September 2009
on Random Uganda (Uganda), 05/Dec/2009 12:26, 34 days ago
September 1, 2009Have 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 toldher 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 theyactually have the stuff….Tomorrow, lecture at KPC…September 24thSomehow 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 ofKampala 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 lowas 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 firedtheir 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 29thStill 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. Onthe 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 VSOcontingent 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 surprisevisit 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 roverand 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 reallyis 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 portalthan 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.