An Adventurette?

.... or a small adventure within the year's big adventure.
We have just returned from a few days visiting fellow VSOers working in the north of Uganda, where after around 20 years of unrest the war ended in 2007.Immediately after the war ended there was a great influx of NGOs and money but now most have gone. VSO have just started placing volunteers in Gulu and Lira, the first batch of five came in February and some more have just arrived and are currently undertaking  in-country training before moving up to start their placements.
Gulu and Lira are equidistant from Kampala - around 350 kms - and the road north is very good and relatively quiet compared with the roads to the west and south west. There are long straight stretches for as far as you can see. There were a few interesting sights on the road. This lorry carrying bags of charcoal with people perched on top is not untypical.

 
Our first stop was in Lira to stay with Debs who is a public health specialist working with the District Health Office. We went out with a senior nurse to their most outlying health centre 80 km to the east over rough roads. 

About half way out we came across the lorry which was stuck in the mud. All the goods were unloaded and eventually it was pulled free by an NGOs 4WD. 

Having surveyed the scene and with confidence but little experience of 4WD I attempted to skirt round the muddiest bit. 

Unfortunately we slithered into the deep mud and were grateful to around 20 locals who manhandled us to firmer ground. (sorry no photos - Rhona wouldn't go wading in the mud!)

When we arrived at our destination we found no drugs, no food supplements for malnourished children and therefore very few patients. We then visited a second health centre on the way back and found a similar scenario. Drugs due to be delivered on 22nd June have not arrived and so the pharmacy has empty shelves.

We also had an interesting visit to a family in Lira with whom Debs stayed for two months when she arrived. The mother Anna looks after twelve children, as well as her own she has absorbed others into the household including a boy she found who had been put on the bus at Kampala who she found lost in Gulu bus station and also the two young children of her sister, who died in childbirth just three weeks ago. Anna was pregnant with her second child when her husband was killed in a car crash. 

The harshness of life in Africa, and the serenity with which people accept it and move on, never fails to affect us. Anna is luckier than many, she has a reasonable job and can afford a spacious house with a tap in the courtyard, and can afford to pay school fees for the children.
After 2 nights with Debs, we moved on to Gulu (north west of Lira - about 130 kms by the main road) and stayed with Mike and Liz. Liz is a community nurse by background and Mike has worked in mental health. They are carrying out needs assessments and working out how VSO can best progress with future placements. 

Again we traveled about 80kms east and worked our way back visiting 4 health centres in total. There was 4 in our party. Mike did the navigating and another VSOer, Judy from Kenya, wanted to gather information on health promotion at the centres. 

We appreciated travelling by car but Liz and Mike usually travel by motor bike sometimes staying the night at the more remote health centres. This is real VSO stuff - our life in Kampala seems decadent by comparison. We visited a range of health centres, which again are out of almost all drugs, including antibiotics and those used to treat malaria. We saw two very young children with a presumed diagnosis of malaria (there were no lab facilities) who were clearly very unwell and could not be given the drugs they required immediately.  

Most of the people in this area are staying in the remains of the refugee camps in numbered thatched round huts with little space between.


There are different levels of health facility, Level 1 are the village health teams, Level 2 the most basic health centre with no inpatient or midwifery service, Level 3 offering inpatient and maternity services, and then Level 4 a bit more expertise and facilities,  with the regional referral hospital catering for complex cases and general surgery etc. The Level 2 Health Centre we saw had no qualified nurses, virtually no drugs and no power. 

Nursing assistants were doing their best, some clearly very able, others less so, but were diagnosing on the basis of a few simple questions and appeared to be allowed to prescribe.

They were also carrying out deliveries, during the  night by the light of lanterns they provided themselves, and had one plastic bucket which had to be used for sterilising instruments and also for collecting the placenta. 

There is no transport in the area, so sick people and women in labour have to walk to the health centres, and the HC2s are often the only place which is accessible, and even then it is too far for some people to reach. With the HC2s so poorly resourced, it would seem sensible to concentrate on improving the HC3s and above, and the village health teams who know their own communities, and provide mobile clinics and transport to HC3s for those who need it. 

In terms of maternity care, mothers are encouraged to deliver in health centres, but it seems more sensible to build on the skills of traditional birth attendants until mothers can be cared for by qualified midwives in well-equipped (and adequately lit) centres. But this may be politically unacceptable, and mirrors the antagonism there is in the UK to closing down small hospitals and concentrating on centres of excellence. Africa’s problems sometimes seem insoluble.

Anyway, on the way  back to Kampala, we stopped at Kasaala,  a new Reach Out facility, which was started in January 2009, in the parish where Father Joseph, a founder of Reach Out, started his ministry in Africa. Unlike the Kampala Reach Out, this centre offers primary health care with some in-patient and maternity beds, to everyone in this rural community, not just people living with HIV/AIDS. 

Being rural, it also has demonstration gardens for teaching clients better ways of growing food, and like Reach Out in Kampala, has an on-site piggery for grannies to learn the skills of pig-rearing so that they can earn money to care for their orphaned grandchildren. It is a new purpose –built building and seeing the busy clinic, run by a full staff of mainly qualified nurses with a few doctors, and a well-stocked pharmacy was such a contrast to the government health centres. It does raise questions about equal access to healthcare, and Reach Out is almost totally dependent on American donors, so it is unrealistic to imagine that Reach Out’s model could be replicated across Uganda, but it seems that the government, with issues of corruption and gross inefficiencies, is unlikely ever to be able to fund an adequate health system.
Kampala is subdued and a bit tense after last Sunday’s bombings, the official week of mourning finishes today so things will maybe get back to normal. Most people, including ourselves, are avoiding the city centre and the big hotels and public places, until things seem a bit more settled.We have started to make plans for finishing our work here and our return to the UK in just over 8 weeks.