Author: drmargaretsdiary

In a few days, our support system will change. Since we arrived, Zish has been here to look out for us. Zish is a GP from the UK, who spent a year here until September this year with his wife and his two young children. He has shown me ropes in the hospital, given limitless practical advice about essentials such as accessing the internet, and money. He has provided us with a car, and a house ready stocked with the puzzles, children’s books and lego left behind by his own children when they were here. We have been supremely fortunate. For me, the clinical calibration has been the most helpful. When is someone sick enough to need a lumbar puncture? What is the dose for ceftriaxone? What tests can we do in the lab? What is realistic to expect on the wards – can we expect observations on sick patients to be done every four hours?

We’ve also had Marian and Ceri as well. Marian is the RCGP’s lead on adolescent health. She has been coming to the hospital twice a year for the last couple of years to support the hospital’s project called USHAPE. USHAPE is a family planning training progamme based here in Bwindi, funded by the Margaret Pyke trust. USHAPE encourages a ‘whole institution approach’ to family planning. The idea that family planning is integrated into all parts of the hospital provision (so for example, ladies can’t be discharged from hospital without a check that their contraceptive needs are being met.) In this area, women have an average of 6 children, and on average, don’t want more than four. There is a very young average age of first pregnancy, and getting pregnant whilst still of school age puts both the new mum and the baby at significant future financial and social disadvantage. Hence the need for family planning. Anyway, Marian’s particular focus has been the development of Youth Friendly services in the hospital, something I hope to become involved in . But more of that later. Marian has been more than kind. She has listened, provided support, thoughtful reflection and child care (!) during our brief time together.

Ceri was the doctor from the UK doing my current role a few years ago. She stayed for two years and remains actively involved in the work of the hospital, through a UK charity she and other previous volunteers have set up called REACH Bwindi https://reachbwindi.com/blog/ She has also been here to support USHAPE. She has deeply established relationships with many of the staff and a strong and realistic understanding of how the hospital works. And she has been happy and generous in sharing those with me and a huge support also. And after all, it is all her fault that I am here. It was by finding her blog on the internet that I first knew about the  hospital.

Marian and Ceri will be leaving this week also. I’ve had gloomy moments, feeling overwhelmed about how I will cope with the clinical demands mostly, when it all still feels so new. But I have to learn to stand on my own two feet and I have really warmhearted and generous Ugandan colleagues to turn to for advice, and Brian and the girls at home…. Let’s see how this week goes!

We have been in Bwindi for a week. What a full week (in fact, by the time of posting, I have been here a bit longer , but haven’t wanted to post without the hospital’s agreement.) Anyway…..

I am now getting to understand the pattern of the working day, so I thought I might describe what happens.

The day starts with morning prayers at 8 am. The staff all gather in the Out Patient waiting area, which is a covered outdoor area, and there is drumming and singing and preaching. Miss A and little Roo have been coming with me, and enjoy swaying to the music and clapping and trying to follow the words in the hymn book, in the local language, Rugika (pronounced ‘Ruchiga’) Morning prayers is followed by announcements to the whole team. This could be about visitors to the hospital, or meetings, or achievements of some of the staff. So far, it has been warm and sunny sitting outside with the sun on our faces and the swallows swinging in and out of the surrounding buildings, building their nests. After morning prayers, there are regular departmental meetings. On Monday, there is a clinical meeting, on Tuesday, an operations meeting for each department, on Wednesday the meeting is about quality improvement projects. Thursday is for reviewing maternal and perinatal deaths to look at processes and lessons to learn. Friday is a departmental teaching meeting, and Saturday is a Grand Round (that means the doctors go and see all the challenging or interesting cases currently in the hospital.) After the morning meeting comes work on the ward or other meetings until ‘break tea’ at 10:30. More of the same after break tea, a lunchbreak at 1ish, and work resumes in the afternoon until 5. Part of my time is to be spent doing clinical work, and part doing quality improvement. That means working with the hospital to support efforts to improve the services offered to the patients. More about that later.

I am assigned to the Adult in patient ward for my clinical time. I have yet to fully understand all the systems. This week, the ward has been very busy indeed as the hospital is having a ‘’Fistula camp.’’ This means that a group of visiting surgeons have arrived and is operating on ladies who have particular surgical problems, doing many cases very intensively over the course of a week. The surgeons and anaesthetists come from Switzerland and Germany, and also from Mbarara, a university town in the South of Uganda. The surgeons are assisted by the Ugandan Medical Officers here. The camp has been running for a week in October for seven years. It runs as a very smooth machine!

Fistula surgery is very important as the problems are so unpleasant and disabling. It is very specialist surgery, not readily available here, or if it is, it is at a cost that most people could never think of affording. A fistula is a connection between one part of the body and another, and in the case of the ladies on the ward, it usually forms between the bladder and the vagina. As a result, the bladder empties out of the vagina and these poor ladies suffer with a continuous and uncontrollable leak of urine. This of course has profound emotional and psychological consequences in addition to the physical effects. There are many causes of fistulae. Sometimes people are born with them, but in this context, the most common cause is problems during labour, when the baby is stuck and can’t be delivered, and the pressure of the baby cuts off the blood supply to the tissues in the mother’s pelvis, causing them to stick together and form the connection between them.

Ladies have come from far and wide to have the procedure. News of the surgical visitors has spread by word of mouth. In particular, I understand that there have been the efforts of a particular man whose wife underwent the surgery a few years ago, and was so grateful for the intervention on his wife, that he wanted other people to be able to access it too so spread the word far and wide.

No pictures of fistula surgery, but here is one of the view from the balcony of the admin block where I was sitting with my computer this afternoon.

 

Marks out of 10

 

Today is Sunday. A week ago, we were leaving Abingdon in a taxi in the rain on our way to Heathrow. What a lot has happened in that week.

 

Whilst we had lunch today, I asked the girls for their marks out of 10 for the week. The overall was 7.

Here is their assessment.

 

Things that were 10 out of 10 were the bread at the guest house. It is soft and thick and lovely and not too sweet (unlike the shop bread we can get here.) Chicken (to eat) also gets 10 out of 10.

 

Meeting W and A also rates 10 out of 10. They are the children of the managers of the guest house which is attached to the hospital. They are 10 and 8 years old, and are home schooled in the morning, and play outside in the afternoons, climbing trees, making a tree house, fishing in the river, building a zip wire and a bike track. Miss A has joined them, and delights in the freedom and in running fast. Yesterday in the forest, they tried (unsuccessfully) to catch butterflies together with a length of old mosquito net as a butterfly net. Little Roo tries to keep up, and it tires her out!

 

Finding a chameleon was also a 10 out of 10. It was emerald green and just sitting on the track as I walked by, juddering backwards and forwards, and rolling its eyes around. We brought it home and it joined in card games and lego for the afternoon sitting on Miss A’s fingers, until we took pity on it and took it back to the wild. We placed it on a leaf, and it changed colour, one side brown with a yellow stripe, the other still green, but with a red stripe, as it camouflaged itself into the foliage and disappeared. According to miss, A, putting it back was a 1 out of 10.

Other low-lights of the week have been, having a bucket shower, rated about 3 out of 10 ( it would have been a 1 if the water was cold), and being sick after eating samosas on the first morning was probably 1 also.

 

 

I’d say my own week comes in at a steady 8+. The welcome and conviviality have been superb, and Zishan, the GP preceding me, has been the best mentor, friend, guide, one could ever hope for.

I wrote this last week, on my second day in the hospital…. I’ve delayed posting it because I wanted to check that the hospital communications team were happy with me writing things about the hospital.

………………………

I am now ‘at work’ to Brian’s disappointment, as he wishes I would spend more time with the family before disappearing into the hospital. But I feel that we are here at the hospital’s generosity, and that it is courteous and respectful to start making a commitment to the hospital as soon as I can, and I also want to get to know the community we are becoming part of.

 

The hospital has an extensive orientation programme. I have not seen anything like it in any place in which I have worked before. It includes a list of departments and a list of issues to be covered through a visit to each department, and the name of the key person to contact for the information. It may well take me weeks to get through it all, but the idea is an excellent one. It means that everyone working in the hospital has an insight into its running from how the finances are organised, to how waste is disposed of, to what to do if a person dies, to how the community clinics work. I have to complete the orientation before I can really start working as a doctor in the team.

 

This morning, I visited the HIV department. HIV is prevalent here, 8.1% of the population are infected / affected (2012 data.) There is still considerable stigma attached. The clinical officer told me about all the regimens for giving antiretroviral drugs to HIV positive patients. Whereas when I worked in South Africa, antiretroviral drugs were not yet available, they are now much more readily so. In Uganda, the policy is to start treatment as soon as someone tests positive.

 

Whereas in the UK, HIV has taken the status of any other chronic disease, with an almost normal life expectancy, here it is another story. Lots of patients only present when their disease is very advanced, and they are showing the signs we associate with AIDS, that is, when their immune system is very compromised and they are unable to fight off infections that take hold in odd and complicated sort of ways. Even for those whose diagnosis is made sooner, there remain issues around adherence to treatment, to how to prevent mother-to-child transmission, and the relationship between HIV prevalence and the power dynamics between genders in a context where having multiple partners is very common. I learnt about the policies for testing, for changing drugs, for treating TB in those who have HIV  (TB and HIV co-exist very often.) The hospital runs support groups for those with HIV – seven groups in the district. It also has a very creative approach to recognising the broad impact of the diagnosis on those newly diagnosed. All new patients with HIV are given a care package that includes a jerrican for collecting water, water purification powders (drinking dirty water carries risks for anyone, but much more serious if you can’t fight the infections), contraceptives, a bed net to prevent Malaria and many more resources.

 

After spending a morning in the hospital, I came back home to spend time with the family. Our hospital colleagues and people around us are so friendly and welcoming, this is feels a happy place to be. On the other hand, there are so many things that leave me feeling disorientated. Whilst I am recognised by everyone in the hospital, I am still confused about who does what, and which names go with whom. I am doing lots of waiting. Waiting for people to be free, waiting for meetings in the hospital, and as I do, I see doors open and close, people coming in and out, and I don’t understand why, and I feel a bit ‘outside.’ I am sure this is a passing phase, the sort of thing that comes with being new anywhere.

Before we came to Uganda, Miss A had been worried. Her first concern was how she might make friends with children who didn’t speak her language.

Here’s a photo from this afternon

 

 

Afterwards she said; ‘’ You know I said it would be difficult to be friends with children who don’t speak the same language as me. Well it isn’t. I had a really good time.’’

 

 

Afterwards she said; ‘’ You know I thought it would be difficult to be friend with children who don’t speak the same language as me. Well it isn’t. I had a really good time.’’

So, after spending the night in a guest house in Kigali, we set off at 9 for the drive to Bwindi – first several hours through Rwanda on well surfaced roads, then into Uganda and far from anywhere.

 

Kigali is a bizarre African city, with swish buildings, neat main roads, no begging and a strong police presence. Off the main roads, the tracks are rutted and made of red earth, and they are heaving with people and noise and motorbikes. It feels as if all that is human has been swept off the main roads. Within about 40 minutes, our car started to loose power on the hills and black smoke started to billow out of the exhaust. We pulled into a garage to try and sort it out. A huddle of mechanics and hangers-on stood about and debated what might be happening. The car had only been serviced the day before. It turns out that the oil, which should have been changed, had probably only just been topped up. Topped up to overflowing, and flooding the engine, such that it was no longer combusting as it should. After an hour of negotiation, draining off the oil, refilling, we were on the way again, out of the capital, past small tea plantations, hills of small-holdings, and evidence of terrible soil erosion at every river bed and hill-side.

 

We got to the border at lunchtime. There is quite a substantial no-man’s-land at the border with a trail of trucks looking desolate as they wait for their papers to be processed. We had to exit Rwanda (one stamp), and enter Uganda (another stamp.) And the car had to give up its temporary export to Rwanda (two offices, two stamps), and be signed into Uganda again (two offices, two stamps). Altogether an hour of paperwork and stamps, but all very sedate and peaceful and we were through.

We stopped in Kabale inside Uganda. It is the largest town in the district. We did some shopping for luxuries like cheese, got some chipatis and samosas for lunch, and stopped at the bank. Then the journey was really under way. We turned off the tarmac, and into the countryside. The road was narrow and made of stoney, beaten earth, with some fairly steep drops at the side. I can see why the car needed its shock-absorbers changed after only a few thousand miles. We were amongst hills scattered with small-holdings with banana and plantain trees, small crops of tea, and people with pigs and goats on the paths. Onwards for several hours up and up into the hills. Eventually, we could see where the cultivated area stopped and the national park began. Our route took us along the eastern edge of the Bwindi Impenetrable Forest.

Bwindi amazing fact number 1 ; this forest has the highest number of different tree species per unit area of anywhere in the planet.

 

It was beautiful, full of forest noise, of frogs, grasshoppers, monkeys calling, birds singing. The trees were gracious and spread over valleys and ravines giving beautiful vistas with canopies of trees in the foreground, and forest in the background. We saw black and white Colobus monkeys playing close by. The road had a few moments when I was glad it wasn’t me driving, where the rains had caused the mud to slip onto the path and the passable area between the hillside and the road edge was a little bit narrow. Apparently the Uganda Wildlife Authority maintains the road because they know this is a route taken by tourists. It does make me wonder what other roads are like. We emerged from the forest into cultivated land just towards the golden hour of the evening, when the light was glancing off the roofs of the small houses. It looked tranquil, and quite idyllic until you you noticed the state of people’s clothes, the fact that so many of the children were obviously stunted and had pot bellies because of poor nutrition.

The sun set quickly, and we made the final miles in the dark.
We arrived in our village, Buhoma (the village where Bwindi Hospital lies), where there were brightly lit small kiosks down the main street. We drove past the hospital and to our accommodation in the staff quarters next door.

From somewhere, we still found the energy to greet our neighbours and new colleagues and to take sight of our small but perfectly adequate new house, then to eat and stumble into bed.

A day of rest and sorting the house tomorrow, then work starts.

I am at 11260 meters up in the sky, travelling at a speed that would be 535 mph on the ground, looking out of the window at Heraklion in Crete (- I know because there is a google map – ) flying is exhilarating. I love seeing the environment spread out beneath me like a real-time geography lesson, there’s snow on the Alps, the Rhone really does flow out from the mountains to the sea, and the Croatian coast is, well, really dramatic. I find it amazing that humans have engineered a massive hulk of metal, and filled it with people, and baggage, and dressed it with fancy gadgets to make it comfortable, and that this can lift off the ground and carry us through the sky. If someone had told this to my grandmother when she was a child, she would have thought this was a crazy dream. Human beings are so ingenious.

 

Being up in the air feels like time-out-of-time. For the past 6 months, my life has been woven with lists of to-do’s, a chunk of my mind always forward planning, always aiming for the utmost efficiency of time and organisation. And now we are on our way. For today, there is nothing to plan and nothing to schedule. It is a huge relief. My body can feel it. Last night was the first night in weeks that I slept through without waking in the early hours with tasks on the mind.

The girls have been wonderful travellers so far. Things have been easy because we haven’t had to rush. There’s been time at the airport to dawdle, and to work out how the escalators work, or to ask questions about the security checks, to go to the loo umpteen times and to eat malteesers. We stopped in Brussels overnight and ate expensive dinner very late in a hotel. The girls giggled for hours after the lights were out. And today’s flight has been smooth so far. The girls who are rationed to  one Disney film a year are binging on movies and airline snacks and relishing the fact that no normal rules apply, just for today!

 

Now I must stop so I can look out of the window. I can see the cost of Lybia (or maybe just into Egypt?) endless sand crossed by pipelines and dotted with the shadows of the clouds below us.

 

By the time we arrive in Kigali it will be dark. What will it feel like arriving in an African night with all my family? I remember when I first arrived in Cameroon when I was 18, we were landing at dawn, in a major city, and it was dark, no street lights, no neon, and it was hot, as if I had stepped too close to the plane’s engines… what an impact that had for me then. What will the girls make of it – the smells, the dark, the heat? I’m hoping that our online visas will be turned into real ones without too much of a challenge, and that Zishan (the British GP whose time in Bwindi is finishing) will really be waiting at the airport to meet us. Let’s see what awaits.

 

 

 

In five week’s time, and save for disasters, I will be with my family, somewhere in the skies above Europe, heading towards Uganda.  I am about to spend the next several months there, working as a doctor in a hospital in the remote, rural South West corner of that country, close to the border with Congo and with Rwanda. I am going with Brian, my ever-supportive husband, and my two wonderful daughters, Miss A who is 7, and Little Roo who is 4.

Five weeks – quite a long time to get ready? It really doesn’t feel like that. Between now and then there are still so many things left to sort out, from antimalarials to mail-forwarding to work meetings to birthday parties. Oh yes, and a new opthalmoscope, and reading books for the children who won’t be in school for a year, and where will I buy shampoo – do we need to bring enough for 10 months? And then there is a house to de-clutter before our tennant arrives …..

Somewhere amongst all this busyness I am trying to reflect on what it is we are about to embark upon.

Here are the facts:

I am a GP Partner (that means I am responsible for a general practice surgery as a business as well as for the patients.) I have been given the most generous opportunity by my colleagues – they are allowing me time away, up to a year away, to do something that feels like it matters. That thing for me, is to be with my family, working in Africa. I have worked in Southern and Eastern/Central Africa before, but never with children. Brian has too, but before the girls and I were part of his life. For both of us, the experiences were formative. We want to be open to being changed again, and for our girls to have that opportunity too.

We will be living at, and I will be working in Bwindi Community Hospital. The hospital was established only 15 years ago as an outreach clinic to meet the needs of a disadvantaged community who had been displaced in that area after the opening of the national Park, the Bwindi Impenetrable Forest. The services expanded, and now there is a fully established, and very well regarded hospital which has been innovative in many of the services it offers. The hospital is part of a network of hospitals run by the Uganda Protestant Medical Board. There is an equivalent Catholic hopistals board,  and a Muslim medical board that supplement the State provision of health services. All of these are not-for-profit and need to generate income to run their services. The income comes from private donors, NGOs, the state, and there is a tiny contribution from user fees. BCH has been at the forefront of creative solutions to funding services. The hospital has developed a health insurance scheme that allows even the poorest families to access services even if they are expensive, and so enable people to take up preventative services as well as ones aimed at curing disease.

I will be working in the Adult In Patient ward for three days a week, and I will be involved in Quality Improvment projects for another three days.

We will all live on the hospital site. Brian is going to home-school the girls,  and put energy into being part of the community.  We will all take as much advantage as possible of the fact that we will be living on the edge of one of the most biologically diverse areas of the world, the forest home to half of the world’s population of mountain gorillas.

Here are the feelings:

There is excitement, of course, but at this stage, the dominant feeling is actually one of doubt. Here are some of them.

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

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

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

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

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

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

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

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

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

Is it right to leave our extended family?

So many questions, and so many doubts. We can only trust that the answers will show themselves with time.