I hadn’t realised it was 4 months since I last wrote a blog post, a lot has happened since then! The rainy season has just started which is a bit of a relief as it had got very hot and dry and people were worried about their crops and the hydroelectric dam that supplies the hospital with electricity.
In October we had a small group of Swiss doctors who came to run a fistula camp. They’ve been coming every year for quite a while and do a brilliant job. This year the surgeries were all funded by WATSI, an American crowdfunding charity that pays the costs of certain pre-approved conditions or surgeries. The transport and meals were also covered (I think by the Siwss team) so there was no cost to the patients at all. The news of the camp spread via whatsapp to an MP in the North of the country who told women in his area. Around ten women heard the announcement and travelled all the way from a place North of Gulu to attend. It must have taken them two days to travel; I thought they must have been so brave to take the risk of coming to a place they didn’t know, trusting in doctors and nurses they’d never met and not being able to speak the local language. Having a fistula can often mean you’ve been an outcast in your community, husbands sometimes leave their wives to find another wife who can produce more children etc so these women wouldn’t have had easy lives. For those of you who don’t know a vaginal fistula is when you have a hole between your vagina and another organ, usually either your bladder or bowel. This means that urine or faeces leaks through the vagina, instead of being able to be controlled by your bladder or bowel, leading to smell, social stigma etc. It is most commonly caused by obstructed labour, therefore is almost 100% preventable. It is now very uncommon in the UK and other developed countries as women would have much easier access to medical help if they were in obstructed labour e.g. in the UK we could call an ambulance instead of walk or find transport, we’d always have a hospital with doctors trained in caeasarian section or assisted labour relatively close, we wouldn’t have to worry about money as the NHS will cover all the costs of a delivery, we’d have usually gone to antenatal appointments with a midwife who would have educated us in when to go to hospital etc. The last fistula hospital in the USA was close in 1895 because there was not enough cases to require it to stay open. I read that there are still 3000-5000 new cases of vaginal fistula in Uganda each year so it’s still really important for camps like this to occur but also to try and work out how to prevent them from occurring in the first place. The women stayed in the hospital for two weeks after surgery as the catheter had to be in place that long before it could be removed so it was really great to see them all recover and realise that their lives had been changed.
Christmas here was enjoyable. We had the hospital Christmas celebration a week before Christmas. The Bishop and some other ministers came to lead a communion service. We’d been practising lots of English and Rukiga carols for weeks and weeks so the service was mainly full of singing. It still feels a bit strange to be singing Christmas carols to a slightly reggae beat in the sunshine, instead of a wintery Christmas with carols sung by candlelight in an old church! Christmas day I had gastroenteritis so missed church and spent quite a lot of the day in bed. This was mainly sad because Leo had brought a huge block of stilton and some parsnips and I was too sick to eat them!
At the beginning of January we ran a USHAPE ‘train the trainers’ course. This was designed to give selected staff the skills to lead USHAPE courses in their hospitals and to run the rest of the USHAPE programme, such as community outreach, screening for unmet need in family planning, encouraging departments to deliver methods etc. This is something that had been talked about for some time and we had managed to get a small grant to help with the costs of running the course and for some equipment. Claire and Clare came for a few weeks and Sarah and I helped them prepare and run the course. We had participants from our hospital, from Kisiizi (our sister hospital which has been running USHAPE courses for over a year), Rugarama hospital in Kabale (another Church of Uganda hospital who are just starting USHAPE work) and a nearby government health centre. It was really busy week with lots to fit in and we learnt a lot from running it. All the participants seemed to enjoy it and made plans about how to start or continue USHAPE work in their facilities. I’m going to Kisiizi and Rugarama for a week each next month so I’m really looking forward to seeing everyone from the course again and helping out with some teaching.
At the end of January I was really lucky to be able to go on holiday to Zanzibar for a week. I travelled with Sheila and we met my sister Lucy and friend Fiyin. We flew from Kigali to Dar es Salaam and then from Dar es Salaam to Zanzibar. I don’t usually mind flying but hadn’t realised the place from Dar would be so tiny. I had to shut my eyes the entire way and concentrate very hard on not panicking! We had a really lovely relaxing week. We hadn’t done our homework and so didn’t realise February is the hottest month of the year in Zanzibar! This meant we spent a lot of time swimming in pools or the sea, drinking cold drinks and reading in the shade, all ideal ways to spend a holiday in my opinion! We spent half the time in Stone Town and half by a beach on the East Coast. Stone Town is an interesting place with beautiful Islamic architecture. It’s very developed since I was there in 2007 and it seems that everyone is trying to make money from the tourist trade. It’s difficult to know how much of the money from tourism actually gets back to the local communities. It seems like all of the East coast was just hotels owned by foreigners. We stayed at a place owned and run by a local Rastafarian. It’s a really beautiful place with a lovely pool and beautiful plants and flowers. It was so hot that the pool still felt like the temperature you’d take a bath in by the end of the day! One night I had to have a cold shower at 2am to try and help me sleep! Despite the heat we forced ourselves to do a few cultural activities. From Stone Town we got a boat out to ‘Prison Island’, named because an prison was built there but never used as a prison, instead used as a yellow fever incubation/isolation place for incoming sailors in the past. It is now home to over one hundred giant tortoises, which were a gift from the British Ambassador of the Seychelles. He obviously didn’t give all one hundred but they’ve been multiplying over the years! They were huge and we got there at feeding time so could feed them some cabbage and stroke them. I’d quite like one as a pet but not sure how I’d smuggle it home…
Last week I went to Kampala to attend the first international symposium of community health workers. It was run by the School of Public Health at Makerere University and Nottingham Trent University, who also have a THET partnership similar to the RCGP and BCH for the USHAPE work. We’d had a poster presentation accepted for the family planning teaching we’ve given to some of our village health workers over the past three years, as part of the USHAPE project and the head of community nurse team at the hospital was giving an oral presentation. It was really interesting to hear what other programmes and countries have been doing. Like Uganda many countries across Africa and Asia have a community health worker system. They’re almost always voluntary positions, relying on the good will of people and their desire to serve their communities. They are essentially doing the job of a GP but with only basic training and without access to investigations or treatment. Some programmes had tried to give the CHWs incentives without actually paying them e.g. micro finance systems to generate income or giving them health related things to sell such as fortified porridge or medication or ‘pay for performance’ where they get paid a small amount if they reach certain targets e.g. number of pregnant women registered, follow up visits etc, some reported improved performance or motivation but it wasn’t clear how these could be sustainable in the long run unless governments stepped in to make these payments.
It made me realise that the community programme at BCH is pretty unique and seemed to be answering some of the problems that others talked about (although obviously it’s also not perfect and actually has had to be scaled down in the past year since the funding ran out). The community nurses were going to each village in the hospital catchment area once a month, until recently when they’ve had to scale back to once every three months. They meet with the VHTs, educate the community and see all the pregnant women and newborns. From interacting the VHTS during the family planning teaching and when they joined us for an easter celebration it seemed like they have a genuine relationship with the community nurses and this is what has led to a successful programme. The percentage of hospital or health centre deliveries had risen to 89% during the time the community nurse scheme has been running and they’ve seen neonatal mortality drop and cases of malaria drop.
So day to day life continues to be interesting, surprising and enjoyable. The longer I live and work here the more I realise how little I understand about how things work here, rather than feeling like I know more about what’s going on! The hospital work is very varied which makes it enjoyable and it’s really good to be able to see patients recover. Most infectious diseases and many non-communicable diseases are treated very well here, as long as patients present early enough. Cancer is still very difficult to treat and we’ve seen some sad cases recently, a girl younger than me with a massive abdominal mass and a hard supraclavicular node that you usually only read about in textbooks, a women with a fungating breast tumour, a women in her 30s with advanced ovarian cancer. Sometimes I see things that I just can’t get my head around, such as two young brothers who have been in the hospital for months with severe burns because apparently they were caught stealing so someone poured petrol on them and set them alight or the teenage boy who came in with stab wounds in the back who had apparently owed some money and unfortunately didn’t survive. Corruption and lack of funding in the police service means that things can happen without any consequences.
Think this is now too long for anyone to want to read so I’d better stop! My phone was stolen in Kampala so I don’t have any photos to add I’m afraid. Thanks to those to you who have been keeping in touch, it’s always nice to hear from you.