Author: drmargaretsdiary

( I wrote this on Christmas Day, but haven’t been able to upload till now.)

So we made it to Christmas day. The last few days, maybe a week, have been tiring. I realise just how exhausted I have been, with the energy spent settling us in, learning all that is new, and working six days a week, negotiating boundaries when there is so much need, all around us. I felt a bit homesick and melancholy for a few days and it was a difficult feeling to shake off.

But today has been wonderful. Such a happy Christmas, and a perfect mixture of holding on to family tradition, and finding new ways just fitting for today. So without any deep analysis or reflection, here is an account of our lovely day.

It turns out that Father Christmas can still reach an area that is ‘hard to reach’’ – the girls were optimistic he would manage, and relieved to find that he had made the journey by night. He delivered some lovely bags, filled with goodies and unusual treats (including a Mars bar.) It turns out that his policy these days is to locally source presents for stockings as part of his commitment to a greener environment.

We spent a lovely slow few hours giving and receiving gifts. We closed our front door (something that is almost never done here) so we had some family time and we listened to the choir of Clare College sing haunting songs. The girls got dresses, made by local tailors and books found in the fantastic bookshop in Kampala (A critique of international trade arrangements for Brian and a book about Reptiles and Amphibians for Miss A.)

 

Then our neighbours told us that it was time for the children’s party at the river. Children of hospital staff were invited. It was hot, so we carried chipatis, sodas, roasted potatoes, popcorn, floor mats and an inflatable dinghy along the river to the swimming place and set up a picnic, as our little neighbour cried excitedly ‘’ We are at the beach, we are at the beach.’’ Even Miss A, usually a bit hesitant about cold water, flung herself in with much happiness, and little Roo – well, she was in splashing heaven.

 

 

We left the party just before the heavens opened, so we scampered back along the river bank, through the tea plantation and across the wooden bridge as the rain pelted on us and made us laugh.

 

Dry and rested, we made our way to supper with our American friends, who had invited all those far from home for a Christmas evening meal. There was abundant food, and wonderful company, and even, Christmas crackers. These had been carefully made by the children with old toilet rolls wrapped in beautiful paper and ribbons, and filled with trinkets and jokes about snow and snowmen.

A lovely end to a very happy day. I hope yours was too.

 

Last Sunday we had an outing. A real treat.

Amongst the fellow comers-and-goers at the hospital’s guest house is Kingsley, an American-Canadian who, for the last four years, has been farming Coffee on the hills near Buhoma. He came upon the place by happen-stance, travelling to Uganda to see the Gorillas, then getting increasingly involved and increasingly invested in the local community. This took the form of engaging with local schools and finding out about the opportunities for enterprise using the best local cash crop, namely coffee.

Kingsley invited us to his coffee farm. We had an amazing day, exploring the production of coffee from coffee-cherry to cafetiere in one of the most stunning settings I have ever seen, with views over the rumples of the hills to the little valley where Buhoma lies to the hills of Congo just next beyond.

Coffee only grows at altitude (Arabica coffee at higher altitude), and our area here is perfect. It is high, well watered and the soil is fertile and the air is clear. Kingsley and his wife Maha bought the land, but the trees were free under a Ugandan Government programme promoting regulated expansion of coffee growing throughout the country. Coffee trees need to be mulched with grasses and with goat manure and urine to promote healthy growth and to avoid diseases. They are productive for 7 or 8 years. There are two crops in a year from august to November, and then February to May. The farm has an office and a store room, but no electricity except that generated by solar, and only the most basic structures needed to run a farm and a business. Kinglsey grows coffee himself and then collaborates with local coffee growers to improve the quality of their farming techniques and their crops, and to buy their coffee for a good price if the quality is right.

Coffee berries called ‘’coffee cherries’’ are picked by hand when they are red and plump. Their first process is to be soaked in water. The good quality ones sink, the lesser quality ones float and are scooped away, then the water is agitated and the process repeated. Then the cherries are squeezed by hand to release the beans which taste fruity and have a sticky juice around them when they are raw. The beans are then graded by a fabulous red sifting machine, passing through several meshes and sieving processes to separate out the best beans. From there the beans are washed in troughs over night, to ‘ferment’ and to remove the stickiness. Then they are dried on large wire racks in the open under tarpaulin for several days whilst the humidity is checked until it is perfect. The husks are removed and winnowed away leaving the green inner bean. These are ready for shipping as a high end product whilst the lower quality beans go through the same process but are sold on to dealers for lower quality products like instant coffee (!) For every 100 kg of beans, the yield is about 16 kg of top quality coffee beans.

 

 

We explored the slopes amongst the coffee bushes, picked ripe beans, washed them, popped them open, husked them, winnowed them. The process was very appealingly tactile. I was surprised by the number of steps in the production, and how each one of them is done by hand. Every single cherry, every single bean is passed through hands again and again and again on it’s journey to a percolator. Then…..hmmm…. , the final step. Kingsley lit a small charcoal brazier in the open air and we roasted the beans. Up wafted the smell of my childhood – the rich, warm, comforting smell of roasted coffee beans. Then we stepped into the office, stacked with this season’s crop, just ready for dispatch, switched on the solar powered generator and ground the coffee in a little electric grinder. At last. Richly aromatic coffee in a deep mug, sipped in the softening afternoon sun looking out towards the horizon and the rift valley in the distance. A deep pleasure that I will take a long time to forget!

Running a coffee business here has challenges, not least the remoteness of the setting. Vehicles are essential to the operation, but if they develop a fault, a good mechanic is 10 hours drive away in Kampala. The farm is the highest point in a high area – a target for lightening strikes in our area that has the highest lightening strike rate in the world. It hails sometimes and the coffee cherries stop growing, it is difficult to recruit the right staff in such a remote area where everyone has to be within an hour’s walk of the farm. There are scrupulous and unscrupulous intermediaries in the exporting chain. But it is a challenge, but the potential rewards are abundant at many levels, and the challenge of making the project work is obviously exciting. For those in the UK who want to try Kingsley’s coffee (Kingha Coffee) you will have to drop by for a cup at our house once we are back home!

There are a few ‘big’ things that I want to write about, like how the hospital has health insurance, and how that can work in a setting like this, and about youth friendly services.

But this week (the last few indeed) have been so busy as I find myself on the wards six days a week, in meetings, with a study proposal to write and then, at weddings!  So instead, here’s a brief glimpse of my week.

 

I would always like to tell you all about my patients, of course, but I can’t say too much out of respect for their confidentiality.

But there is one girl who stands out in my mind that I must tell you about. She is 14, and a few years ago, she was diagnosed with type 1 diabetes. This is the kind of diabetes that most often starts in childhood, where for some unknown reason the body attacks it’s own pancreas so that the pancreas stops working. The pancreas has several functions, but amongst these are making insulin. Insulin is essential to life. It is the hormone that allows the body to take the the sugars from our diet, and parcel them off into the body tissues that need them to give us energy. Without insulin, the body’s tissues are starving, the person loses weight and starts to break down their muscles and tissues to make energy instead. And the bloodstream is swilling with sugar which has all sorts of terrible effects. Untreated, type 1 diabetes kills. The treatment is with insulin, but insulin is a dangerous drug. Take too much, and your blood sugar levels fall too low and you might fall into a coma. Take too little and your body enters that starvation state again and you become extremely ill. If you spend more energy (because you go and play football for example) you need less insulin, more if you have a bigger meal. It’s tricky stuff. In the UK, when children are diagnosed with insulin, there is heavy investment in support for the child and their family in learning how to monitor their blood sugar levels and adjust their insulin doses and food intake accordingly. One of the key tools is a glucometer – a little monitor which can use a drop of blood to measure and give a reading of a blood sugar level. Here, we don’t have the possibility of such intense support.

 

So, back to our girl. She came in the hospital in diabetic ketoacidosis – her blood sugar levels had got dangerously high, possibly because of stress or an infection, and she came in drowsy and her body in an acid state. We have a marvellous paediatrician here Dr Isaac, originally from South Sudan (that’s another story) and he stabilised her, but because of her age, she came to our adult ward. Over the days, she was weaned off her insulin infusion and her drip and we started to get her ready to go home. But how could she go home safely with insulin? Thank goodness for a donation of glucometers from a charity. We gave her one, and showed her how to use it, and a book to record her sugar levels. Isaac and our chronic disease nurse spent a long time talking to her and her mother about her insulin, and we agreed she would come back to the ward after a week with her book to see how she was getting on. Her family were worried about the cost of transport back to the hospital for the clinic. We said the hospital would pay.

 

She didn’t come back.

Three days after the scheduled clinic date, she did return, but quite unwell. Not as bad as the first time, but needing admission. Her blood sugars were very high. We asked what food she had been eating. Only Matoke and ‘’irish’’ (potatoes) – veg, beans and meat (proteins) were not on the menu. These are foods that are very high is fast sugars and alone, are not enough to sustain a growing body. We asked to see the record book of her blood sugar measurements that came with her glucometer. It was empty. Why? It turns out that, at 14, this young lady still doesn’t reliably know her numbers to 20, and certainly not well enough to read them from the meter, and make sense of them.

Education is crucial to being able to enjoy good health.

 

Where on earth as health workers do we start?

 

We’ve had a few ideas. Such as giving patients like this very simple mobile phones and credit so we can call them to follow up, and having a young diabetics group that can meet at intervals for mutual support and education. And making pictogram advice sheets. There is lots of work to do!

Here’s a glimpse of today.

An adolescent came into the ward yesterday. She had some swollen lumps. She’d been a bit off colour for a few months. We expected something easily treatable. We did a blood test. The result showed us that it was not something trivial at all. The test strongly suggested an advanced malignancy. I tried to explain to the patient as best as I could that it would help if we did some further tests. The patient said she didn’t have money for tests. She isn’t in the hospital insurance scheme (‘’E-quality’’ – more about this later) . With insurance, the test would cost just a few pence. Without insurance, the test would cost barely a pound. We didn’t do the tests.

I spoke about her with the other doctors and we all felt that her only chance of recovery (this is a treatable cancer) would be to go to the Uganda Cancer Centre in Kampala. There, the treatment would be free, and chemotherapy is reliably available. But she would have to get there. An ambulance would be best, but Kampala is far, and the ambulance is expensive. Perhaps she could go on the bus?

I had another conversation with her relative. They felt they couldn’t make it. The bus fare was unaffordable. At 40 000 shillings (about £9) it is the cost of the difference between hope of survival and certain death.

The hospital has a ‘’Good Samaritan Fund’’ for people in extreme need. It receives contributions from church collections and the profit from hospital’s little cafe. Reverand Caleb, the hospital Chaplain administers the fund and has the challenge of identifying the most extremely vulnerable from amongst the generally very vulnerable population. We asked him to speak to the family. The young lady is the only remaining grandchild. The father and mother had died. Grandmother and granddaughter try and cultivate a small patch of land to scrape a living. Grandmother told Caleb that she didn’t think she could even raise the money by selling the land.

Thankfully, the fund is paying for the bus to Kampala for the girl and her grandmother, with a little left over for expenses in the city. At the inconceivable sum of about £20, there’s a glimmer of hope for her.

Shall I nip to the shop and buy that bar of chocolate after work? Maybe not tonight. My head is still full of how much and how little things cost, and how much and how little has a value.

(PS: Here’s a Christmassy after-thought. Anyone who doesn’t have an idea of what to give to someone for a Christmas present, or knows someone who has everything already, maybe consider a donation to the Good Samaritan fund – it might make a big difference to someone?)

I feel like I need to write a caveat. My recent posts have been about the many pleasures of living here. I just want to say that I do do some work some of the time, really! It is just more difficult to write about work than to write about the lovely things we find to do outside of work. Of course I need to respect patient confidentiality, and the hospital’s institutional integrity before I write about it, so it is slower to write, and to be able to post.

That said there’s been no work this week, and we have found plenty of time to do lovely things as a family. My trip to Kampala went so smoothly, that I still had a few off days with the family left over. On the spur of the moment, we decided to drive to Ishasha National Park to take a look at the wildlife. Ishasha is on the border with Congo. The Ishasha river represents the frontier. It is only a couple of hours from here, though it has a completely different ecosystem. Whereas we live in the mountainous forest, Ishasha is savannah land.

Close your eyes and picture …. grasslands, Acacia trees, herds of antelope, large horizons, blue skies, fluffy clouds… that’s Ishasha.

Travelling there as a family isn’t quite so romantic as it sounds. There are some quite spectacular potholes and gulleys on the way which means that the driving requires attention. It’s hot, and the bananas are squashed because someone sat on them. The girls in the back of the car say ‘’ are we nearly there yet?’’

But my goodness, it was lovely. We arrived at the park gate in the late afternoon, as the sunlight was getting more golden, and the shadows were getting longer. As a ‘Foreign Non Resident’ I am entitled to a reduced park entry fee, and I think the park staff were glad to see a family arrive with young children, in a Ugandan registered vehicle. Most visitors are from overseas, coming as part of tours. The lady at the desk told us where to find our accommodation. She said that we should first turn right about 500 yards down the road, then drive on a few kilometres. Other visitors had reported lions in that area. Not a chance to be missed.

And there were indeed lions. Six of them, sprawling languidly in a large old fig tree, draped over the branches like domestic pussy cats on the back of an armchair. From time to time, one or other would open their eyes, stare intently at us, then yawn and go back to the serious work of resting. There were four cubs in the family. They would stretch and turn and change branch, swish their tails, then settle back down paws dangling. They were muscular, and their paws were obviously powerful weapons.  We parked our car under the tree and watched them do very little for a very long time. It is quite something to see such magnificent creatures in the wild.

There are about 40 lions in Ishasha. It is one of only two places in Africa where lions routinely climb trees. The other is in Tanzania. No one knows why they do it here (although in fact all lions can climb) . There are lots of hypotheses  – to get away from the flies, to be at height to be able to scan the horizon for prey (our lions were certainly not scanning!) and many other notions. The lions can live for 15 years in the wild. Apparently our family were two adults and four cubs. The cubs were less than a year old, so not able to hunt for themselves yet.

We left the lions so they could meditate on the expansive view and went to find our accommodation.

We stayed in the simplest and cheapest accommodation we could find. The Uganda Wildlife Authority owns two small huts called bandas which we could rent for the night for 40 000 shillings (about £8.) For that sum, we had beds, bedding, bednets and lovely big solar torches for when the sun set. Scola from the UWA who met us explained that we should only move around by car as the hippos (notorious for their bad temper) come and graze around the huts. We went down to the main camp for supper. The camp is made of a number of mud and thatched bandas, one of which serves as the canteen. We had beans and rice and chippatis as the sun set and the fireflies came out and flashed spots of light into the darkness.

There were maybe 40 bandas in the camp, and the armed men in military fatigues sat under a thatched roof watching TV by satellite. It was explained to us that it this was largely a military camp because of the proximity to Congo. Congo from this side of the border sounds like a completely lawless and frightening place.

Two armed guards were allocated to guard our hut for the night. They accompanied us from our hut to the long drop loo a hundred yards away, and kept a respectful distance. All night long, they lurked a bit eeirly in the shadows. The girls were happy that there were people to protect us from the hippos. I was glad too though I wasn’t so worried about hippos.

We were up to see the sunrise. Everything felt very still and suspended for a pause between night and day. Then went for a drive in the very early morning.Our guide, Scola was knowledgeable and observant. We had a wonderful bumpy drive through the grasslands. The variety of birds, grasses, butterflies was breathtaking. I suppose that is what wilderness is. Where nature is left to itself, there can be abundance not possible where humans get in the way. We saw the very elegant Ugandan Cob – a muscular antelope with beautifully curved horns that make it look like a well built dancer. We saw elephants in the distance (quite easily mistaken for huge boulders) a rowdy family of baboons and a stuttery, stop-starty gaggle of mongooses (mongeese?) As we were heading for the park gate, Scola got news that there was a leopard to be seen. This is an ultra-treat as leopards are scarce and very elusive. But there it was, up a tree, resting. Some kind tourists also enthralled lent us their techy binoculars so we could really see the spotted beauty.

Possibly my favourite wildlife experience of the whole weekend was when Brian pulled the car up suddenly to avoid hitting a teeny chick which had toppled over in the ruts of the track and which was wiggling its outsize orange legs in the air and cheeping frantically as it couldn’t right itself. Brian picked it up and it sat in our hands for a few minutes until we released it to scurry away into the long grasses.

We drove home, stopping in Kihihi for a touch of car maintainance. A most memorable 24 hours.

I am sitting in a lovely room in our friend Kinglsey’s house in Kampala contemplating my day, and still reeling a little. I am covered in dust, my lungs are smarting from six months-worth of petrol fumes inhaled in the course of one hour. I have my passport open beside me and I keep looking at the beautiful embossed red sticker that is the visa, confirming that I have a right to live and work here for a year. I feel absolutely triumphant!

I applied for my visa online from the UK. Uganda has a new and pretty efficient online visa processing portal. But I still had to go to Kampala for in person to present my documents and for ‘biometric capture,’ and until it was stamped in my passport, I wasn’t counting on visa success. I have five ‘off-days’ every month in order to make up for working a six day week, so we decided that it would be good if I made use of them to go to the capital to do the deed. Brian and the girls need dependents’ visas which can’t be applied for until mine is granted, so we chose for them to stay behind in Buhoma to avoid the long journey and the fuss.

It is no mean feat coming to Kampala. It’s 10 hours of road, the first three of which are lurching, bumpy and un-tarred, and the last two of which are an assault on the senses. On sight – the bustle of bodies and boda-bodas, on smell – the stench of rotting meat and swampy effluent at the market under the flyover, on hearing as the horns hoot and the sirens blare, and on touch and taste as the dust pours in at the window.

I had a super-easy ride. Kingsley had to go to Kampala to service his vehicle as failing to sort it in time, and towing a broken truck from Buhoma to Kampala, is enough to break the bank too. He offered me a lift and a place to stay in central Kampala, and fantastic company for the whole journey. The last few miles of the long journey are crazy. It is worth noting that in Uganda you don’t need to have passed a driving test to drive a car. It is possible, I understand, to get a fake licence for a few thousand shillings. The only rule of the road that seems to apply is that generally cars drive on the left. I say generally because we did meet one going the wrong way down a dual carriageway (a new dual carriageway, to give the driver his due.) The other rule is perhaps that size matters. Big trucks squeeze out littler vehicles and the boda-bodas (motor cycle taxis) weave in and out and get squeezed most of all. The most reckless of drivers seem to be those of the long-distance buses that carry people from up-coutnry areas such as ours into the cities. Like so many things here, in the domain of travel, there is high risk to life associated with having few resources. If you have to go by bus, you have to take your life in your hands. It’s as if the drivers are in some sort of competition with each other to get to town the fastest. And if that means overtaking the four vehicles in front on an uphill blind bend, well so be it, and everything else on the road should just get out of the way and make space.

Bodas are another source of traffic chaos and high risk. They are cheap, and in the gridlock that clogs Kampala’s road network, they can weave in and out and get places fast. A few market themselves as ‘’Safer Boda’s’’ – that generally means wearing a helmet. We saw families of four astride a single motorbike, helmetless and squeezed between cars and lorries as they negotiated the potholes and cattle other hazards that add an extra frisson to the journey. And just to complete the mixture there are matatus; – small minibuses which bring people from the suburbs to the city, with one guy (or sometimes a girl) leaning out of the window shouting the destination and opening the doors whilst another hurtles the vehicle at full speed into the traffic or veers off onto the edge of the road to drop passengers, usually with no working indicators and sometimes without brake lights.

 

I know I have a thing about road safety but this takes the biscuit.

We made it to Kingsley and Maha’s haven of serenity, and I had a quiet evening of good food, good company and good play with their two year old son, and even…. a swim!

And then it was visa morning. So, to avoid the challenge of the road network and for a bit of exercise, I decided to walk to the Directorate of Citizenship, Department of Internal Affairs. It was a good enough walk. Crossing the roads was hair-raising. At one place I made the mistake of supposing that a pedestrian green/ red crossing signal might help me to find a time to get across the road. I was mistaken. It seems that green means that bodas can still hurtle out of nowhere and mow you down. I decided that my best strategy was to lurk near a traffic police officer at the junctions, so at least if I did get hit, there might be someone there who could help.

I made it to the Immigration office by 9 and was signalled towards the correct department. There was a wait whilst the immigration officers were in a meeting, and at half past nine I joined the crush to get to the appropriate window. I wasn’t quite sure where, so I showed my paperwork to an official looking lady who told me that in fact the paper was wrong. It said I had nothing to pay, but in fact I should pay $250 dollars, and I should first go to DTB bank to make a payment, get a receipt and then return. I wasn’t surprised. I couldn’t understand why I hadn’t been charged by the electronic system, so it seemed a reasonable request. This required Uber number 1 (I have never done Uber.) Uber driver number 1 was ingenious and took me to a branch of the bank in an industrial area where there was going to be less of a wait than in the central branch. He explained that the ‘whole problem’ with Uganda was that everything was corrupt. Starting with the top. His fare was 4500 shillings. Ironically, he also told me when he dropped me off that the technology meant he couldn’t accept a payment of less than 5000. That, I learned later, is incorrect.

As I entered the shiny, air conditioned quiet bank and was ushered to a seat, I felt my confidence start to ebb away. I might just be entering a vortex of bureaucracy which would be difficult to climb out of.  But my despondency was misplaced. A helpful lady wrote an ‘assessment’ which explained what I needed to pay for and she sent me to the bank teller. For some reason, she converted the dollar amount into Ugandan Shillings. And I had carefully come prepared with exactly the right amount of dollars to pay, and far fewer Ugandan shillings. I anticipated another ‘’challenge’’ (the euphemism for ‘difficulty’ which is common round here.) But I didn’t need to worry. I paid a mixed bunch of notes, and got a stamped receipt and was ready to go to do immigration again. Thank you, Uber driver number 2.

Happily this time I met with Daniel and Rachel from the hospital guest house who are also in town for visa issues so I had company and reassurance that I was in the right huddle by the right doorway. So first I had to go and have the payment I had made verified. A few minutes standing in an office, some polite smiling and a big hefty stamp, then to the next door. At that door, the lady asked me for all my documents. She looked at my bundle and asked where the ‘’Recommendation Letter from an NGO Bureau’’ was. I don’t have a recommendation letter from an NGO bureau as I work in a hospital, not an NGO. This caused my second dip in confidence. But she took my documents and passport and suggested I wait till my name was called. At midday I took my place on the tin benches under the tin roof to baste gently in the 36 degree heat. It was so interesting to watch. People clutching passports from so many places, Eritrea, Sudan, Nigeria. Indian nuns and Asian businessmen, Chinese entrepreneurs. From time to time a tall confident man would emerge from the office with a sheaf of papers and passports and call out the names of those to go forward. This was exciting. This was going to be the stage of actually being granted a visa.

By 1 o’clock I had been called forward, had my fingerprints taken, my photo taken, my signature electronically scanned and I had my passport back in my hand and in it, a lovely red-orange visa entitling me to stay here for a year. What a wonderful feeling.

It was a long process but there was a system, and the system was friendly and orderly enough. There was no pushing and shoving, there were no raised voices, and lots of politeness and smiles. It felt quite moving to encounter the functioning of the state at close quarters like this. I thought about what a privilege it is to be granted leave by another country to be allowed to remain in it and work in it. I thought about how the immigration system in the UK is actively hostile towards outsiders, both explicitly in its policy, and implicitly in its practice, especially when people arrive whose skin is a different colour or whose name sounds strange. And here I was, receiving permission to consider this country home for the coming months without suspicion of my motives or confrontation or downright dismissal of my case and my information. What a fortunate position to be in.

I celebrated by going to Accacia Mall (thanks to Uber driver number 3 who supplements his Uber income by playing bass guitar in a jazz band.) Accacia Mall the place where the Mzungus and the richest Ugandans go to shop and to eat ice-cream and hang out. I bought myself a cheese sandwich and a coke (oh the delight after so many weeks without) and then felt a mixture of awkwardness and familiarity as I browsed in the bookshop and gawped at the groceries and the luxuries in glorious technicolour, well beyond the possible imaginings of those back in Buhoma.

Uber driver number 4 took me back to Kinglsey’s. We sat in the rush hour (slow hour) traffic whilst the boda-bodas bobbed in and out, drove on the pavements and the matatus stopped in front of us without warning. ‘‘Kampala… it is somehow hectic….’’ he commented.

And I will have to do it all over again in a couple of months with the rest of the family…Ah well. It’s an adventure.

 

 

 

 

Sunday. How did it come around so quickly? I’ve now completed a very busy two weeks on the ward as the Medical Officer – time enough to start to get to know the nurses, to start to find out how things get done, to start to understand the pressures, and the pleasures, time to get to know patients.

Our family Sunday ‘’weekend-in-a-day’’ is much anticipated, and today has been such a full day.

This morning we had to fix the handbrake on the car. Apparently the best mechanics are in Kampala, but that is 12 driving hours away; – quite a treck to get to the garage. But our colleagues kindly told us that the mechanic who fixes the hospital cars was coming today, and that we could probably ask him to look at our car too so Brian volunteered for car duty, and the girls and I went on a walk.

We decided that we wanted to climb a hill. There are steep hills all around us, and tracks all over the place, but we had advice that if we went to the next village, Mukono, we could take a track past the church on the left, and find our way up onto the hill.

If you are a mzungu round here (a white person), it isn’t really possible to go walking un-noticed. Today as we set off up past the church, we were accompanied by three delightful 12 year old girls, all of whom are in P6, the last year of primary school, in the village school. One girl in particular, had really good English. They giggled at the idea that we might be going walking just to explore and for pleasure. They decided to show us the way. And a good thing they did, as there were hundreds of paths, dividing left and right in between banana plants, small homesteads, coffee and tea bushes, streams. It was steep and, last night, the torrential rains had turned the paths into rutted slippery mud-runnels. The girls leapt confidently along, holding Miss A’s hand, sometimes carrying little Roo higher and higher onto the hill.

At one point we spotted a small pig-sty in amongst the bananas. As we watched, a smiling young man called Nelson came and joined us. He invited us to go and have a look at the piglets. ‘’They are my school-fees’’ he told us.

He’s still at school. He says he wants to be a Reverand when he leaves. They are his Dad’s pigs. The sow had six piglets a month ago. They are robust, noisy, hungry snufflers, who nuzzle their long-suffering-looking mother in search of more fattening milk.  Nelson’s father will sell them soon. Each piglet should fetch around 70 000 Shillings (about £15) and a term’s school fees will be about 37 000 Shillings (about £8.) Growing school fees seems like a good plan if you have the start up funds. To put this into context, the average monthly household income round here is around £20. Nelson’s dad also has a small holding of coffee bushes – he was busy drying the beans after yesterdays downpour, but Nelson took us to see the sackful of beans that they had been able to put aside. When the beans are dry, they will be taken to a town not too far away where they can be treated and sold. This looked like a reasonably resourced smallholding, compared to many round here. Quite a number of people are landless.

Our little girl guides took us higher, and stopped at various plants to show us the different crops around. Matoke (green bananas) – a staple round here, bean pods, yams, mango trees (no fruit till January though), papaya, passion fruit trees. The land is so verdant here.

We reached the border of the forest at the top of the village, but decided not to go into the forest as it was getting pretty hot, and pretty slippery. Little A bounded back down the tracks with the girls, disappearing out of sight, whilst little Roo and I slithered very un-gracefully a long way behind. Back in the village, the drumming was calling parishioners to church, people were walking up the hill in their Sunday best, or riding pinion on Boda-Bodas (motorbike taxis) to get there in time. In the heart of the village, many people were carrying plastic bags full of what looked like green chillis. Why, I wondered? Someone had a whole sack and was filling the plastic bags, so we went to have a look. The ‘chillis’ were jumping. They weren’t chillis, but grasshoppers.

Grasshopper season is here. Much to everyone’s delight. They are a fantastic snack. Eaten fried, then prepared like seafood (I presume), so that the protein rich body is eaten with relish. We’ve smelt them cooking. Something like bacon. Brian is keen to try, the girls are not sure, and I am stating my vegetarianism, and am very keen to avoid!

We left the girls picking up grasshoppers and meandered home. My thought for the morning was this… Those girls we met were sharp, inquisitive, and were able to think ahead what things might be of interest to us new-comers in their village. What does the future hold for them? Based on the local patterns, there is a good chance they will be pregnant by 15 or 16, not in school, perhaps farming some land in adulthood, quite possibly being left behind by a partner, with a high risk of being victims of domestic violence, or of being left with sexually transmitted diseases or HIV. Why is it that a bright sparky 12 year old girl in our home village will have such a different future ahead of her? How on earth can this difference ever be acceptable? What do the changes need to look like that could bring about a different outcome for the twelve year old girls in Mukono village?

Watch this fantastic animation (it only lasts for 3 minutes) for some thoughts about things that might change the proximate causes. No-one has yet animated the political and structural issues that need to change also….

I wanted to tell you about our early morning today, because to me, it says something about how accepting a group can be here. I don’t want to idealise. In wider society here, mental illness is poorly understood. But the hospital is different.

Today was about tolerance.

Normally we have morning prayers outside in the Outpatients waiting area. Today it was in the staff dining room, because it was going to be followed by a staff meeting. We sat down to sing and for prayers, and were joined by a number of patients, as is usual. One lady has bipolar illness, and in her mania, is hyper-religious. After the singing, she burst into a stream of prayers, people closed their eyes and listened respectfully. It was clear her out-pouring wasn’t going to come to a natural end any time soon. After many minutes, our colleague, who happens to be the Mental Health clinician for the hospital, gently started to sing a prayer, allowing everyone to join in, and enabling the lady to stop. Meanwhile, another psychotic patient belched, took his shirt off and and climbed onto the table. Again, our colleague didn’t blink. Instead he made sure that the bible passage he was reading was translated into Rugika for the patients to be able to understand, and then he drew the session to a close, saying ‘’ and I am now just going to help our friend (the patient) back to the ward before we start our meeting.’’ The patient followed without argument.

The action was skilful and compassionate.

I was left wondering how we in the UK respond when we find madness in our midst, and whether we do it as well as this.

Today has been a heavy day. On of my patients died. This isn’t the first time since I have been here – many people come to hospital only once their condition is so critical that there is little that can be done to save them – but this person was young, only 20. And although she was very very sick, her death wasn’t expected (by me, at any rate.) We (my Ugandan doctor colleagues, and the nursing staff) spent several hours trying to resuscitate her, but our efforts made no difference, and in the afternoon, she took her final quiet breath.

 

What struck me was how public death is here. In our open ward without curtains, all the other patients and their caretakers could see our young lady in extremis. As we were trying to help her, the ward was quiet whilst people watched. The patient had her relative with her to care for her personal needs. The relative’s suffering and sadness was also public, she cried quietly and with dignity in full view of the ward.

 

The moments around her death were really moving and challenging for me. Her relatives came and prayed around her bed. Others on the ward joined in, the staff came and went, and carried out their duties whilst the mourning was ongoing. And then the carer packed up the small bag of belongings that had accompanied them both for the week they had spent on the ward. A thermos, a blanket. Not much else. The body was taken to the mortuary. A jumble of the deepest feelings and the mundane, and also an awareness of how little material stuff accompanies most people’s lives in this region.

 

Life and its ending are so very much part of present experience here. Many adults know the feeling of loosing a child. Or more than one child. Explanations aren’t demanded as they might be in the UK. There seems to be an acceptance of the fact of death and a way that it is integrated into the experience of being alive that I am not used to. In the UK, so much of death and dying is hidden. When we know people are dying, we often withdraw. It is not a public phenomenon, and I feel somehow cut off from it for much of the time. Here, at least on the hospital wards, being alive feels a very delicate thing.

 

The spiritual dimension of life-and-death is ever present. Morning prayers at the hospital. The prayers said at the bedside. The ministry of others once someone has died. They set into relief the fragility of life. It seems obvious that we will call the chaplain to the ward when we have a dying patient, just as obvious as giving intravenous fluids.

 

Sunday is my only day off in the week. To compensate, I am entitled to 5 days off in a row every month or so. So for now at least, I am working a six day a week. And the week has been full of new things to learn and has felt quite long.

 

I was delighted when Sunday came. I still woke at 7:15 when the lady came with the milk (pretty much straight from the cow, maybe watered down a little.) It is still quite dark here at 7 in the morning as the hills are high and the sun has to be high to break over the tops. For one day in the week we can wander around in our pyjamas, at least until showers are done. Showers are a palaver. We have a bucket which we fill using water heated in our kettle, and power with a little camping shower. It’s a bit chilly as we are in the rainy season and the floor of the bathroom (and the rest of the house as well) is concrete. It is fair to say that it is the low-light of the girl’s week.

 

We decided to go to the National Park at the edge of the village to do a short walk in the forest. The rules here are that you can only do a short walk unaccompanied. Because we are very near the border with Congo and because of the gorillas, any walks deeper in the forest have to be with an armed guard. Unfortunately, the park ranger told us that the short walk was ‘’not possible’’ today. Perhaps we would like to spend 70 dollars and take a guide instead? We politely declined and went home, a bit gloomy. Only to find our verandah and the surrounding trees full of red tail monkeys. What glorious creatures! They played on the car, lounging on the warm roof, looking at themselves in the wing mirrors, sliding down the front windscreen. Then when they had had enough, they swung from the electricity cables and into the trees. And then they spotted our open doorway and open windows and the ripe fruit inside…. The different animals really had different temperaments, some willing to come right up to our doorstep to take a fruit, others more wary. The red tails have white heart shaped noses and rusty red tails which they hold in beautiful question marks when they are on all fours. It is quite something to look straight into the eyes of another primate at such close quarters, and to almost see that it is thinking and planning.

 

 

After playing with monkeys, and then playing outside with the children around us, we decided to walk along the river just next to our house. The river comes out of the impenetrable forest about a mile away, and tumbles down in pools and small waterfalls. It is incredibly beautiful. The vegetation is so lush. Things grow and grow, tumbled one upon another, and on the vegetation are bugs and butterflies of such variety. Butterflies that are white with black underwings, others with markings like swirls of ice-cream, dragon flies, assassin bugs. We were caught out by the rain and took shelter under a tree with only a small umbrella to protect us from the deluge. The girls sang the Ugandan national anthem to keep their spirits up whilst people herded goats past us and looked with amusement at the huddle of damp English people who couldn’t cope with the rain. We had a fantastic walk, and on the way back, a group of Batwa ladies and assorted children joined us.

 

The Batwa are the traditional forest dwellers of the central African region whose lifestyle was one of hunting and gathering in the resource-rich forest. They were evicted from the forest when the forest was gazetted as a national park in the early 1990s. There are about 6000 in the region as a whole. They are of small stature. They suffer lots of discrimination and the hardships that accompanying displaced indigenous populations all over the world (alcoholism, lack of employment opportunities, generally poor educational attainment, lack of secure land tenure, even poorer health outcomes than their surrounding neighbours.) In fact, our hospital was started as a health clinic to meet the needs of the Batwa. Sadly now, the most lucrative income for the Batwa is to dance for the tourists. It feels sad and unjust and ironic that their income is at the beck and call of visitors who come to see the ‘’pristine wilderness’’ which was actually their home, their larder and their spiritual base.
I was walking with a feisty woman called Truth. Her English was pretty good – I presume from all her contact with tourists. She told me she has five children, but ‘’ I don’t want family planning, I  just want some more.’’ She wants seven children. She had her first when she was 15 and she was still at school. She completed primary only. She told me, ‘’ but now I am married.’’ Her husband is good to her, she says. She is 28.