Looking back and looking forwards

A year ago to the day, I set myself a series of questions as I wrote the first post of this blog. We were about to set out for Uganda, and I wondered how it would be.

Now we are back in the UK, and though not yet ‘’home’’, I think the time has come to look back at what I asked myself, and to see if I have any answers.

It has taken me a while to feel I can even do this. I had many days when I first arrived back when I couldn’t talk about our life in Uganda. That would mean using the past tense, and I really couldn’t bear the thought. Now, after a couple of weeks of being buffeted by the wind and rain in the north of Scotland, I’ve finally dared to turn on Radio 4, to go to the Co-Op supermarket, to engage with what is around me and to admit that there are things I like about being here.

So, what do I say in answer to myself of a year ago?

How can a GP like me, settled into the ways of primary care in the UK, make any sort of meaningful contribution in a setting so unfamiliar to me,  when I will be there for such a short time?

Making a meaningful contribution really means making relationships because relationships provide the soil in which good work can grow. If that makes it sound like relationships are a means to an end, that isn’t it at all. In Uganda, relationships underpin everything. You don’t start a conversation without a greeting, and meaningful enquiries about how people’s family members are. Whilst work is important, social ties are even more important – attending funerals, preparing for weddings, sharing food with people – and these are threaded in and out of work. These events bind people together. My Ugandan colleagues – soon to become friends- were keen from the start to build those relationships of trust and collaboration. They were open and welcoming and warm. Having the family with me, particularly the girls, provided a social glue that cemented those relationships as the girls became the general property of the hospital team. We were invited to share in the life events of our neighbours/colleagues/friends and so we were also woven into the fabric of the hospital community. I was fortunate enough to have my predecessor, Zish, present in Uganda when we arrived. He helped us to feel that our presence was part of a continuing presence, an embodiment of a partnership between the hospital and the RCGP which preceded us and would continue after us – another thread -and he helped us think about how we might valuably contribute.

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Being part of the team…..

 

 

Have I made a ‘’meaningful contribution?’’ In terms of work – there were different ways of contributing. Part of my role was to work as a doctor (a Medical Officer) and part of my time was to be spent doing ‘Quality Improvement’ work for the hospital. At the start, I envisaged these activities to be quite separate, with time on the wards being about patient care, and quality improvement time being spent in front of a computer or in an office. In fact there was far less distinction in reality, and most of my time was spent meeting the needs of patients.

For the ‘’meaningful contribution’’ of my quality improvement, let’s wait and see what of the projects in which I was involved will be sustained. I tried to build my QI work on projects already initiated by the hospital, or on issues seen by the hospital as priorities. I tried to make sure that what I did was guided by my Ugandan colleagues, so that the result was a formulation or a distillation of a collective understanding rather than something being imposed from outside. Nonetheless, things move slowly, and I see that my aspirations at the outset were rather too ambitious. I had in mind for example to tackle child protection issues, including training, community training, procedures and more. In the end, I managed to help the hospital team to review its child protection policy and procedures, and to update its policy to reflect best practice. We worked together to share this policy across the hospital team, and with the relevant district officials. I also helped develop some electronic training resources for all staff to ensure that everyone in the institution had (or rather has) a baseline understanding of child protection issues and an awareness of their role and responsibilities in regards to safeguarding children. That was plenty to get through in the limited protected time I had! I also did work on care for chronic disease, and in providing youth friendly services.

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Quality Improvement projects – oh it looks so straightforward on the wall of my office

Possibly more /equally useful as quality improvement was something less tangible than a quality improvement project per se, but more bound up in the clinician part of my role. It was being there on the ward, sitting with nursing staff to help them define audit questions and write quality improvement journals, teaching student nurses on ward rounds, supporting clinical officers as they clerked patients, helping the nurses to understand why doctors made clinical decisions this way, or that way. It was about having less pressure to get through an overwhelming case load than my Ugandan colleagues, so that I had more time to share the thinking with my nursing colleagues, and to share by example. Being present as a member of the team, being willing to get stuck in rather than being aloof. Well, that’s what I tried to do. And that, of course, is back to what I have already said, about the importance of being a human and making human connections.

 

Being there for too short a time?…. certainly. After almost a year (actually more like 9 1/2 months after the comings and goings), we felt that we were just reaching a place of mutual trust and understanding to be able to engage with change and with processes, to see opportunities and to understand constraints and in that way, to be able to start to do work with impact. We were not there for long enough …..

 

After 15 years in General Practice, will I still be able to deal with people who are seriously unwell? Will I be of any use putting in a cannula, setting up a drip, putting in a chest drain, doing a lumbar puncture? I did all these things when I was younger, but will I remember how? Will my fingers remember the technical stuff? Will my presence on the ward be useful?

Can I still look after people who are seriously unwell? Yes, I suppose that I shouldn’t have doubted that. The skills of decision making that I use as a doctor every day are so deeply embedded that I know how to assess and to deal with a very sick patient even if I haven’t done it in a hospital setting for years. Can I still do the hands on stuff that isn’t part of general practice, like putting in a cannula, setting up a drip and putting in a chest drain? Yes I can, and I made sure I did, but far less often than I had anticipated. The nurses in the hospital are so skilful in technical aspects of care and they saw many of these tasks as their responsibility, whereas these would lie with a doctor in the UK. These skills are second nature to them, so more often than not, they helped me out when I was at the limit of my rusty technical abilities. They could see the gaps I had, and helped me round them. (‘’Doctor, might you just want to have this size needle..? ’’)  I owe them a good deal! I think my presence helped them in turn. For the time I was there, the ward had a ‘permanent’ doctor, so that there could be continuity of care, and focus on the patients and on the work of the ward team. In a country so short of doctors, such attention is a luxury.

For half of the time I was at the hospital, we were only three medical officers. My Ugandan colleagues were only five and two years qualified, respectively, and yet they had full responsibility for the provision of clinical services 24 hours a day, 365 days a year. This meant being on call night after night, getting up for caesarean after caesarean, intubating sick neonates, operating on ruptured appendices and fixing broken limbs. They were outstanding, and had technical skills far exceeding mine, born of the necessity of the role they found themselves in. There was no way I could keep up with them, and often I felt guilty about being unable to share the workload they were carrying. But in the end, that wasn’t my job. I was glad to find I could still do the work of an acute hospital doctor when I needed to, but my role was a different one. I played a different part in the service delivery to them.

 

Do I have the stamina to see people die so frequently and in ways that would be unthinkable back in the UK? How will I respond? 

I saw lots of death. Death was so much understated in some ways. It wasn’t some exceptional it-should-never-have-happened kind of event as it can be in the UK. It was public, it was a very present fact of everyone’s every day life. So much so that at morning prayer, the starting prayer would often be a prayer of thanks that we were still alive after the night. Being alive was not something to be taken for granted. Death on the ward had a social and spiritual dimension as well as a biological one. Families wailed, people gathered, prayers were said. That seemed wholesome.

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Morning prayers – being thankful each morning for being alive

It wasn’t the death that got me down, so much as the dying. I have several patients whose faces are vivid to me as they lie in the ward, often in the full knowledge that their lifespan can be counted in days, with wounds that won’t heal because the cancer is too advanced, whose frail bodies are like coat-hangers, whose eyes are staring out from deep sockets. What are they thinking as they anticipate their death? I wish I had the language to ask and to try and understand.

How can I understand what will be useful for the services in terms of quality improvement, and find a way to make a difference?

I hadn’t appreciated just how much structure the hospital had in its planning for quality improvement. I should have known. After all, to go from a clinic under a tree to a hospital with a fully staffed operating theatre, maternity service and neonatal service in sixteen years doesn’t happen by happen-stance, it happens with some very good strategic thinking and very good planning about improving quality. There is a planning cycle that is more elaborate than anything I have seen in the UK. There is a hospital strategic plan, departmental plans, five year plans, annual work-plans, and activities are checked against these plans every quarter. I was fortunate enough to participate in the strategic planning in action, and was struck by how collaborative and open the process was. Every member of staff could see how the budget might be spent, and could contribute ideas and have a say, until, by a process of sifting, a five-year plan was evolved. Good quality improvement initiatives spring directly from these processes.

As to how to get things done? I still am not entirely sure. Relationships are key (see above), but they are not the whole story. Even through my rose-tinted retro-spectacles, I can still see myself standing in the stairwell in perplexed frustration about what I need to do to make something happen that really NEEDS to happen (or at least, NEEDS to happen in my opinion!) I don’t think I have a clear answer. I think this is, and will remain, a conundrum for all but the most patient and most embedded of expatriates working in this setting.

 

Will I be able to spend the time with my family that we will all need? After all, part of the point of the whole undertaking is to spend more time together than we do when we are in our busy lives at home. Will I really be able to stop working all evening (or is that just me) ?!

The answer to both parts of this question is emphatically NO. The fact of living on the hospital site, being constantly aware of what was going on on the wards, there being only two medical officers and myself to provide clinical services to the wards meant that there was always a need to be met. Boundaries are perhaps not my strongest point – but when a nurse asks you if you would PLEASE just look at that patient who has come out of theatre and their blood pressure is only 70 systolic , and the other MOs are delivering babies or intubating neonates, it is pretty difficult to say that it is after 5pm, so it isn’t my problem – even if you are better at boundaries than me. So from my family’s point of view, I wasn’t able to spend the time with them that was hoped for.

In small ways, I felt like I saw much more of the girls than I do in the UK. After all, we had lunch together every day, and the girls came into the hospital, so I’d see their faces pop up at the window of the ward office every few hours as they went to the guest house or to our home. I home-schooled them a day a week. Teaching little Roo about tens and units with wooden blocks for units and empty boxes of anti-malarial tablets  as ‘tens’ was a pleasure I will never forget. There weren’t after-school clubs to rush to, or places to go, so when we were together, we spent time playing games and making things.

 

All the new experiences about living were intensely shared by us as a family, and that meant, to me at least, that we felt very close. Spending time with Brian suffered most of all. With the social aspects of our lives – communal eating and living with the front door open, for example – there was very little time to tend to our life as a couple or even have the time together to adequately process the ups and downs of the roller-coaster we were living. We had no other consistent child care and hardly any physical space. We both felt an imbalance in our commitments – me with long hours spent at the hospital, and Brian with too little opportunity to have time away from the girls to pursue his photography work. It was not easy at times. Off-day adventures were the opportunity to discover Uganda’s wonders together, and to celebrate what mattered to us as a family. They were amazing beyond telling.

Will I be thrown off course by things that previously I took in my stride, like bad roads and dodgy public transport?

No. I can drive on dirt roads in a four-wheel drive vehicle. I had to deal with more uncertainty than I usually feel comfortable with. That did me good.

Will the children find the newness of it all too much of a challenge? Will they settle?

The children barely noticed there was settling to do. They made friends. They made the most of every new thing and every wonder of the natural world that came their way. They can sing the diocesan anthem (the Kinkizi anthem) in passable Rugika, the East African anthem in Kiswahili, and the Ugandan National Anthem as well as any native. They quickly lost the habit of wearing shoes, and even quicker forgot about brushing hair. Eating Ugandan food was always a challenge but trivial in comparison to all that was new to celebrate. Their adaptability was such a boost for us, their parents, and made us very proud.

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sometimes being adaptable is just exhausting

Will Brian and the girls have enough to do each day so as not to resent the whole project?

Daddy school kept everyone busy. I came home at lunchtime to ‘’don’t interrupt, we are doing fractions…’’ on more than one occasion. Making up the curriculum as we went along was interesting. And out of school there was biodiversity popping out of every bush.

 

The problem wasn’t of not having enough to do, but rather of not having enough time to do it. Brian, the photographer, had to beg time from me to go out with his camera, and he only snapped the surface of all that there was available to document. The more time we spent, the more people we knew, the more stories there were to tell in images, and the less time there was left to do it. In the end, with his unplanned return to the UK for his mother’s final illness, his already limited photographic time further was curtailed. But, again, relationships mattered, and, by being part of the community of the hospital, Brian had access to its many stories. He produced a social documentary archive for the hospital and for its wider audience of donors and supporters. It’s beautiful. There will (all being well) be an exhibition at the Royal College of GPs in London to display this work soon.

 

Is it really fair for me to leave my colleague to manage the practice without me and carry the responsibility for so long whilst I swan off indulging my whims in this way?

That’s a difficult one for me to answer. The practice appears to have continued swimmingly without me, but I expect the burden of my absence has been carried by a particular few who will have felt it. I won’t know till I am back.

Is it right to leave our extended family?

Our time away did not fall well in this regard. My mother in law declined rapidly over the autumn, much faster than anyone had anticipated, and she died in March. Brian was at her bedside for her final weeks, and at the moment of her passing. There was lots of soul-searching about being so far away when she was ailing, and after, of leaving the matters arising from her death to Brian’s siblings.

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For Brian – fleeting moments to capture fleeting moments

Answering the questions that I had at the start feels important now. Thinking about the answers, I can see that the experience has been beyond what we could have ever expected or hoped for. It has transformed us all, but even then , we carry our messiness and our habits (I find it difficult to put boundaries around my work, for example) with us where-ever we go.

 

Looking back to the questions give the impression that the experience has ended and is in the past. In one sense it has, of course, but in another, it is just beginning. The time spent at the hospital has opened us as a family to something that we are just trying to feel our way towards. But it is something that for the family, will probably involve Uganda, and for me, will certainly involve Bwindi Community Hospital and our ‘’BCH family.’’

 

Bwindi hospital has quite a high turn over of staff, as many go on to seek further training and professional development. And then often, they come back. So much so that the Executive Director, Dr Birungi, doesn’t think it worth considering it as a person leaving , but usually just a change in their relationship to the hospital. When a staff member leaves, there is a tradition that we sing the following whist we wave to each other…

 

‘’Till we meet, till we meet, till we meet,

Till we meet, till we meet, till we meet,

Till we meet, till we meet, till we meet,

God be with you till we meet again.’’

 

That seems a pretty good note on which to let this blog rest for a while.

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Leaving

Even as I write this title, I don’t really mean it. I think we will call the hospital guest house later and tell them that the family will be in for supper tonight (as we do every day), and we will go back to our house in staff quarters and make sure the washing is taken indoors before the dark and the dew (as we do every day.)

 

But the reality is, we won’t do either of those things. I am sitting on the plane, flying from Kigali to Brussels, to be back in Heathrow by morning. How can this possibly be?

 

This week has been one of leave-taking. Although I worked on the wards until Wednesday, the tone of the week was to prepare for our departure. We had a leaving party last Saturday afternoon for the children, and one on Saturday evening for the adults. The children had a sleep-over with their friends on Monday (in a tent – at least until midnight, when they all left to go to their respective beds!), on Tuesday there was a birthday party, on Wednesday and invitation to have supper with the Principal of the nursing school, on Thursday a ward leaving party. And in amongst all that, there has been packing and dispatching our belongings of the year to our friends or to those who could make use of them.

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party time

 

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getting ready for a sleep over

And then, there have been goodbyes. Often more than once to the same person. Heartfelt, with meaning, difficult because these friendships are so relatively new, and yet have become so important. Once you have shared meals with your friends every day for months, seen them from getting washed in the morning, to the last thing at night, collected their washing, chatted on the doorstep, played scrabble, tended to the same patients, been their patients, shared prayers with them, cried with them, ones lives are interwoven.

 

In between all this leave-taking, I’ve been trying to work out what it means to leave Bwindi, and through this, to find out what the place means in my life, and what that means about where life is taking us. But despite trying, I’ve not been able to get in touch with the feelings. It is almost as if there has been too much to feel to be able to manage. It’s felt almost impossible to understand the reality of leaving. Although the words are there, the truth of it; that Bwindi won’t be our home, it too difficult to understand. I’ve walked to the special places, spoken to the special people, and still the feelings have been locked away.

 

Until this evening, that is.

 

As previously, we chose to leave Uganda via the land border with Rwanda, then to fly from Rwanda on a stopping flight back to Europe. The road to Rwanda is shorter, and a million times more gorgeous than the route to the airport at Entebbe in Uganda as it winds through the impenetrable forest. Anyway, we reached Kigali airport and went to the check in desk. Despite our efforts to prepare (giving our possessions away, and weighing and re-weighing and checking our bags) – we hadn’t packed so well, and our the bags that we had were too heavy for the baggage allowance. Only by a kilo or two, but enough to be noticed. The lady at the desk eyed us sternly and said we would have to pay for our overweight baggage. We offered to re-pack, (we had an extra bag tucked away,) but she wouldn’t allow it – the extra bag had already passed through her check-in process and couldn’t be recalled. An officious impasse. And at that, I burst into uncontrollable sobbing. Tired out by the hectic-ness of recent days, and the lack of unbroken sleep, and completely un-done by this example of an inflexible, rule-bound system, driven by an agenda that I don’t understand and values that weren’t mine…. I couldn’t hold back the tears. This interaction was in such contrast to the life we were leaving where people matter more than rules, where we look to find solutions rather than barriers, and where things happen on a human scale.

 

The flood gates of feeling had opened, and the sense of what we were leaving behind – the community, the shared values, the work built on relationships – it all came cascading out and I sat there, on the suitcase with my head in my hands and tears pouring down my cheeks.

 

How on earth could I move on from here?

 

For now, I think the answer is for me is to be patient and to be still. For now what I need to do is nothing more than to watch an in-flight movie and see what emerges once we are back in our ‘other’ home.

 

(ps; The airline lady was actually more than OK in the end. She called her boss at our request. He was equally firm but said they would let it go this once. Brian apologised to him after for the drama of our check-in, and he was pleasant and helpful, so it was all good in the end, though none of this made a difference to the volume of tears shed!)

 

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Leaving Kigali – taller, dustier, wilder, wiser than when we arrived nearly a year ago

 

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I wrote the above just as we were leaving, on the plane. In fact, a few hours later, there was a twist to our departure. On leaving Rwanda, our plane struck a bird, and whilst the plane was repaired we were grounded in Entebbe (the city with Uganda’s main airport)… So with the loveliest of irony, we found ourselves back in Uganda. After some chaos as we were disembarked in the early hours, we were placed in a sumptuous hotel and had a sun-warmed 48 hours of time-out-of-time exploring and resting and being family. That was a gentle blessing.

 

 

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Stranded in a bed in an Entebbe hotel  at 2 am. A bed bigger than our living room!

 

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Hanging out in Entebbe botanical gardens

Since then, I haven’t had the courage to write. I have been waking each morning with a profound sense of grief and loss. We’ve come somewhere else for a short while to try and start making sense of our experiences. To help me, I’ve been reading books about other people who have worked or explored in Uganda, or in Africa. Thor Hanson was a Peace Corps worker in Bwindi in the 1990s. He was involved in the establishment of the national park and the development of gorilla based tourism in the area. In his book, ‘’The Impenetrable Forest’’ he writes about leaving; ‘’ The conclusion of my time in Uganda left me with a strange mixture of release and regret complicated by the …..wrenching stress of parting from friends. I needed a transitional landscape, a foreign, anonymous place where I could restore myself before moving back home.’’ Henry Morton Stanley, the explorer, described his feeling at a journey’s end. ‘’When a man returns home and finds himself for a moment with nothing to struggle against, the vast resolve which has sustained himself through a long enterprise dies away, burning as it sinks in the heart… and [this is] accompanied by a peculiar melancholy.’’

 

Both writers describe the feeling much better than I. I just hope for me it will pass into a phase that is less acutely painful and more creative soon.

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The very best and the very worst of things

As our time here draws to a close, I am trying to think of the very best and the very worst things that we have encountered during our time here. With so much glorious nature and biodiversity around us, it would be easy to look in the natural world to find the best and the worst. And yes, we have encountered the magnificent and the destructive in the nature here. But my outlook here has been very much focused on the human world, so it is there that I look for the very best, and the very worst.

 

So, here is almost the very worst that I have seen here.

 

Nothing had prepared me to see the patient. I was handed her chart before we went into the room that she has been assigned, on the private ward where she could be kept in isolation away from the risks of infection. The first sensation was of the smell. The smell was of rotten flesh. The next sensation was the stillness. The patient was a young teenager, sitting on the edge of the bed, stiffly, as if cast in lead. Her sister was with her, holding a newborn baby swaddled in a blanket. Everyone was still like a tableau.

 

I looked more closely at the patient. She was stiff because she couldn’t move. Her chest was burnt from her neck to her waist, over her breasts, and under her arms. Her skin had been replaced by a stiff eschar***, rigid like armor and broken into plates, separated by oozy, sticky under-skin. Old burnt skin clung around her neck like rolls of molten plastic. Her nipples had been completely burnt off, and the tissue underneath was extruding through the spaces like cake mixture squeezing through a funnel.  Her breast milk was pouring onto her chest. It was truly horrifying. I did not know what to say, or what to think. At that moment, the baby started crying. It’s caretaker quickly made up some formula, and fed it to the baby in a spouty cup. The baby settled and gnawed on her hands. It was then that I noticed just how huge her head was, how large her eyes, and how absolutely tiny were here fingers. Baby was not getting enough to eat.

 

Here is the story. I have her permission to share it. The girl was married, the second wife to her polygamous husband. This baby was her first child. She had delivered her baby at a health facility, and had returned home a few days later. Something upset her when she reached home, and she and her husband argued. As her anger increased, so she began to have a fit. She had had seizures before, often when she was upset, but had never sought treatment. Why should she ? She knew they happened because she was bewitched since she had run away from home as a child when her father re-married. Her life had been blighted by these convulsions since then. They were a marker of her father’s dissatisfaction with her. This time she had been cooking when she was arguing with her husband, and as she lost consciousness, she fell onto her cooking stove. One of the children around pulled her away, and put out the fire in her clothing. The baby had been on her back, and hadn’t been affected.

 

She had gone to another health facility for a few days where her wounds had been dressed, but they had run out of dressings, so she came to our hospital instead when her skin started to stink, and she was getting worse, rather than better, at risk of sepsis and at high risk of dying. Being unable to feed her baby, it had lost very large amounts of weight, and was clearly malnourished by the time mum and baby presented to our hospital.

I left the room after that first review, and with my nurse colleague, we both could hardly speak. I felt as if I had been thumped in the chest. How, how could the situation have come to that stage? That this young lady might well die, and her baby was clearly struggling to cling to life, and nothing had been done about a simple treatable condition such as epilepsy because of how her illness was understood, and communicated to her. The weight of unchangeable forces felt so heavily on her shoulders.

 

What does this terrible story tell me? That models of understanding of health and disease that are widespread in the community here can be so destructive to a person’s health. That family bonds and family expectations are so potent that a parent’s disapproval can blight a woman’s life for all the years that remain. That some health facilities around are so poorly stocked and staffed that they don’t even have gauze to bandage a patient, that a baby who can’t breastfeed faces a huge challenge if it is to survive the first six months of life here.

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A place to catch breath

If this is something of the worst, here is some of the best. The doctors and nurses who care for patients here. Over the course of many weeks, the nurses have tended to our patient’s burns with meticulous care. Her burns were so severe at first that she had to be given a general anaesthetic for the dressings to be changed. Painstakingly, my Ugandan colleagues have grafted new skin onto the most deeply burnt areas, slowly, slowly, the skin is healing. The nurses have washed her, cared for her huge compassion. When her caretaker was called back to the family, the patient worried she too would have to go home, because who else could look after the baby (she still couldn’t hold her baby by herself at that stage) . The hospital stepped in, and appointed one of the ancillary staff to care for the baby and for the patient’s personal needs. She was started on anti-epileptic medication and counselled about the nature of the attacks that overcome her. She’s started some physical therapy to help her move her stiff contracted scarred skin. Baby has had a nutritional review and is being supported to feed and now is gaining weight. It may be that in a few more weeks, she will indeed be well enough to go home. There is reason to be hopeful.

There is so much pain and so much goodness in each day here, so much that is worse than you could start to imagine. And yet there is so much compassion and kindness, and smiling and joy. That has to be the very, very best of things.

 

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Wonderful doctors and nurses at work and at play

I’ll leave you with something of the best of nature after all. On the way back from our holiday, we took my favourite road of all. It’s the road from Kasese to home that runs through Queen Elizabeth National Park. The whole road shimmered with butterflies, for the two hours that we drove, there were butterflies and more butterflies and more butterlies. The air was full of them. It was like driving through falling blossom. This was one of the most beautiful experiences of my life.

Here’s a picture of one of them (a forest caper white for those interested), and the open road. I wish I could post a video, but I can’t!

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My favorite road in the whole world

 

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Forest Caper White (courtesy of Brian)
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small person in awe at the open road and the wide open wild

**** eschar – doctor-speak for scar tissue

 

Border disorder

(With thoughts as I write this to my sister, Madeleine, who is an anthropologist and whose special interest in borderlands may have sparked my interest in this particular story….)

 At supper at the guest house there was a new visitor. Nothing remarkable about that, except that this gentleman was from Congo and he could not speak any English at all, whereas most of our visitors speak at least a little English. I unpacked my French and we started to chat. It turns out that he was an topographical engineer from the Congolese Ministry of Internal Affairs in Kinshasa. He had been sent by his government to this remote corner of Uganda after several years of negotiation to meet with his Ugandan colleagues and to try to get the border back in the right place! Half way through dinner, and mid way through his animated description of his job, my new Congolese friend jumped up from the table and disappeared to his room. He emerged shortly after with a bundle of large rolled up sheets of paper under his arm. This was his work. Here was the border. And here is what he showed us.

 

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Beautifully detailed historic maps

In 1908, officials of the King of Belgium and the King of England sat down and drew a line on a very detailed map of this far-flung corner of their respective colonies and thereby determined who should be under Belgium’s rule, and who should be under British authority. Nothing has ever been updated, map-wise, and I doubt there has been much local engagement with the formal knowledge which is kept in a vault in the British Library (our Congolese visitor’s team had to go to London to get a copy.) People in the area pass the knowledge of the border in their lived experience down the generations. In the time since the border was drawn, the border has moved to the east a little bit here, to the west a little bit there, as families have shared out their fields to their offspring, and married across the border, and lived on one side or the other interchangeably.

 

Our Congolese friend’s job was to walk the border with his Ugandan colleagues and to put up border marker posts on the line of hills above Buhoma where the frontier lies. 16 kilometres to be defined on this visit, and twenty the next, until the whole border was clear.

 

I went to bed musing about the way colonial powers could make assertions about the lives of people so far away, geographically and psychologically.

 

On the ward a few days later was an elderly gentleman in a bright red T Shirt. He had been admitted during the night, complaining of dizziness and breathlessness and light-heartedness and chest pain. After a night’s sleep he was a little better but still feeling shaky. Was this a heart problem? an infection? Malaria? (anything can be malaria!)

 

Probing more deeply, he described how he felt something gripping in his chest, and how his breathing was tight, and shallow, and how when he thought too much, he started shaking, Was he describing a panic attack….? I asked if there was anything that might be worrying him or on his mind. Well, yes.

 

This gentleman was a farmer with a large family. His land was on top of the hill, overlooking Buhoma. Until a few days ago, his land was in Uganda, and he traded here and made his life as a Ugandan. But, as the border was being re-asserted, he had been informed that in fact his land was not in Uganda after all, but in Congo. Ugandans had, over the years, encroached into territory that formally belonged to Congo as their field boundaries had been shared and shifted over the generations. Our patient was told that he was in Congo illegally, and that the land he had thought was his would be taken away from him by the authorities. Not surprisingly, he was experiencing the symptoms of an acute stress reaction to such a life-changing event.

 

How vulnerable are people’s livelihoods here, now, to decisions made far away geographically and far away in time.

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The boundary between agricultural land, and the protected impenetrable forest is very clearly seen

There are other forces at work, determining where and how people farm too. The small fields and crops that are clinging to the hillsides in our area are very picturesque to the observer, but the farmers are not planting their crops high on the steep slopes close to the border with Congo because of the wonderful view, or because of the quality of the soil (quite the contrary-), but because of the pressure of population in this area. There are 198 people per square kilometre in our district. Uganda has a much higher population density than the neighbouring countries of Tanzania , South Sudan and Kenya, and the population density has more than doubled since 1991, reflecting the huge increase in population in the intervening years. , Uganda’s fertility rate remains very high

(https://www.ubos.org/onlinefiles/uploads/ubos/NPHC/CENSUS%20FINAL.pdf). The total number of births per woman is an internationally monitored statistic called the TFR. Uganda’s TFR has only just fallen below 6 (that means an average of 6 births per woman), only Somalia, Niger , Chad and Congo manage a higher rate. Uganda’s population is increasing by more than 3 % a year. This means there is a net gain of one Ugandan every 22 seconds. A young population has many babies, and fewer people are dying very young. On a background of population pressure at a national level, Bwindi has particular pressures on its population and agricultural land. The influx of tourists to the area, here to visit the gorillas, means that owning property in the area opens the potential for profit from these lucrative visitors. So land is bought up by people from outside the area to build lodges and resources for tourists. Incomers (often from Kampala) out-compete the local farmers with the sums they can offer to pay when land is for sale.

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tea planted all the way to the ridge

For our patient, the hospital could offer counselling and psychological support, but ultimately, there would be little he could do to change his family’s new situation – it is part of a much larger historical- , geopolitical- economic- and population- disorder.

 

 

 

Risk and Uncertainty

 

I’m in reflective mode. Our holiday continues and on the long bumpy, unpredictable journeys in the car, I have time to think about and talk to Brian about some of the big issues that have shaped our time here.

 

Driving behind a small lorry loaded with planks of wood, not secured in the back, wobbling at every bump (ready to fall out), whilst being overtaken by a low-slung battered toyota, and facing an oncoming road-haulage lorry in the middle of the road (all at the same time) it seemed a reasonable time to think about risk and what it means here and at home.

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Putting all your eggs in one boda

 

 

Risk has always been a concern to me. At home in the UK, one can’t get very far without something in place to mitigate risk – mortgage life insurance, home insurance, travel insurance, pension planning, playgrounds without sticks, no ball games, no children walking to school alone, no talking to strangers. Our communities have gone to an extreme to minimise the risk in any aspect of life. It seems to me that children, particularly, can grow up without ever experiencing much risk (breaking a limb, being scared etc.) So much so that when it comes in larger form later on (driving your friends home from the pub, drugs, sexual experimentation), we haven’t learnt the skills to navigate risk, and that we can’t manage it very well. ( Tim Gill writes excellently on this, see https://timrgill.files.wordpress.com/2010/10/no-fear-19-12-07.pdf)

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”Don’t worry, Mummy. The last tree I was in was much higher than this one…”

Here, life is at the opposite extreme. For all but the elite, uncertainty and risk play a large part of every day life. The risk of not being able to set aside money in case of illness, the risk of injury when a young child has to wield a panga, the risk of having to drop out of school because someone in the family becomes ill, the uncertainty and the risk of going into labour and having no means of transport to get to a health facility….risk is everywhere. People here are accustomed to living with a much higher level of risk and uncertainty in everyday life than people from Europe and North America. Simple things – like travelling by boda without a helmet (or even travelling by boda), or not being sure if there will be something to buy to eat in the evening.

 

For us as Muzungus (particularly having small children to look after) we find ourselves in a state of flux or self-analysis about what to do about risk, and we find that we tolerate risk here that would be unimaginable at home. Seat belts or no seat belts? Here, almost no-one wears seatbelts. Can our girls go in the car without a seatbelt like everyone else? If so, how far? On what roads? And to get from A to B in Kampala, shall I take a boda? It might well save me an hour in travelling time? (even though I would never go near a motorcycle in the UK….) Shall we go to the market at the border with Congo? Should we drive after dark? Shall we drive through the ‘chasm of doom’******if it saves an hour?

 

How do we make these decisions? How do we balance a sense of risk in a context where the risks are much higher in so many domains, and our Ugandan friends live much more comfortably with uncertainty, and see our worrying about risk as fuss about something that doesn’t warrant fuss?

 

The flip side of risk and increased tolerance of risk seems in my mind to be a lower level of preparedness. Those who know me know that I don’t go far without a plan or an anticipation of every possible eventuality as a way of mitigating the discomfort of uncertainty. Anticipatory planning just doesn’t seem to be part of the culture here. That said, it can, of course, be done, and the hospital as an institution has to plan. There are systems in place for ordering medications and stock. And of course, good clinical practice involves anticipation and planning ahead. When events are scheduled (like the visit of dignitaries to mark a significant date) then things are organised to prepare, but with much less of a head-start than we would have in the UK.  There are plans for meetings and rotas. But the reality is that much organisation takes places rather more on-the-spot than this. Arranging things in person to happen soon, has much more of a chance of being successful than arranging a plan long in advance, and without the human contact. I have had to learn that things will surely happen. Things go better if you don’t fuss, but instead you just trust.

 

This formulation has helped me to understand how people here, and the hospital in general, is preparing for some significant risks on the horizon. One of these is the prospect of Ebola, over the border in Congo, though a little to the north of us in Bwindi. The border itself is very close to us – I can see the trees on the ridge that marks the border with Congo from the window of the volunteer’s office. The border is also very porous – made up as it was by an agreement between the Belgian king and the British empire in 1908. People cross with relative freedom.

 

From a Mzungu perspective, there is little to see at the hospital in terms of Ebola preparedness. Patients temperatures are taken at the gate from dawn to dusk. Everyone must wash their hands in jik (chlorine) before entering. There are posters around. There’s a small triage tent. There is a protocol. But no huge banners, no formal buildings, no reassuring infrastructure. But my feeling is that, for our local friends and for the institution as a whole, the risk does not feel imminent. The uncertainty of what would happen if a potential patient crossing towards the hospital is not one that feels pressing, right at this moment. When the time comes, the hospital and the community around ****will step up and deal with it.

 

These matters of risk and uncertainty challenge me every day. I live here with more uncertainty than would usually make me comfortable, and with much higher levels of risk that would be normal for me. This is very good for me, it is stretching, exciting, exhilarating and exhausting.

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Risk and the unknown…. there may just be a Rhino in the gents.

 

*** ‘The chasm of doom’ is the name given by our Mzungu friends to a cleft in the rift valley that is very sharp and steep. The road to Rukungiri (and all destinations east) runs in a spine-tingling, chilling, spectacular, single track zigzag down one side, across the bridge ,and up the other side. On this road travels the long distance bus, the container lorries, tea lorries and other large vehicles. Meeting one of these vehicles whilst on the precipitous road is too much for my nerves. We (and most of the other bazungu) take a much longer but less hair-raising route.

 

**** In general Ebola preparedness depends very much on community awareness and engagement in responding. This has been part of the terrible problem in Congo, where the current outbreak of Ebola is in an area that has been politically disenfranchised for decades and with very little positive presence of the state in generations. There is distrust of outsiders, so when outsiders come telling people that ebola is a disease, not witchcraft, and where they take people to a health facility simply to die, they stop people handling their loved ones after death, or advise people not to use traditional burial practices, there is huge distrust and lack of compliance. Uganda by contrast, has had ebola outbreaks before which have been successfully contained. The community health system is well developed and the communication of health messages is something very familiar. In general the community in Uganda is well informed about Ebola. I’d encourage everyone interested to read Oliver Johnson’s fantastic book, ‘’Getting to Zero’’ about the Ebola outbreak in West Africa in 2014.

My family and other wild creatures

I am sure that my desire to come and live in Africa was in small but significant part (- there were other influences of course – ) influenced by my author hero of my teenage years, Gerald Durrell who was a naturalist and who travelled the world researching animals and writing about his experiences. His most famous book is ‘’My family and other animals,’’ which documents his early childhood in Corfu where his family had relocated in the early 1930s.

I grew up wanting to be like him – an animal researcher, later I wanted to be like Diane Fossey, and then like Jane Goodall. Until my last years at school, I wanted to live and work in a national park in Africa, or perhaps in India (I wasn’t very specific.) And then my curiosity about people got in the way, and I ended up with the wonderful career that I have. Nonetheless, my soft spot for wildlife remains soft. So it was fortunate that I met and married Brian – a zoologist by training and an insect obsessive by habit. Brian has an instinct for ecological story-telling. Since Miss A and Little Roo were tiny, he and they have done nature walks, looking at the slugs and slimy things that have inhabited our local environment and learning about their habits and their habitats. We have housed worms, and toads in the utility room in England and June Bugs in the living room. Both girls have inherited Brian’s animal-fascination.

 

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So imagine what happens when we all find ourselves in one of the most biodiverse corners of one of the most biodiverse countries in the world. It sometimes borders on madness. Imagine the scene when we walk home from the guest house where we have had supper. It is dark, it is bedtime for the girls, but in the gutter just outside the house we find a MOLE CRICKET…. what could be more exciting. The strongest creature in the world, weight for weight, it’s a grasshopper-type thing with huge front legs modified for burrowing in mud and pushing it aside, like the paws of a mole. It is almost impossible to hold this little creature in your hand as it prises apart your fingers to make its escape. On mole cricket nights, there is no such thing as bedtime. On the mornings when the girls find a chameleon, specially one when it is moulting, then there is NO SCHOOL (or else, I just accept that chameleon love is a kind of school.) Yesterday we found a pachyderm dung beetle (that is a dung beetle that likes elephant dung) that was at least 8 centimetres across. If flew in a bumbling, buzzing way, like a huge drunken bumble bee until it crash-landed on the floor. Everyone abandoned their hot supper to investigate. After much attention, we put it on the ground to scuttle away, and the poor creature took defensive action, and found a brick to bury himself under. We could see him scraping and scrabbling, lifting the brick with his back until he got a place of safety. A few seconds later, we lifted the brick. All that was left was some finely scattered earth to show that the dung beetle had hidden himself there. We could talk of nothing else all evening. And that is to say nothing of what happens when we find army ants, or toads or singing bell frogs or dragonflies…..

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Miss A with a pachyderm dung beetle!

 

Our explorations of Uganda have allowed us to visit several national parks. And in fact we have one of the most special on our doorstep, the Bwindi Impenetrable Forest. Over the past year, the girls have got to know the guides and the staff there. There is a short walk in the margins of the forest. We are almost always alone when we go there. It takes us beside the stream on a cleared path with thick forest on either side. Every visit offers a new adventure. It is probably only a mile or so in distance, but can take us more than two hours as we look under each leaf, or log or loose piece of bark. Once I have had a phone call whilst I am back at the hospital, from Brian to say that they have just found ‘’this enormous snake, maybe two metres long, they didn’t see its head or tail, it was as thick as a man’s arm….Isn’t that excitiing….?’’ Sometimes I get a call to say that they are turning back because there are too many baboons on the path.

 

Beyond ‘our own’ forest, we have been privileged to visit several other of Uganda’s national parks. From the intimate and wild experiences of Lake Mburo and Ishasha and Maramagambo forest, to the spectacular expanses of Murchison falls. As a result, the girls can distinguish a Ugandan Kob from a Hartebeest at a hundred paces, and Little Roo’s piercing voice can be heard to correct people, ‘’no its not, it’s a hadeda ibis….’’ On our holiday in the last week, we have woken to rhinos outside the window, and tried to go to bed whilst hippos block the way to our tent.  Perhaps our favourite place has been on the fringes of Kibale forest (famous for its chimpanzees), where our friend, Julia, a researcher, has enabled us to stay. We have been able to take part in the community bird club which her team has helped to set up. Along with seventeen local children and young people, we have been shown how to distinguish the appearance and the calls of red eyed doves, emerald cuckoos, plantain eaters, sunbirds and blue turacos. Her brilliant guides have initiated us into the beautiful mysteries of the myriad of butterflies that turn this forest into such a magical place.

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Rhino in the gents
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Learning all about butterflies

 

As we have got to know more about the wildlife around, so my own two creatures have become increasingly feral, running bare foot in the dust, climbing trees and hunting for chameleons. I am very very happy to witness the wild-ing of my children, in every sense. I sometimes think we are becoming as eccentric and as fortunate as the Durrell family all those years ago in Corfu, and what a celebration that is for all of us.

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Young friends equally smitten with butterflies. (Note Brian crouching to photograph some other creepy crawly…)

 

 

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….and learning all about bird identification

 

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little wild and free

Health – out and a-bout

We have some off-days and are away from BCH exploring Western Uganda as a family. It is wonderful to have time just the four of us. We’ve needed this time to re-connect with each other and to slow down after the relentless busyness of life at the hospital.

 

As tradition has it amongst Muzungu volunteers at the hospital , we have gone to Lake Bunyonyi to unwind. Lake Bunyonyi is a volcanic crater lake in the very south west of the country, almost at the border with Rwanda. It is high (almost 2000 metres) and deep, and has 29 islands in it. The surrounding hills are steep and the local farmers practice terraced agriculture. It is picturesque and the sound of water is very calming. Bunyonyi means little birds and indeed, they are everywhere. Much to Miss A’s delight.

 

Little did I know it, but when I asked to go on a boat trip to the islands, I was embarking on a reflective tour of the reproductive rights in Uganda. My first stop was to punishment island ( Akampene) – a tiny patch of marshland with one tall tree – where women were taken when they were found to be pregnant outside marriage. Being pregnant outside wedlock meant shame on the girl’s family and a loss of bride price (only paid for a virgin bride.) Girls becoming ‘worthless’ in such a way were taken to Punishment Island and left there. Without water and shelter they were unlikely to survive long, but it seems that most would be picked within a few days up by local boys who couldn’t afford a more expensive ‘un-tarnished’ wife. The practice continued well into the 20th century, even though it was illegal. (see https://www.bbc.com/news/world-africa-39576510)

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Dugout canoes

 

The island adjacent to the one on which we stay was given to a Scottish missionary doctor in 1921. On it, he started a leprosy hospital with a church, model housing and health facilities with the idea that it would provide a welcoming community to lepers who would self-segregate by moving to live on the island, and thus no longer infect the communities from which they had come. The community attracted patients/residents from the areas that are now Kenya, Tanzania, Congo and Rwanda as well as what is now Uganda. It ran from 1934 to 1968.

 

Instead of a leprosy centre, there is now a government health facility – a Health Centre III.

In Uganda, the government has a four-tiered primary health care system. Level 1 is the village health worker (VHT) who does community based health education, health promotion, health surveillance and house-to-house visits. Level II health centres are staffed by nurses. Level III have a clinical officer and basic lab facilities (near patient tests such as malaria rapid tests, blood group tests and so on) and can conduct deliveries.

 

It seemed to me an odd idea to have a health facility on an island, but the idea is that its situation is equitable – equally accessible (or inaccessible) to the communities on the islands in the lake and around the intricate shoreline. People access it by dugout canoe.

 

Never one to pass up a visit to a health facility if I see one, I asked to visit. We arrived by boat at the small jetty, and walked up the track through the vegetable garden to the cleanly painted, fresh buildings at the top of the hill. We were greeted by Edward, the Clinical Officer and Benjamin, the lab technician. Both of them have worked there for a number of years. The patients had finished for the day, and the clinicians were having some down time. They took me on a guided tour. There are eight simple rooms in the main building of the health facility – one is a consulting room, one for HIV services with a large register and a stack of brightly coloured files, one a triage room, one a lab, one (with a padlock) a pharmacy. Then they took me to Maternity unit with its blood pressure machine, ledgers, weighing scales and a a simple fetal monitor. The staff were very proud of their unit. They told me that they could do 30 deliveries a month. Thirty a month – that means about one a day, but there was noone there. That didn’t add up. Where were all the ladies? I asked.

 

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Well prepared antenatal clinic room

 

It turns out that you can’t cross the lake in a dugout canoe safely when you are in labour, unless the lake is calm and you really are nearby. You need motorised boat transport and that is expensive. Local communities complained that to the government that it should support pregnant women by providing them with a water ambulance to take them to the health centre when in labour. And so a water ambulance was provided. The idea is that, when women come for antenatal care at the clinic, they are given the phone number of the boatman, and then, when they are in labour, they can call him and he will come and fetch them and bring them to the clinic. But here is the problem. The governement has not provided a regular supply of fuel for the boat. The fuel comes sporadically when the boat comes with stocks for the pharmacy, but there is never enough to last till till the next visit. Sometimes the boat goes out to fetch a patient and runs out of fuel in the middle of the lake. Then the clinic staff dig into their own pockets and make up the cost for fuel for the rest of the journey. Without the safety of the ambulance boat, the women just don’t come.

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The ambulance boat. Waiting…….

 

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An empty maternity unit

 

The maternity beds remain empty and women’s deliveries are more risky than they could or should be. All for the lack of fuel…. (or is it a lack of political will….?)

It seems that somehow, in a century that has passed between Punishment Island and the Bwama island ambulance, the penny hasn’t dropped that pregnancy isn’t just women’s business and an accident to be dealt with when it arises, but is a central and vital fact of life that deserves attention and planning and resources at the level of the whole of society.