For the first time in my life, I took part in an international sporting event a few weeks ago. One with Ugandan, American and British participation; the Buhoma Bike Ride.
This fantastic event was organised by Dan who runs the hospital guest house, and who is a fanatically keen mountain – biker. His children are too, and his wife Rachel has also got the bug. There are wonderful trails all around us, through the plantations, into the hills. The countryside is so beautiful, and undulating. Just asking to be explored by bike.
And there are some nice bikes. There is a social enterprise project called the Bwindi Women’s bike project which has made bikes much more readily available locally. https://web.facebook.com/pages/category/Non-Governmental-Organization–NGO-/Bwindi-Women-Bicycle-Project-215104825711522/?_rdc=1&_rdr. The project is funded by one of the tourist lodges. The project received several container fulls of bicycles which local women have been trained to do up and to maintain. The bikes are loaned to tourists , and some are sold locally. And kids have bikes, usually too big for them, but the road near the guest house is usually fully of nine -to twelve year old boys messing about on bikes.
So the rule was to sign up, pay the entry fee and bring a bike and a helmet to the starting line in front of the church on Saturday afternoon. And there I found myself, not having ridden on a bike for some months, not off road for years, and not in a race, well…. for ever.
It was wonderful. The route started at the village church and went up through the banana plantations along tiny muddy footpaths between the plots. It went through brooks and past a little valley, up to a road parallel to, and higher than the village, with a view out over the village to the hills on the opposite flank and away down the valley. A sweaty, white, unfit forty-something was the source of much hilarity as I puffed my way past. Children called out at me, and women carrying firewood on their heads moved gracefully out of the way of my clanking, wonky ride. I only came off once. Ungracefully, in a gulley in the track, with my legs in a ditch and my head in a tea bush.
And I made it around the course. Splash through the river, and over the finish line marked on the grass with red paint. Twice. I came forth out of four in the ladies race, but as they say, it was the taking part that counts, and the exhilaration and freedom of cycling in such beautiful countryside has stayed with me.
I now make a habit of Sunday morning rides before the heat fills the day and whilst the routes are quiet. I still prefer to fall off without an audience!
Sorry if this sounds like a rather dry topic – in fact it isn’t at all. I’m writing about this because it is so interesting (to me, at least.)
One of the things that is unusual about this hospital is its particular focus on quality improvement – the process of looking at what you do, and seeing if it is working, reviewing it, making changes, looking again. It really is part of the institutional culture. This is quite unusual for any organisation, and strikingly so for a remote, rural health care organisation. Every department is expected to audit its activity monthly, and submit the data for collective scrutiny once a month. The hospital has an overall five year strategic plan and within this, each department has an annual work-plan.
Today was the day when the audits and workplan for the second quarter were reviewed. For the last few days, we have been gathering our audits together in my department (the adult in patient ward) and reviewing them as a team. Each nurse is assigned an area of work to audit ;- questions such as; Do we screen patients for HIV within 24 hours of admission? Do new patients receive an orientation when they arrive on the ward? Do we screen people for unmet contraceptive need? Is our antibiotic prescribing rational? What is the rate of post operative wound infection? and so on. In a way that I am beginning to get used to, there were an awful lot of loose ends to tie up, and reassurances that things would all be OK, and then some last minute fixes for everything to be ready on the day. There’s been excel spread-sheeting, and graph making and data transfer in a frenzy.
Our team had a meeting with the hospital’s executive director to go through our audits and our performance. We were really rigorously scrutinised. Questions like ‘’ you said your target was about proportions, why are you giving us a percentage?’’ ‘’ Are you clear about your numerator?’’ It was a really detailed and exacting process. And it makes a difference, because the outcome was a really useful discussion of how we can build on what we do to make changes and improve services. For example, now that we screen all our patients about their contraceptive choices, what can we do to encourage people to take up long acting contraceptive methods? Another audit shows that we don’t prescribe antibiotics according to guidelines because we don’t have guidelines for certain conditions – we could write them. It is stuff like this that really can bring about change and can be really inspiring.
In other news, somewhere in the day, there was a ward full of patients to review, and it was Miss A’s birthday today, so we ended the day with presents and ……chocolate cake.
( 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.
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!
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.