one last road trip
on Random Uganda (Uganda), 28/May/2010 06:25, 34 days ago
One last road tripOver 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 homebecause 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 nothingto 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, theIMF (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.