... but I know that my mum has made it down from Kampala to see me off the plane.  It's been a long nine hour flight, made longer by my excitement to get here, but a familiar feeling of enthusiastic trepidation returns from my arrivals in the past to Nepal and Cambodia.  Our driver, James, expertly picks his way through the congested road away from Entebbe.  It's now 8pm, and whilst Scottish rush hour traffic knows it's time to chill out by now, there is a sense that the night is very much yet young!  He's under strict instructions to take the road slowly (and safely), however this isn't a view shared by other drivers.

So my first few hours of Uganda are flavoured with car fumes, a hot and humid climate, and a realisation that Uganda doesn't seem to sleep.  Whilst James picks his way through the congestion, I am amazed to see so many people out and about.  The atmosphere against the background of crickets exudes friendliness and welcome. 

Today was my first experience of Kampala in daylight, and even though it's a public holiday, there is still an air of business amongst the stallholders of the market.  Bright yellow, green and red make up the pallet of unimaginable quantities of bananas, oranges (yes, oranges are green here) and tomatoes.  Mum and dad are showing me the sights (and the driving, this time under Dad's command) of crazy but friendly Kampala.  

We stop off at the VSO office, a tranquil retreat for all volunteers... and then head on into the centre.  We do the taxi park - think Buchanan Street Bus Station but a million times bigger and busier - which, like the rest of Kampala has potholes even to envy Glasgow.  Organised chaos describes it well, but with the 14-seater taxi buses only leaving when full, there is a heavy suggestion of efficiency. 



We pop into the Garden Centre for lunch, and immediately at least 8 waiters from different restaurants swoop on us with their menus.  This is the expected reception at the food hall, where 3 lunchers could choose from 3 (or more) completely different restaurants - including Italian, Chinese and Lebanese.  I haven't seen this before, but it's a nice idea!

Hoggs like hills and so later in the afternoon we go for a wander up the back of mum and dad's house.  A winding path takes us past village houses, with smiles and shouts of "hello" from every direction.  A genuine inquisitiveness - moreso for my camera - is evident, and here's some of the children who insisted on taking their turn for a photo!

We end the day with some shopping, drinks on the veranda with my parents' neighbours, and a fantastic meal at Katch the Sun (sic) - a new one for the "recommended" list.  In 24 hours I have developed some fast first impressions of Kampala.  I am reminded once again how sound and smell are the missing links to the sights that photographs can only frame.  I like it.  I like it a lot.  And I still have 11 days to go!

Weraba (goodbye) from Uganda.

Collaboration

31st May, 2010
We have had a busy month with more visitors. Two students, Carolyn and Danielle have been over from Edinburgh for four weeks working on Reach Out Studies for their MSc dissertations. They are studying at the Institute of International Health and Development at Queen Margaret University in Edinburgh, and their coming here is the first step towards a collaboration between Reach Out, Makerere School of Public Health here in Kampala and IIHD.
Carolyn and Danielle stayed with us the first weekend so that we could show them round and let them get orientated, and then they moved to Red Chilli, which is  a great place for meeting up with others, including a good few working on research projects. 

We took them to Ndere Cultural Centre and then took them to a dance class so that they could try it out for themselves. They have had an amazing experience here, and it reminds us just how special an organization Reach Out is and what an easy place Uganda is to live in, perfect lush climate, safe and full of lovely gentle people. 

Then Carol and Bregje came, both previously research fellows working on studies with me and now friends of ourselves and of one another. Carol comes from South Africa and Bregje is Dutch and has spent a considerable amount of time in Malawi, so we had lots of comparisons. They stayed with us for a weekend to do Kampala, including a trip by boat on Lake Victoria to a local market. 

Then  they went off on safari including gorilla-tracking at Bwindi and game watching in Queen Elizabeth NP for five days and we all went to Jinja for the weekend before Carol went home. By coincidence at Jinja we met another VSO couple, Renate and Ian who were also staying at Gately on Nile. Renate is originally from South Africa so Carol and Renate had a lot to discuss. They have a people carrier so all six of us were able to go to the Source of the Nile and the Bujagali Falls together, which was fun as usual with lots of birds to see.

(The falls are due to disappear in the next few years when a new dam is constructed down river)
On our return to Kampala on Sunday we made our customary stop at Mabira Forest. We had a 2 hour walk with a great guide. He showed us where we could expect to see snakes basking in  the sun but none put in appearance for us. 

Our most dangerous encounter was with this strangler fig but we moved too fast for it. (I reckon we would have moved too fast for the snakes if we had encountered them!)

 

Bregje stayed on three days to meet people at Makerere School of Public Health and Reach Out, and we had some very productive meetings and made plans for collaborative working and to apply for funding to facilitate the process.
On Sunday after our gym and swim regime, we went for lunch with the same twp VSo ers and also Debs who is a public health doctor working in Lira in the north of the country. VSO have put a good few new volunteers in Lira and Gulu to give support to the people there now that the war is over and there is a need to set up health care etc. It is very different working there and conditions seems more challenging than life in Kampala where we can shop in supermarkets ( and even see Sex and the City 2 on Saturday evening). I think I would have to try it out to see which I prefer for a year. However, recently we have had a lot of power cuts at home and work and our computers at work were affected by a virus which has made the last two weeks very unproductive and frustrating.
Now we are getting extremely excited about the arrival of our son David tomorrow evening. On Friday we go off on safari with him to Queen Elizabeth Park NP for a few days, having done the other big game reserve at Murchison Falls with Hamish and Morven at Christmas.

Looking up the Nile from Bujagali towards Jinja and Lake Victoria