The Royal Pride Academy

Well! In 4 weeks time we expect to be home barring any airport strikes. Our attention is focused on end of placement reports and checklists for our return.
The last of our scheduled visitors departed on Thursday. We had an enjoyable time with my sister, Anne, and her husband, Wofgang who live in Germany. They were with us for 2 weeks on their first visit to Africa and experienced the chaos of Kampala traffic as well as the abundant wildlife and the friendly Ugandans.
Before we left last September a number of our friends gave us money to put to a "good cause". If you have read many of our blogs you will realise that we are aware of too many good causes in Uganda and choosing one has been difficult. However there is a primary school not far from where we stay (on the  other side of Mutungo Hill).  

The Royal Pride Academy has 200 primary school children with seven teachers for the classes P1 to P7. It is a private school (no funds come from the government) and is dependent on the fees paid by parents. Although the government has introduced universal primary education, the reality is that in most places, including Kampala, there are no state-funded schools and many children do not attend school. The school is located in a slum area of Kampala so the concept of a private school in the UK couldn't be further removed. The school has little resources apart from the dedicated head, Godfrey, and his staff who we think receive no pay.

 
You will see from the photos that the buildings are basic. 

The school is at the foot of the hill and until recently the classrooms were regularly flooded. The partner of one of the volunteers recently organised the builiding of the concrete plinths to keep the classrooms above water level and the chute and roundabout were provided by another volunteer. 

It is likely other funds will be given to improve the buildings so we are adding our contribution to this. We hope those who gave us money to use in Uganda will feel that this is a worthwhile project.


On another note, we were delighted to hear yesterday from our younger son, Hamish, that he and Morven are engaged.  With David and Kelli's wedding next spring, 2011 should be an exciting year.

Health Visiting African Style

Rhona -
Most of my time and energy has been focused on increasing Reach Out’s research capacity and capability.
For the last few weeks of my placement I am concentrating on helping to develop better care of our babies born to HIV women. Although Reach Out seems to provide, in African terms, a Rolls Royce service to their clients, there is little monitoring of the babies in the Prevention of Mother to Child Transmission (PMTCT) programme, into which mothers are enrolled during pregnancy. 

Babies are discharged at 18 months of age if they test negative at that stage. If positive they are enrolled as clients in their own right. Babies and their mothers are given drugs to reduce the risk of transmission during pregnancy, birth and breastfeeding, which is the best option for HIV exposed babies here, given the costs and risks of infections associated with replacement feeding in an urban slum area. Almost half of children under the age of five in Uganda are malnourished, which given the fertility of the land is difficult to understand in rural areas. In Kampala, people with no jobs depend on trying to earn very small amounts of money by selling cooked food, or fruit such as mangoes and pineapples and it is common for families to have no money for food . Many families only eat once a day, which is not enough for babies, so many become malnourished between six and 18 months, when breastfeeding is not enough for them. However, there is no routine monitoring of children and some children present with moderate and severe malnutrition.

Up until now the babies have not really been clients in their own right, but now  they are being given their own file and their growth will be monitored and charted, so that faltering can be identified before they develop moderate or severe malnutrition. So before this happens, I am doing a baseline nutrition survey of all the children aged between 0 and 24 months, and then the nutritionist, the PMTCT staff and the mother-to-mother community health workers can make decisions about whether they need to increase health education or increase access to food support for some families. Fortunately there is free software available form WHO’s website which makes the survey fairly straightforward.

I have been out doing home visits with the clinicians and the community health workers, especially the mother-to-mother supporters (including Saban, who features in the photos) who look after women in the prevention of mother to child transmission programme. The M2Ms are all clients themselves, who have been trained to support women during pregnancy and until the child is 18 months of age.

While everyone is aware of the poverty and desperate conditions most children in the world live in, and living in Africa makes it all more real, actually coming face to face with the reality of living in a Kampala slum and even more, assessing it from a professional perspective, puts it into 3D. Most of the women have come from villages up-country but they do not want to return because they will face a lifetime of hard physical work, digging fields to grow their own food and trying to sell any surplus they have. The reality of life with no safety net is very stark.

However, while it was the differences that struck me most at first, I now see the same problems I see in health visiting practice in Edinburgh  - fathers who do not take responsibility for their children, domestic violence and some mental health problems, though post-natal depression is not recognised. I also see great similarities in the way parents really care about their children, they are very interested in seeing how their children are growing and respond very positively to being told that they are doing a really good job.

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.

Kampala blasts - short blog

We were shocked to hear of the bomb explosions in Kampala yesterday and fortunate not to be involved. Rhona and I left Kampala yesterday morning to spend a week in the north visiting friends is Lira and Gulu and comparing health services here in the north . We are also grateful as It would appear that none of our volunteer friends were caught up in the incidents.
Thanks for you emails with your concerns.

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.