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.

 

 

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)

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.

 

*** ‘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.