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.

 

Feeling low

I’ve been aware of neglecting the blog for a while. And now that I want to write, I am not sure that I know what to say. My head feels congested, as if it is stuffed with mashed matoke. There’s no room for the thoughts to get an airing or become clear, to me, let alone to anyone else.

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sometimes things are a bit heavy-going

I think I am just exhausted. We’ve been back here for two and a half months since our visit to the UK for my mother-in-law’s funeral. I haven’t had more than a day off each week. My evenings have been crammed full with projects for the hospital and my days with the wards and with meetings. Our mealtimes are shared with others – there have been crowds of visitors at the guest house in the last few weeks  – and the family needs me in all the other moments. Brian and I have been a tag team, trying to make sure that the girls have care and attention, whilst we try and get our respective projects tied up (*****). I need to stop and find space to breathe, and our relationship needs a bit more time as well.

This is all the challenge of entering a transitional phase. We are bringing things to their closure here, and that means reflecting on what we have done, and what gaps there remain that we had hoped or tried to fill. We struggle with the concept of leaving here where life feels lived so intensely and so fulfilling.

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nile at dawn

 

Yet we have committments back in Britain which we can no longer ignore. The result is that,  rather than being quite so un-questioningly immersed in the hospital’s routines, a bit of my outsider-observer self has crept back, a nagging, sometimes critical voice.

For example, we had a hospital data quality meeting yesterday. It is a great thing that every month, the hospital key staff stop and review all the data collected , look at anomalies, scrutinise trends. It is very laudible and valuable to collect and to analyse this data set. But the meeting takes ages. Maybe it is having done it ten times now, maybe it is because I am focussed on the time things take, maybe because my brain is moving towards another place. But this time, I found the fact that it went on for so long pretty unbearable. There were 16 people in the room, the meeting took four hours. That’s 64 staff-hours…. a full working week. Surely there must be a more efficient way of completing this task? But who am I to say, as soon, it won’t be my problem. Hmmm….. I really don’t know what to make of these feelings. I know, too, that my current state of mind and my tiredness make me less patient and less tolerant.

 

Only a week ago, I was in a state of energy and great happiness. Last Sunday, we had a morning getting showered (it takes that long when the hot water needs to be boiled in a kettle), we had a lovely walk in an atmospheric storm, we felt at home amongst the hills and in the nearby valley that have become familiar to us in the past month. We shopped for fabrics, our friends came for tea. A day full of the riches of our life here. And we thought at that time, ‘’how can we ever imagine leaving this place and this community?’’

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We probably need a break, and thankfully, this coming week, we will be going on holiday as a family, to explore a bit of Western Uganda further afield than we have ventured so far.

*** Brian’s projects… I haven’t mentioned these yet. He has (amongst other things, and critically, looking after the girls and teaching them), being documenting the hospital’s work in photos. He has created a beautiful archive for the hospital to use, for fundraising, for health education and publicity. We are hoping there will be an exhibition in London in the autumn of 2019

Something chronic…….

Most people when asked to think about the disease affecting this part of the world might (rightly) come up with HIV,  Malaria, and TB. And these abound, to be sure. But as some of these are brought into line, other patterns of illness emerge, particularly chronic diseases like diabetes and hypertension (high blood pressure.) These illnesses are less ‘charismastic’’ than infectious disease, but they have a huge impact on people’s quality of life and their ability to function in society. They are also increasingly the cause of death, accounting for 27% of deaths in Uganda even now. I’m a GP. I’m quite interested in these. Chronic disease management is our bread-and-butter. I’m also interested because I like thinking about systems. I think of the problem of disease control like this. If you want to control an infection, you probably need to find a good drug, or a good vaccine***. But to control a chronic disease, you really need a good system.

Once again, our hospital is at the cutting edge of thinking about this in a rural African context. Every adult patient who comes to the hospital has their blood pressure checked when they arrive at the out-patient’s department. People who have persistently high blood pressure or who are found to have diabetes are referred to the chronic care clinic. This clinic takes place once a week. A nurse and a medical officer review people’s blood pressure or diabetes, check their diet, check that they understand their medication, provide more tablets or make adjustments to the dose if the clinical parameters are not well controlled. There’s an digital template for entering all the data so that each person’s records can be followed from visit to visit.

There are some gaps, though. Some problems are with what we can do here at the hospital. For exampe, there is a really simple blood test for diabetes that can tell us how well a patient’s blood sugar has been controlled over a period of three months. It’s called HbA1c. It is cool because it is such a simple idea. It measures how many of a patient’s red blood cells have a sugar coating and gives the answer as a percent. As red blood cells last a long time, up to three months, it can tell us whether the patient’s blood has been a very sugary solution (poor control), or a nice slightly sweet one (good control).  High blood sugar determines the negative outcomes (kidney failure, sight loss etc) in diabetes so this is critical information for the doctors. There are even near-patient test kits for this (that don’t need to be done in a lab, they can be done in a clinic) – but we don’t have these or even the lab test. Even if we had the machine, the consumables, like test strips can be exorbitantly expensive. So in our clinic we have to rely on measuring the patient’s blood sugar at the time they come to clinic. This might be low, because they haven’t eaten in the morning because of coming to clinic, or high (because they’ve had to wait to be seen, so they have just eaten a banana) – so making an assessment of whether someone’s diabetes is well controlled has an element of guess-work. There are other excellent (and simple) tests, like a little mono-filament which can be used to check the sensation in people’s feet. It would be great to have, but we don’t. Incidentally, foot care for diabetics is really important. Anywhere in the world, but importantly here. If diabetes is not well controlled then people loose the sensation in their feet. Here, where most people walk without shoes, having poor foot sensation is risky. If you step on a thorn and don’t notice, and then in some animal dung and a bit of mud, it is a recipe for an infection that can spread, and lead to gangrene (and then to amputation.) Taking care of all these things matters. Eyes are important too. Diabetics can get cataracts and damage to their retinas. Loss off sight means loss of independence, and has a direct impact on the patient and those who care for them. We don’t have enough eye care staff to test everyone who needs it.

 

 

Just as some of the problems are challenges for the facility, some of the challenges about chronic disease care are to do with what the patients can do. There may be little understanding of how diet can influence health, or people simply can’t afford or are too bound by habit to change their diets. Sometimes patients can’t come to the clinic when they are scheduled to do so. It can cost a lot to come from far in the district to reach the hospital. So they may only come once they have run out of tablets. And so we ask ourselves, is their high blood pressure because they haven’t had tablets for a few days, or is it because their tablets aren’t working? Sometimes patients have to pay so much to travel to the clinic that they have little left over to pay for their medication. THey collect enough supplies for a month because that is all they can afford, whereas if they had the funds, they could take three month’s worth home and not have to come to clinic again for a longer interval. Or they may not have enough money to pay for monitoring blood tests. Of their home may be in one of the more hard-to-reach areas in this already hard-to-reach district. The only transport available may be by boda-boda. And travelling by this means for an hour or two may not be feasible for a frail elderly person.

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Stunning countryside but difficult to cross for the frail

So, managing chronic care in this setting is fraught with lots of interesting challenges, both medical and practical. It makes it really interesting.

This is one of the things I have been thinking about during my time here. And after a careful review of the data from the clinic, a research study has been proposed to explore some of these issues in more detail. I hope that this might lead to some transformation of the service into the future. It would be so exciting to see care devolved from the hospital to the level of the community and from a centralised approach to one that is devolved outwards and truly patient-centred. But that is for others to do.

 

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*** Yes, I know, control of infectious disease also needs public health systems…sorry, public health colleagues for a crass over-simplification

 

Out and about in Buhoma

I realise that these posts have been very hospital-focussed. That’s because our life here has been very hospital-focussed but to go without describing our local village and our local community would be a major omission.

So, Bwindi hospital is in Buhoma (village), Bwindi being the term used to describe the area generally, and certainly the term which is used in the tourist sense. We found this really confusing when we got here. “Buhoma?” “Where is Buhoma? Oh here?” “Then where is Bwindi?”

Everything – geographically and economically revolves round the National Park (which is the impenetrable forest.) It’s a funny shape. The park gates serve as the end of the road, though the forest can be crossed by foot (in about 6 hours) to get to the other side and to another district called Kisoro. If you chose to drive to Kisoro, it will take much longer by beautiful mountain roads along the edge of the forest. So, my guided tour of our home village starts at the park gates which is the highest point you can get to in the valley in the car.

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who needs a bank when money is mobile (and smiles as much as this!) – I don’t have a picture of park gates

Just outside the park gates is the village of Nkwenda. The main road here is lined with kiosks selling gorilla carvings and paintings and fabric, and offices advertising community walks, or orphan projects (with orphans dancing for tourists……..). Folk of Nkwenda are used to seeing tourists, speak good English and know how smiles win sales. Back down the road (back down the valley) you drive towards Buhoma. The road is beautiful as the valley floor is on the right hand side, and the slope beyond it on the far side is completely forested. In the floor of the valley, and on the lower slopes, are settlements and small plantations of bananas and crops. The river and the hydroelectric plant nestle there too, though you can’t see them from the height of the road . The trees on the forest side are elegant with their white straight trunks, and the canopy is bushy and lush. Some of the trees are in flower, giving a creamy dusting to the tops, and a mixture of other colours at times. They rise up to the undulating ridge that forms the horizon.

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The far side of the valley – tea bushes and the forest

Follow the road down the road past the tourist lodges – “Trackers” (an up market lodge with a posh swimming pool where they won’t let us swim), “Volcanoes”, “Engagi,” ”Mahogany Springs.” Then down towards Buhoma and another class of lodges for more local visitors. Then the road dips down towards the centre. The ”Highway” bus is parked on the side, with people washing it, changing the tyres, doing repairs on it as it rests between its 14 hour hauls to Kampala. On the right is the gym and then the sign to Monkey House – our hospital guest house, our second home, our place of companionship and rest and fun.

On down the hill to the junction – the most important junction because the road to the right leads to the hospital. The junction is the centre of things. Here is the boda stand, where the motorcycle drivers stop with their vehicles and wait for passenger. Here is the bar, the “Good Shed” bar, and the chippati man and the roasted sweetcorn, and the kebabs.  There has been building work behind the boda stage since we arrived, so there are piles of sand and bricks to negotiate as you walk through. It is also the home of the ever-noisy, every busy, weaver birds who chatter relentlessly.

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At 7 am…is still sleepy in central Buhoma

Next is the supermarket. This wonderful place brings comfort to our lives. It’s been here for a year, I think, and (usually) has supplies of bread, biscuits, fizzy drinks, tomato puree (essential for sandwiches on the sweet bread) and even, sometimes. cheese! The cheese is round and called Edam which is a nice euphemism for something salty and cheese-like. It is kept in a deep freeze, next to the meat, sometimes not wrapped. When I pick it out, I say a little prayer that the power hasn’t failed and the meat hasn’t defrosted its juices onto the cheese. So far so good. Sometimes the supermarket has dairy milk chocolate and sometimes raisins. These are for an eye-watering price. But sometimes it is worth it,  just for a taste of the familiar.

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The supermarket (Pringles included)

Opposite the supermarket is the “excellent drug shop” which is indeed excellent as it appears to have everything I have looked for there, even if I cant find it in the hospital. Next  is the track up to the ‘proper’ market. The Market itself takes place on Saturday afternoons, but, during the rest of the week, there are still several permanent stalls selling pineapples and cabbages and sweet potatoes and yams and tomatoes and bananas. We get our veg from a lovely lady who rescued the girls when a massive storm caught them off-guard in the market, and the market turned into a muddy river with no way to get out. She took them into the hut behind her stall and comforted them. She’s had our market business ever since.

On Saturday by mid afternoon, the market has come to life. Beyond the veg stalls is the meat area. Everything is outside. There are goats hung up, slaughtered and draining blood, various cuts of leg and body of beef and goat. There are, knives, pangas, slabs with lumps of fat congealed on them, flies, puddles of blood, dogs, weighing scales, bustle and salesmanship. Behind all these, the temporary framework of stalls are covered in blue plastic sheeting so people can shelter from the sun or the rain. In the stalls, clothes are piled for sale – they look like piles from European jumble sales – white shirts, black trousers, skirts, sheets, fabrics, socks. Then there are stalls with flip-flops and shoes for school, one that sells light-bulbs and solar panels and batteries, there are ladies selling banana fritters and other goodies. There’s a hustle of men in military fatigues who come down to a little camp from the border post on the ridge.  And there is our friend, Godfrey.

Godfrey has a dignified appearance, and imposing frame , a thoughtful smile and glasses, and he sells smart shoes. We first met Godfrey when we were invited to attend a wedding and the girls had to be bridesmaids. We had to find ‘smart shoes’ quickly and Godfrey came up trumps with shiny patent leather affairs for both of them. Godfrey buys shoes in Kampala and sells them locally. He has realised that Mzungus have a soft spot for birkenstock sandles and can’t resist the non-European prices. Miss A and Little Roo have built up a striking collection of high quality (second hand ) footwear since they have been here, and become Godfrey’s friends in the meantime. Godfrey like so many here is overqualified as a travellilng shoe salesman. He has a masters degree in Business administration and excellent proposal writing skills. But around here, there are few employers for these skills, so for now, he uses his acumen in entrepreneur-ism and developing his own NGO.

There are two more crucial businesses on the rutted path up to the market from the centre. There is Ruthy, the tailor, and Bright and Ellen’s vegetable shop. We met Ruthy whilst meandering through the village soon after we arrived. We were drawn to the lovely items in her shop. I have a brown and yellow dress to show for it (!). And she has, in the months we have been here, made the girls a number of really beautiful clothes. Our shelves in our home are filling up with fabrics to take away courtesy of Ruthy. Next door, Bright and Ellen have a veg shop. This is an outpost of the hospital as Bright (who has a qualification in agricultural engineering) manages the hospital’s vegetable garden. The profits from the vegetable sales go back to the hospital, and the range of vegetables is a source of greens for the community and place for nutritional outreach. It’s dark inside (there is no electricity) , on the ground there is a pile of potatoes a metre deep. There’s a shelf with pineapples and another with water melons. Passion fruits are kept behind the counter, five for a thousand shillings (20 pence.) Ellen has a brass weighing scale for measuring which the girls delight in using.

 

Then there are the people. Doorways to the shops are always open, People coook and chat outside their stalls and the kids run between. Boda’s rush past. The hospital staff wander into the centre after work just to look around, the nursing students too.

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School’s out

 

A visit to the centre means meeting and greeting a dozen people and catching up on news. It means dodging tea lorries and avoiding the rubbish in the muddly runnels at the edge of he road. It means keeping clear of the tourist vehicles hurrying up to the safety of the lodges. It means stopping by the weaver birds tree to look at the nests and hear the crowds. It means looking at the highest posts to see the Maribu stork presiding over it all like a huge dirty folded-up parasol. Mums with babies on their backs, men with tin sheets balanced on their heads, someone reeling drunk across the path, old Batwa ladies with no shoes, kids in uniform, former patients.

On down, down down, past the mechanic, past Anna’s Gorilla tailors, past Winnie’s boutique and Isaac’s hair salon. Past the shop that sells blankets, and then the iron-mongers, the stationers that sells agricultural pesticides, past Aunty Peace’s house and Dennis’s hair place, past the nursing school, past the many bars and night-places .

And then you leave Buhoma behind you, on down the road to the villages Kanyashande, Kyeshero, and the towns of Butogota, Ntungamo, Kanyantorogo, Kihihi and beyond. This is our world.

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Everyday tragedy

 

Our A +E emergency room has three bays, separated by curtains. Today I was in one of the bays, tending to the needs of an unwell tourist. I could see that the baby’s cot in the next bay was occupied by a toddler, and by the body language of the nursing staff around, I could tell something serious was going on.

As I checked my patient’s ears and throat, I heard the unmistakable sound of cardiopulmonary resuscitation taking place at the baby’s cot. Two breaths, 30 chest compressions, two breaths, 30 chest compressions. Two breaths, 30 chest compressions.

I kept up the chit chat with my patient, made a diagnosis and sent her on her way.

The noise from the cot behind the curtain stopped. I peeped around. The baby’s grandmother was drawing the little white blanket over the baby’s face. It was dead. The grandmother picked up the swaddled dead baby, and cradled her close to her chest. She stayed only a few more minutes then went away, carrying her bundle of sorrow.

Apparently the baby had been vomiting, and so the grandmother who had been left in charge, gave her a tablet that she had in the house. The baby must have choked on the tablet, because almost immediately it had stopped breathing. The family had come on a motorcycle a distance of one hour by road with the not-breathing baby to seek help. It was too late to save her.

I stop for a moment, catch my breath, then carry on with my day. How can I even begin to think about something so terribly sad?

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