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)
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.
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.
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.
Dr Margaret's diary 