Category Archives: A matter of opinion…

Blood: It’s complicated

An anxious mother stumbles into the clinic, carrying a fragile bundle wrapped in blankets and a faded kitenge. The baby boy – perhaps younger than one year of age – is breathing heavily and seems frighteningly pale for an African child. The MH triage nurse takes one look at the child and ushers them towards Maranatha’s version of an ICU, although it has none of the machines and gadgets one would find in an ICU in the west. As fast as can happen in a Ugandan setting, with a culture of people who cannot be rushed, the child is examined by a clinical officer, is cannulated, tested for their blood type, and then (with relief) the lab staff report that they have some blood available from the child’s blood group. The clinical staff let out the breath they were unaware of collectively holding, and everyone carries on doing the work that needs to be done.

In peak malaria season, this scenario may happen a few times a day. A common complication of severe malaria – especially in children – is anaemia.

I’m not a clinician. But basically, in this context, where severe malaria is really common, regular access to donated blood is essential. At MH, we sometimes transfuse several units of blood every day. Blood transfusion for these children is powerfully and phenomenally life-saving.

So, blood is important.

It is also frustratingly difficult to get our hands on sometimes.

The other day we had a call from Bundibugyo, a neighbouring district 60kms away. A child that had been taken to a hospital there needed a transfusion, and was extremely sick. Before the parents traveled, they decided to call ahead to the regional referral hospital, which is also in Fort Portal. They did not have blood. They then called another big hospital here, a Catholic hospital, which also had no blood. Then they called Maranatha. Our lab tech quickly checked the fridge and to our great relief, there was 1 unit of blood left, and it was the blood type of the boy. We told them to come. A rare win!

Every few months, MH invites the blood bank in FP to do a blood drive at the MH clinic, and we try to get as many units as possible donated. It’s quite a community day, actually, and fun.

The blood banks across Uganda, including the one in Fort Portal, were funded in part by some significant donors. But the donors have recently pulled out, and most of their funding is now from the Ministry of Health. With two old vehicles, and a small team of staff, they are expected to find enough units of blood to service about 8 districts – probably more than 5 million people. The blood bank is now expected to find this blood – miraculously – with no budget for transport and reduced staffing levels.   There are some pretty substantial challenges beyond the obvious time and resource constraints: there is not a culture or awareness in the general community around blood donation; there is no social pressure or reward for donation; with the majority of people poor farmers, people do not have time or resources to commute to give blood regularly; and with HIV (and other STDs) the highest in this region of Uganda, there is a substantial amount of blood that simply cannot be used, even if collected.

This epic wall of barriers to donation culminates in the variety of stressful situations we often have at MH, where there is just

Not. Enough. Blood.

When we are busy at MH, often our lab tech will find himself down at the blood bank a few times a week, begging for another unit. He will call the staff with the keenness of a 15 year old girl having her first crush, racing to the blood bank the moment there is a rumour of a few already screened life-saving-units ready to go. He knows all of the staff there by name. In emergencies, when there is really nothing left to do, we will send family there to donate and then wait around while the blood is tested and bring it back to MH. Of course, it was much more difficult in Kamwenge days, when collecting blood from the Fort Portal blood bank sometimes felt like an episode of the amazing race. We needed to send an esky with a public taxi from Kamwenge, with the request for blood signed by a certain MH staff. After bargaining on the price of this ‘service’, the taxi driver would take the esky to a supermarket in fort Portal town that had agreed to store a few icepacks for us, and then take it to the blood bank. Someone from the blood bank would pack the units for us (once they were available) and then organise another taxi driver to take the units back to Kamwenge, often tied on the roof of the vehicle. Once it arrived at the taxi park in Kamwenge, we would get a phone-call and go and pick it up, normally in a desperate rush knowing there was a child on the very precipice of life itself.

Basically, in a word association game, if someone mentions blood and Uganda, my immediate thoughts go to frantic phone conversations, empty fridges, the oxymoron of pale-black-children, and our shabby red esky that has been thrown into the work ute ready to collect blood from the bank on about a million occasions. Then comes to mind the afore-mentioned pale-black children’s chubby legs running around the ward a day-or-two later, defying the odds of the malaria gods by being an under-5-Ugandan-patient brimming with life.

The government referral hospital does not have the same record of transfusion as MH though. Their not-so-reliable transfusion record has been the focus of many a Ugandan’s frustration. To offer some context, the public health system in Uganda is broken. Staff often simply aren’t there, equipment is broken, drugs are often not available or shifted to ‘private pharmacy’s’ within the hospital, bribes are the norm, rooms are extremely overcrowded, health staff have low morale and some simply don’t care….

In this scenario, one can imagine there is much that could go wrong when a patient is in need of a blood transfusion. The stories that I have heard when quizzing friends and our own staff about their experiences when in need of blood are numerous and horrific: clinic staff demanding payment for blood, blood expiring in the fridge while people wait in the wards in need, patients being sent to private pharmacies in town to purchase the basic equipment lacking to give blood, unqualified staff overseeing the process or staff unavailable so the blood is never transfused…

All of these issues are of course irrelevant when there is almost no blood available, and so much demand, as has been the case in the past few months.

A few weeks ago, one of the Ugandan newspapers published a story reporting that recently at the Fort Portal referral hospital, 8 people died in ONE DAY due to a lack of blood. This, understandably, created a political storm of sorts, so much so that the Ministry of Health sent some high-ranking officials in expensive suits with shiny cars to Fort Portal to find out what indeed happened. Trying to understand what the problem is, so that it can be fixed.

But there are no easy solutions.

I wish there was.

The solution is for people to be free of poverty

The solution is for the government health system not to be broken.

The solution is for the Ministry of Health to take seriously their mandate to provide basic services to the population, and to be held accountable to this by an educated, politically engaged population.

The solution is for malaria to not be endemic in this population and take tens of thousands of children’s lives every year

The solution is for people to come to the health service earlier before they become anaemic, confident in the knowledge they will be looked after well.

The solution is for the culture of blood donation in the community to be changed

The solution is for more funding and greater resources and better systems and services

It’s one of the most all-consuming realities that I have experienced and have been forced to eventually embrace (kicking and screaming) while working in the developing world.

The frustration of discovering that poverty and disadvantage is complicated. And systemic. And cultural. And contextual. And economic. And political. And relational.

It’s just plain hard.

Blood is a beautifully tragic example of this.

If anyone tells me about an ‘easy’ or ‘simple’ solution to poverty and disadvantage these days, in any context, I smile. I listen. Then I politely disagree.

False quotes and failing health…

In light of all that has happened over the past few months, including the closure of the Maranatha Health clinic due to a factory being illegally put up next to our land, I have been following the Ugandan media with interest this week. Mostly, to track the articles that are being written about Maranatha. (By the way, I wrote this blog over 6 weeks ago but have only got around to posting it now!)

When I first moved to Uganda, I took an overly-keen interest in the newspapers, delving very deeply into the politics of this country.  Like many Ugandans, I became quite wrapped up in the politics of Uganda, the key players, the scandals, the economy, the issues. The average educated Ugandan’s interest in politics is a fascinating phenomenon that I’m still getting used to. After 25 years of my life lived in Australia, where most  young people who have finished high school can barely offer up the names of the PM and deputy, it is still bizarre to me that so many Ugandans know all the key ministers, their families, their business dealings, and scandals. In essence they are the Ugandan version of celebrities.

However, about 1 year in, and after reading about the millionth corruption investigation story, my interest in the media waned, especially since 99.9% of the time nothing was achieved by reporting the story. It made me a little too cynical, reading again and again of men being found ‘not guilty’ for crimes that have appeared to cost the country millions of dollars in tax payer funds. Although I would’ve loved to, I also didn’t feel (and still don’t) that I should share my thoughts publically about such issues considering the sensitive nature of my employment and status in this country. Furthermore, although the media is open, free and can report essentially whatever they want, I feel almost every story is fanatically event-based, rather than drawing Ugandans into a bigger-picture conversation on long term solutions to the issues facing the country.

Last week reminded me again of why I have tried to avoid getting too heavily invested in Ugandan politics and media. Keeping track of the headlines, two things have been highlighted to me:

Much journalism in this country (in my opinion) is amateur and opportunistic*. I was completely ignorant until a few weeks ago that when one needs to have a story written in this country (unless it is a national issue) one must PAY journalists to write it. Yep, you heard me correct. Over and above the wages that journalists receive from the newspaper, to have an investigation and story written about the issue in Kamwenge (or any issue for that matter, so I’ve been informed from Ugandan friends), we were expected to fork out money (per media outlet/journalist) for the mere privilege of their interest. Now let me get this straight. We do not pay them for a one sided account. After you fork out such ridiculous sums of money for mediocre reporting, they write what is purported to be a ‘balanced story’ (while others take your money and write nothing!). So far however, the quality of articles has been at best slightly inaccurate, at worst totally missing the point of the issue. Every single article written so far has described us as being from Austria (it really isn’t that hard to get the donor country correct, these journalists are degree holders for goodness sakes!); has dramatically misquoted or just plain made up ‘quotes’ we are purported to have said; and the one published the other day quoted a man in Kamwenge town – a maize dealer who is OF COURSE going to benefit and side with the factory – claiming that the residents don’t need or want the health centre, and can easily go to Fort Portal (70kms away) for treatment. Might a journalist point out or question the agenda behind his one sided view? Not in Uganda it seems! Moreover, most neglect to highlight or only vaguely mention, (1) the level of corruption and negligence of district officials which surely must have been present to put up a factory next to a health centre, and (2) the extremely poor quality of health services currently being offered in Kamwenge, that has been redeemed dramatically by the services at Maranatha, and do not currently exist elsewhere in the district.

The second thing that was sadly highlighted to me this week as I poured through the newspapers is, in a demonstration of ironic timing, a collection of articles lamenting the state of health and health services in this country. Of particular interest in the past week, I have read that new figures have shown the HIV rate is rising from 7.5 To 7.9% (the figure I suspect is much higher in Kamwenge); Family Planning levels in rural areas are decreasing; that child malnutrition rates are on the rise and now stand nationally at 35% (in Kamwenge they sit at around 60%); and maternal mortality is again on the rise, with the national figure now at 438/100,000 live births. Michael and I observe the practical realities of these stats everyday and they simply confirm what we are seeing in our own district. However, most alarming is the last statistic about maternal mortality rising. See, from my Masters, I have learnt a bit about health systems – their elements, different ways to strengthen them, schools of thought around this and also how to measure their capacity and effectiveness. One of the key ways to assess the efficiency and effectiveness of a health system is through maternal mortality statistics. Why?  Because maternal services rely on so many different aspects of the health system – things like the presence of primary health care services (ANC and delivery), staffing levels, transport mechanisms, referrals, emergency response, availability of drugs and equipment, and availability of tertiary/specialist care. All these services combine to ensure women do not die in pregnancy or labour (and so poetically, in countries like Australia, that maternal mortality barely exists). Basically what I am saying is that health services in Uganda, generally, are decreasing in quality, in turn producing these unfortunate statistical realities.

Which begs the question – why allow a health centre doing such a fantastic job fighting against these statistics, to be forced to shut by putting a factory next door? Why aren’t the district leadership – among others – viewing this as an issue of urgent and significant importance?

And, why oh why, didn’t the journalists of Uganda identify – and point out the link – between the broader problems of health in Uganda they were writing about this week, and the articles written about Maranatha Health, a much needed service subsidizing a broken health system.

Thus endeth my rant.

*As a disclaimer, I’m sure there are many fantastic journalists in Uganda – I may have lucked out! Also, there are many things that combine to make this a problem – including lack of support and good educational opportunities, corruption, and small salaries.

Think.

Below is a very honest journal entry I wrote after being back in Australia for about a month. Needless to say, in many ways its nice to be back home in Kamwenge….

Rolling and rising and revelling and envying

Costing and clinging and consuming and careless

The herd moves forward fast and furious

On towards the promises of profit and of perfection

Of needs. Of wants. Of desires. Of luxury

Just that little bit more…

And I can no longer stand still in the midst of the chaos.

I stumble.

Despite the best of intentions I am pulled forward by the inertia of culture and expectation and cravings I cannot hope to decipher.

Toyota. Apple. Ikea. Woolworths. Nestle. Unilever. Nokia….

Food processors, Personal spas, i-everythings, treadmills, must-have beauty products…

It is in no-one. And it is in everyone. I guess that is what culture is.

But the culture of consumerism costs.

The currency that we use to pay for all of this is money, and perhaps our relationships

But

It costs the developing world in cheap labour. There are millions and millions across the world that live conveniently below the poverty line, so we can maintain our standard of living. It is only because of their vulnerability and lack of voice, that we can afford such affluence.

It costs the natural resource base, with its finite supply eventually doomed to fail us all. And with so many of these resources comes the chaos of greedy conflict – Sudan, Congo, Angola, Nigeria, Iraq, Kuwait…

It costs the environment its life-giving force, as we pump CO2 into the air that is slowly heating the world, heightening the struggle for survival in Africa as the land becomes tougher, harsher, drier;  and creating wave after wave of refugees born from natural disasters.

It costs the planet’s wildlife their survival, as we pump tonnes of waste into our ocean and into our earth.

It costs our society the intrinsic beauty of needing each other. We stay behind closed doors, scared of losing what we have, forgetting the collection of people is more important than the collection of possessions

I’m not sure what the solution is. I have none to offer in this blog. I am part of the problem.

But I live in a place that is not governed by the law of luxury packaged as needs:

When the water goes off in my house (which it often does for weeks on end), I am pissed off and impatient and struggle to know what to do. My staff shrug their much stronger shoulders and collect their water in jerrycans.

When I spend time contracting carpenters to make wardrobes and tables and drawers to store my stuff, most of the people I know in Kamwenge fit what they own into one simple room.

When I collect up my rubbish for the week and proudly burn off what feels like so little, my neighbours find other uses for almost everything that I would consider disposable.

This is not judgement, this is an observation of my own heart and soul and culture. But when does it end?

What we consider ‘basic needs’ have been utterly corrupted by the messages we are fed, by the invisible lens of culture that covers the eyes of our spirit.

So next time you turn on the TV and watch an advertisement, or envy a friend’s <insert new piece of technology/furniture here>, or visit the shops, think.

THINK.

Just think.

Maybe one day…

I believe that men and women were created equal.

*gasp*

I believe that I can’t be bought or owned.

*gasp*

I believe in reproductive rights for all, regardless of race, age, religion…and gender.

*gasp*

I even believe that myself, as a woman, deserves to be treated the same as a man in my position.

*gasp*

Am I a radical? I think not. Well, maybe if I lived in 1940s Australia.

Or if I lived in Kamwenge, today.

*                          *                            *

Our staff, including Michael and myself, were eating matooke and beans for lunch the other day in our newly constructed shelter. They were discussing someone’s wedding. Deep in thought, one of our staff asked innocently… ‘Dr, do you have dowry in your country? How much did you pay for Kim?’

Michael explained that we don’t have such a thing. That he visited my parents to ask for their blessing, then asked me to marry him, to which I happily agreed.

Another staff member, a woman joined the conversation. ‘What about polygamy?’

I replied that polygamy is illegal. You can be put in jail. Even when a man cheats in Australia, he can lose his house and land if the couple divorces. I explained further about women’s rights, choosing my words carefully, aware of the presence of a woman in the shelter whose husband I had learned had taken a second (younger) wife against her wishes.

There was a great pause in the midst of lunch. A moment to digest this information.

Then a young shy woman, a staff member that has grown up in the village, speaks very little English, and that I have a strong infinity for spoke up.

“That means that in your country, women are equal to men.”

*                          *                            *

I was chatting to the clinical staff about a course that one of our staff would be sent to undertake, for contraceptive and Family Planning training. Another staff was sharing her experience with family planning programmes in the village. My ears pricked up – I am currently writing my Master’s thesis on fertility choices in Kamwenge, focusing on reproductive rights and normative cultural values/expectations that constrain choice. I asked about how women in Kamwenge received the idea of contraceptive advice/counselling. Were they opposed to it? The answer devastated me.

‘Some do not want. But there are many that do. The problem we are having is that husbands do not allow their women to use contraception…

.. A few months ago, there were a big number of women in my home village that got the implanon, in secret, so they could stop producing [having children]. But the husbands got very angry. Some were thrown out of their homes, their villages. Others were beaten.’

*                          *                            *

I hadn’t even given much of a second thought to the set of values around equality that I hold, when I lived in Australia. It was part of my assumed knowledge, growing up. In my teenage years, if anyone was to treat me differently – unfairly – because I was a woman, I would have acted with indignation and disgust, and the matter would have been settled, fair and square.

I’m not trying to say that Australia is the land of milk and honey, where women have achieved complete equality with men. But we are actually doing ok. We are on to the business of more minor stuff in the big scheme of equality these days.

Uganda is doing ok in some areas. They have one of the highest percentages of female politicians in the world, with a compulsory female MP position for every electoral zone. There are lots of female managers of businesses. Plenty of middle class women who go to University.

But if you even get close to village life, you can smell the stench of inequality rising from the thatched rooves of your average family’s household.

Beyond anything else we achieve in Kamwenge over the next 10 years, beyond any goal to assist people to escape grinding poverty, beyond even saving lives at the clinic…

…what I wish more than anything deep down in the justice-craving areas of my soul, is to start a movement of village women who believe that perhaps, just maybe, they could be equal with men.

That maybe they should have control over their reproductive choices; who they have sex with, how many children they have, or where they give birth.

That maybe they have the right to equal access in health and education.

That maybe they could be in a marriage without having to be one of several wives.

That maybe they don’t deserve to be abused and trodden on, beaten and bashed

That maybe they don’t want to be defined only as mother and wife; their value attributed to the number of children they produce.

That maybe they shouldn’t have to be the bread winner for their children, dig in the garden, cook, clean, and raise their children alone.

That maybe they have the right to have control over resources, including land.

That maybe they could fight for all of this.

Maybe one day.

www.maranathahealth.org

The Power of One

It’s finally happened. The much desired, dreamed of, it-feels-like-this-day-will-never-come, inevitable luxury has arrived.

The Maranatha Health buildings are going to be connected to the newly built hydro-dam and we will have electricity for the first time. WOW.

I think I’m a little bit shocked. We have been waiting for so long that I think we had resigned to the idea it might never come. ‘Hope’ in Uganda is a dangerous thing. I think we have had over 30 conversations with the electricity company since April (when the President came out to officially commission and ‘open’ the dam) where they have fed us false fables of electricity just around the corner.   We have been promised everything under the sun – from connection within a few hours, a few days, a week, a month. Every week there is a new rumour in town, about a cousin’s, father’s, friend’s son, who lives near/works with/is related to someone from the company who is operating the hydrodam and knows the inside scoop. The latest I heard was that the dam ‘had a problem’ and ‘donors from out were coming to fix it’ in March.

But now it is happening. There are engineers driving around in trucks with wires and men walking around with legitimate looking blue overalls, and the Ferdsault office is open and has given us a lovely little certificate to say we are ready for connection.

Driving back to the site after paying our registration and connection fee yesterday, Andrew (the MH administrator) and myself were dreaming excitedly of all  the things we could now use/do/have once we are connected. For the first beautiful moment in months, we had allowed ourselves to hope:

  • Guaranteed lights at night rather than Kerosene lanterns
  • No more frustration at laptops running out of battery power at work or home
  • A toaster, so we can pretend that Kamwenge bread isn’t stale
  • An iron, so our clothes aren’t wrinkled  (I could never bring myself to use a charcoal iron)
  • Hot water from our instant water heaters, rather than cold water showers
  • And most exciting for me – A REFRIDGERATOR!

In Kamwenge, we will be one of the only residential houses with a fridge. I am aware that it is a massive luxury. I lay in bed at night actually thinking about that (sad, I know). But it will change my life. How?

I no longer have to buy and boil milk every single day – we can keep it in the fridge so it doesn’t go off in 24 hours. It also means one less saucepan to clean each day

I can cook food for several days and store in the fridge

I don’t have to shop at the market every second day, as tomatoes/carrots/beans etc won’t go off within a few days

I can buy foods from Fort Portal/Kampala that I can’t get in Kamwenge – cheese, fresh non-sweet bread, nice cuts of meat, sauces…. YUM

I can cut up a pineapple and not have to attempt to eat the whole thing in one go- they’re just a little too big!

I can have COLD drinks- juice, soda, whatever. It will be COLD!

We have had solar for the past few months. It is incredibly unreliable and only charges a laptop or two and some lights (on a sunny day when it isn’t too cloudy). Realising how little a solar panel generates and all the appliances it won’t run (irons, toasters, kettles, fridges) and monitoring our energy needs/consumption so preciously has given me a new appreciation for the luxury of power. Of light. Of convenience. Of temperature control. Of power consumption.

In Uganda, the 10% or so of the population that make up the middle class might have a fridge. Often they will have a toaster and kettle. Perhaps a water heater. A TV. Beyond that, everything is still manual. Household electricity consumption is still so minimal. Only 10% of the population of Uganda even have access to the electricity grid. Those that do, often go days without power at a time, due to the lack of power generation and government failures to deliver on infrastructure.

This is unacceptable. But you know what frustrates me more? That in Australia, we take the luxury of power for granted. There has been so much complaining coming from Australian newspapers I have been reading online over the past 6 months, about the carbon tax and electricity prices going up in Australia. The general gist is that people are annoyed – ‘its not fair’ – and the government needs to find a way to lower prices. We assume we ‘need’ all of these appliances and all of this convenience so our lives can move faster. You know what though?

We actually don’t.

Take it from me. I have lived without a lot of that stuff for almost a year. Even the basics – irons, fridges, toasters, TVs, kettles, washing machines, even lights, for a lot of the time. Let alone the other stuff – dishwashers, microwaves, water heaters, air conditioners, a million gadgets, the flat screen, donut/icecream/waffle makers, clothes dryers, hair dryers, spas, the 2nd (or 3rd) fridge, etc. *

Instead of complaining about the cost of electricity, what about we try and lower our consumption? Because all of this electricity – it has to COME from somewhere. Electricity is costly to generate. Financially and environmentally. And if the rest of the world tried to consume as much as we did, our planet would be destroyed tomorrow. The end.

I am not trying to preach. I’m not an idealist. I have lived in Australia for most of my life. I understand that you think you need all that electricity. I have only really learnt about my consumption in the past year. I’ve learnt this as I’ve seen what I can live without, as I have been forced to check every appliance I brought over here to see if it could run off our little solar panel and now, if we can afford the cost of running it off the main grid.

Rather than idealistic, I am trying to be realistic about the state of our world. The cost you pay doesn’t even come close to the real environmental cost of coal-generated power. So If you don’t want to pay so much for electricity, than reduce the amount you use. Start looking at how much you consume. Which appliances are ‘necessary’ in your eyes, and which ones can go. Whether you can do some things manually. I’m not asking you to use Kerosene lamps or candles, or boil your milk or water each day in a saucepan, or hand wash all your clothes and sheets and towels and dishes, or go without fans, fridges and air-conditioners, like me and everyone in my community does.

But I am asking you to care about the future of this planet

and own the choices you make.

 

*You will notice I haven’t mentioned laptops here – perhaps it is the exception to my post. I can’t live without mine! We are almost inseparable and I use mine (unless we have no solar power) everyday – for work, study and keeping in contact with people….

Patients or Profits?

Perhaps it has something to do with the lack of, and ineffectiveness of, regulatory bodies. Perhaps the training at many Universities is below par. Perhaps it is due to the everyday Ugandan’s powerlessness and incapability of demanding and knowing their rights. Or perhaps it is the simple truth that money-motivated-medicine around the world always seems to behave badly.  I’m not sure why it is the way it is – I will not presume to give an opinion on a complex issue I know almost nothing about.

What am I talking about?

Poor quality medical services – in this case the private system – in Uganda.*

The public system in many developing countries has a lot to be desired, and a thousand reasons why this is so. But the private system? The system with money and drugs and equipment and trained staff on good salaries?

I wanted to share a simple story of something that happened the other day that left me bewildered. Before I share my experience, let me first say that there are many intelligent, professional, trustworthy doctors in Uganda who practice very good medicine. Unfortunately, they are not by any stretch of the imagination the majority.

Michael and I stayed with our family in Kampala for a few days last week. One night, our brother Pete (who’s a year older than me) staggered through the door complaining of a severe headache that he’d had most of the day. It had come on suddenly. After a heap of questions, Michael was convinced it was a migraine and all the symptoms pointed to this – whatever the case, we decided to take him to the Gensi’s family doctor, a private middle-class clinic a block from our place where he could get some fluids and painkillers. We (Michael, me, and Margaret, our mum) loaded Pete into our car to take him. It was peak hour, and so we sat impatiently waiting in traffic even though the clinic was literally around the corner, as Pete moaned and threatened to vomit in the car. Eventually, Margaret had had enough. She instructed Michael to put on his hazard lights, ordered him to drive on the wrong side of the road, abruptly jumped out of the car and starting stubbornly walking into the oncoming traffic (have I mentioned before that you don’t mess with Bakiga women?) as Michael eased his way past the jam on the wrong side of the road ignoring the glares from passing vehicles. Her display of motherly love was quite astounding, but I didn’t know whether to laugh at the situation or hide from angry faces in the vehicles that Margaret had forced to the side of the road.

Arriving at the clinic, a small building with a consulting room, a lab and a few rooms with beds, we found the doctor reading his newspaper. After getting his attention, he took a very short history from Pete – like 2 questions. Pete was convinced it was a migraine and not malaria; after all he had had malaria dozens of times in his life and knew what it felt like. Clearly though the doctor felt he had gathered the info he needed and had had enough of interacting with his patient, because at that point he wrote some things on a piece of paper, ordered a blood test, and told us to wait. There was no explanation given. Pete, in the meantime, was struggling to stay on his chair due to the pain.

After a few requests from Michael, they led him to a room with a bed in it, and shortly after a nurse came in. They apparently had the results of the blood tests back, although no staff mentioned this. She came loaded with several injections and ordered Pete to remain still as she jabbed him several times. He had no idea what the diagnosis was. No conversation with the doctor. No idea what treatment he was getting. No permission was sought to administer the drugs.

Pete was still dehydrated so Michael requested they get a drip into him. Reluctantly, they agreed. The headache had lasted a long time, so Michael also checked for signs of bleeding on the brain. Something they had also not bothered to do.

In the meantime, we were all curious to know what was happening, and what the diagnosis was. (These patients and their demands, how annoying…) Margaret went to find the doctor, who informed her that Pete had a bacterial infection. No further explanation.

Eventually, we found out what they treated him with. The list is as follows:

  • 1 shot of malaria treatment
  • 1 shot of anti-nausea
  • 2 shots of extremely heavy duty antibiotics
  • 1 shot of an anti-inflammatory (this one was actually for the migraine and very helpful)
  • 1 drip of glucose (used in patients with malaria), not helpful for rehydration

By this stage Michael was a little confused. He was convinced that all Pete had was a migraine, and he needed fluids and rest. So he asked the nurse to show him the lab results.

It turned out that Pete tested negative for malaria and negative for any bacterial infection. His white blood cell count was within the normal range.

After several hours, when he had slept and was feeling better, they discharged him and he came home. However, not without being told he would need to come back for the next three days, to have more anti-malarial and antibiotic injections. Up to this point, they had not mentioned money, but Pete was dreading the cost. From past experience, Pete estimated it would be around 300,000UGX  (A$150) or possibly more. That is big money in Uganda.

Now, I’m not a doctor. I have not been through medical school. But being married to a GP – wait – even visiting a GP on many occasions in Australia would have made me more equipped to deal with this situation than the doctor who saw Pete. Here’s ‘Kim’s General Practice Medicine 1-0-1’.

Lesson 1: Talk to your patient, gather a comprehensive history, think of all possible causes (not just malaria because it’s an easy diagnosis).

Lesson 2: Once you have a diagnosis, communicate this to your patient.

Lesson 3: Make sure your diagnosis is based on facts/lab tests/at least some semblance of science and NOT based on the fact that you can charge more money for medication if its malaria or infection (or both?!), which it clearly was not. If in doubt, run the tests again.

Lesson 4: If you are going to administer drugs, explain the diagnosis and medications to the patient and SEEK his permission to administer them. Again, communication is key! In Australia we call administering drugs without permission ‘assault.’

Lesson 5: Do not treat your patient for diseases he doesn’t have, so that you continue the spiral of malarial and antibiotic resistance that are out of control in places like Uganda where drugs are not regulated well.

Lesson 6: Don’t be a money-hungry incompetent idiot.

Thus endeth my rant for today.

*By the way, I don’t deliberately mean to exclude some of the terrible displays of medicine practiced in Australia – by a wide range of doctors.  Statistics show that the average private surgeon in Australia will operate many more times than necessary if there is a bit of money to be made and some fun to be had – often to the detriment of the patient.

 

the word I spit out…

Corruption.

It is a word that I spit out, hard and quick, desperate to see it leave my mouth and my body and my soul.

Desperate for it to be purged and destroyed.

The Oxford dictionary defines it as this:

Corruption: dishonest or fraudulent conduct by those in power, typically involving bribery. The action or effect of making someone or something morally depraved

I define it as this: An evil that eats away at truth, humility and integrity. On a national level, it rages like a disease that seeks out and destroys the cells that are the lifeblood of a developing country emerging from poverty: representational, accountable democracy

And Uganda is full of it. Full to the brim.

One of the newspapers here recently published an article about a corruption index undertaken each year by ‘Transparency International’, ranking Uganda as the 2nd most corrupt country in the East African Community, second only to Burundi. That means that Rwanda, Kenya, and Tanzania are all less corrupt than us.

I never quite understood why so many people raged against this disease; trying to find cures or vaccines or at least treatment for the symptoms. Missionaries I met in Africa in the past spat the word out, as I do now.

I used to laugh it off. What’s a $5 bribe to a policemen here? Or a quick under the table $20 to a government official there? It just speeds the processes up a bit. Adds a bit ‘extra’ to the shameful government salaries in this country.* An unofficial tax you might say.

But it is much more than that.

Corruption filters down from the top. It demonstrates a lack of accountability to the people to which government is mandated to represent. It violates the contract between leaders and their people, which states that leaders of a democratic state are there to protect and ensure rights.  It takes away any semblance of a system, so all you are left with is millions of informal interactions characterised by power and exploitation. The more power someone has over you and the action you are trying to achieve, the more money they can ask for.

For example

Earlier this year, I needed one signature from a Ministry of Health official, to recommend us to the NGO Board. Without that signature we could not be a registered NGO in this country. Without any sign of guilt but with a face of greedy entitlement, he asks for a 5 million shilling bribe. That is about A$2000. For one signature.**

Recently we have had a shipping container full of medical equipment brought into Uganda. We also had a few boxes of personal effects. Both are supposed to be completely tax free, under Ugandan law. Medical equipment for an NGO – tax free. Anyone who is changing residence to another country, is allowed to bring to that new country their personal items, tax free. Simple. An internationally recognised system. And yet we were forced to pay 1 million (A$300) – on my wedding gifts, on books I had collected since I was 10, on our mattress, on towels I had used hundreds of times before.

Our lawyer earlier in the year helped us get our NGO certificate. He was told the fees had changed for NGO registration, from 15,000 (A$5) to 3,000,000 ($1000). That is a big jump. We all protested, suspecting corruption. But they produced documents, official papers, even a government bank account to transfer the money into. So we paid half the money to start the process. Then we found out it was a fake syndicate, a group posing as the NGO board who had a contact within the bank, who was later syphoning the money from the account back to them and taking a cut. We never got our money back.

We are trying to help a young woman in town at the moment, as she begins her Diploma in Laboratory at one of the biggest Universities in Uganda. She has her sponsorship from someone already. She has been admitted. And yet as a Kamwenge local, a stranger to the power plays of big city life, she has requested us to help her negotiate the system. At every step she has met officials demanding bribes. Bribes to get her papers back. Bribes for official admission. Bribes to get a copy of the fee structure to take back to her sponsor. All she wants to do is study the course she has been admitted into.

The more in need you are of the signature/service/requirement/registration – the more you pay.

So the big men in big offices are the ones who take the most money. And so doing anything becomes a very difficult, long process, with little respect for official systems and dozens of ethical dilemmas along the way. You want to report it? You pay extra ‘fees’ to corruption boards and committees so they will actually bother to look into it. Except the big men can afford to pay them off, with the money YOU gave them.

Trying to get

          A business registered                                                                                                                           Any kind of registration/recommendation
          Anything imported
         A passport/visa/permit
         Land titles processed
        Your wife treated as she dies of obstructed labour
        A thief arrested
        A university transcript/results for your course
        The council road graded to your site
        Your child taught at school
        Out of a speeding fine when you KNOW you were travelling within the speed         limit

                          involves corruption

And of course, this ‘tax’ is higher, the more you look like you can pay.

No matter how long you have been here, how well you know the law, how well you know the real costs, how many times you explain you are not benefiting and this is a project for the community, or how many times you explain you are on a Ugandan salary*.

If only I didn’t have money-coloured skin.

*One of my friends who works as a full time worker at the local Kamwenge government Post Office earns 50,000 a month, which is about $18. That is NOT a living wage. She however, manages to remain honest and integral.

** For the record, we didn’t pay the 5 million! Not one cent of it.

*** Ugandans come up against issues of corruption as much (if not sometimes more) than I do. I don’t want to give the impression that we are the only one’s who have to deal with it! There are thousands of stories I could tell of my friends here trying to get all sorts of things done where they have been forced to pay bribes.

Note: I don’t normally write such scathing critiques of Uganda. Please note this is not an issue that has ANYTHING to do with Ugandan culture. It emerges from the culture of leadership.

The views expressed within are ENTIRELY my personal views and are not the views of the NGO that I work for.  I am aware this piece is a very candid account of my experience, but I believe strongly in the democratic process and the need to keep leadership accountable.

Bring your blade, bedding and basin…

A good friend of mine who lives in Kamwenge town is pregnant with her second baby. During the birth of her first child, her labour became obstructed. Because there was no place in Kamwenge that could help her, she travelled 1.5 hours on a dirt road, in severe trauma, on public transport to reach the nearest clinic that could operate on her. Her and her beautiful boy survived, although she now has a great fear of childbirth. Every time I see her, she fervently asks for me to pray for the safe arrival of her baby due in August.

But she was fortunate enough to be able to afford the cost of transport to Fort Portal, and was able to get there in time.

In Kamwenge, where the population has reached at least 350,000, there is no district hospital. The two main clinics in the district do not offer Emergency Obstetric Care. There is no working theatre. No running water or electricity. Many of the health staff are hardworking, compassionate individuals who are tired of having so few drugs and equipment.

Being a woman in Africa is tough. And one of the toughest things of all is giving birth. I read lately, in a journal article written by an anthropologist (I can’t remember the name of the article!), that in an area of eastern Uganda, childbirth is sometimes referred to in vanacular as ‘the trap’ because of the risks involved.

The maternal mortality rate in Uganda is 506/100,000 live births. In Kamwenge it is unknown, but expected to be much higher. Every year, 1.5 million African children are left  without a mother because she dies trying to give birth to a brother or sister. The risks in child birth are a struggle faced almost exclusively by poor women, with 99% of maternal mortality in developing countries. It is astounding in this era of medical advancement, that so many women continue losing their lives giving birth, and it is for this reason that Maranatha Health have chosen to focus on improving maternal mortality in Kamwenge.

Despite what I know, every now and then I wonder if what we are doing is worth it – maybe the situation in Uganda’s health care system isn’t ALL that bad.

Then, I read an opinion piece by Frederick Golooba-Mutebi in this weeks East African:

Maternal deaths: Why Ugandans are victims of their own civic incompetence

Recent media reports detailing the tragic deaths of expectant women and their unborn or newly-born babies in referral hospitals and health centres across the country have laid bare the crisis in Uganda’s healthcare system and made a laughing stock of the NRM government and its extravagant but empty claims about being focused on service delivery.

The anger, despair and disgust the many preventable deaths have caused are captured in the decision, reported in this column last week, by activists to take the matter into their hands and drag the Museveni government to court.

Reports from the “grassroots” indicate that in some cases relatives of the victims take matters into their own hands and threaten health personnel with violence. Others, however, behave as if their experience were the natural order of things and simply return home to bury their dead.

Before the decision of activists to enlist the law, only in a few isolated cases had victims of Uganda’s shambolic maternal health services sought to enlist the help of the police or courts of law. Two cases stand out.

One involved the death in early May of one Joyce Nabatanzi at Nakaseke Hospital, allegedly because nurses had been negligent. I have no idea how or where the story ended. However, a senior officer who claimed his staff were hardworking attributed the incident to the hospital having run out of essential drugs and supplies without which lifesaving surgery could not take place. Several phone calls to the National Medical Stores had not led to the desired response. To make matters worse, the hospital did not have an ambulance to transfer the patient.

The other was of a couple who lost a baby at Jinja hospital, also because of alleged negligence by nurses. The bereaved woman spoke for herself: “These people should improve. I heard countless insults from the nurses using obscene language. They handled me like I was a thief, pulling me from all sides.”

Unwilling to accept what had happened, her husband filed a case with the police. Here, as in Nakaseke, the hospital lacked drugs and supplies, as the father pointed out: “I bought everything since the hospital did not have the needed items to facilitate delivery.”

To add insult to injury, he could not get a post-mortem without coughing up more money: “Now someone tells me if I want a post-mortem, I have to give the pathologist transport.” According to a police officer on the scene, this was not the first time incidents of this kind were happening at the hospital.”

With all this in mind, it is difficult not to equate going to give birth at a public health facility in Uganda to going to war. As with combatants in war, here too, there is no way to tell whether one will come out alive.

There is, however, a sense in which combatants going off to war are better-off: They do not buy their own uniforms, guns, bullets, bombs, boots, or even food.

Meanwhile, expectant mothers going into government facilities must carry their own food, gloves, razor blades, sugar, tealeaves, bedding, basins and even saucepans. You have to see it to believe it. You would be forgiven for thinking they are moving house.

It is all too easy to buy into stories of the by now legendary negligence of health workers in Uganda. That is until you learn a thing or two about the conditions many face at work. Consider these statistics, which appeared in a recent newspaper report: Hoima hospital has 97 staff out of the 197 required. It requires 56 nurses but has only 34. It is run by eight doctors out of the required 35.

A brave nurse summed up how things work over there: “There is no other option than doing what we can and leaving what we can’t. What do we do when things are beyond our reach?”

The essential virtue for a life in Africa

Considering the amount of time and energy I have of late invested into learning the virtue of patience, I thought it would be appropriate to find out an accurate definition of this word that encapsulates so many of my challenges:

pa·tience  –noun

1. the quality of being patient,  as the bearing of provocation,annoyance,  misfortune, or pain, without complaint, loss oftemper, irritation, or the like.

2. an ability or willingness to suppress restlessness or annoyance when  confronted with delay: to have patience with a slow learner.

3. quiet, steady perseverance; even tempered care;  diligence

All 3 of these definitions considered, I think my steep, stumbling climb towards the mountain peak of patience is moving along. Slowly, but I am moving. Of course, all is relative. I mean, how exactly do you define ‘without complaint, loss of temper, irritation or the like’? Such ambiguous terms…

One of the many wonderful things about being in Uganda is the unremitting opportunity I have to work on this virtue. To set up an Organisation from scratch, there are many many registrations, hoops to jump through, walls to scale, and lines to wait in.

I often look longingly (and yes, slightly jealously) at the many foreign volunteers wondering around Kampala, as they enjoy their weekends off of work, a spring in their step from the freedom that comes from knowing the buck does not stop with them. They need not worry about registrations & regulations, of NGO certificates & tax issues and of course the ongoing sagas of legal issues and land boundaries.

Michael and I have lost count of the number of days we have spent waiting in lines, at offices, & searching in vain to find unstipulated officials to sign unstipulated letters.

Last week we spent the week in Kampala attempting to obtain work visas.* The following takes place over the course of the week. We had absolutely all of the documents that were listed, and others that were not, just to cover all possible bases. Nervously, we entered the Ministry of Internal Affairs, where a swirl of mostly defeated looking people were waiting in lines for passports, visas and all manner of documents. By chance, we stumbled upon a helpful office lady. She pointed us in the direction of ‘window B’ which seemed to be the place to obtain visas, which we quickly deduced by the number of weary mzungu standing nervously in line for their n’th attempt at a visa.

Attempt 1: In anticipation, we step up to the window, exchanging greetings in a futile attempt at cracking a smile from the woman that could decide our fate. After a failed attempt (Michael’s charm normally works on Ugandan women, even I was smiling!) we explain that we need the “G” work visa and have all documents. Without even glancing up at us, she declares we need to submit all documents in a folder.

Attempt 2: An hour later, we are back with said folder. However this time, we have the wrong receipt from our NGO registration application. So, we call our Ugandan brother, who has the receipt, and he gives it to us that evening at home. Already, my ability to ‘suppress restlessness’ is waning.

Attempt 3: We now have necessary receipt and come smiling smugly to the counter in the morning. But alas, that is not enough. She now sends us off to get an official signature from the NGO board, where we spend 2 hours talking with the secretary (she was very helpful actually) before returning with the signature.

Attempt 4: It is now lunch time and everyone has knocked off for a good hour or so.  We are told to come back around 2 or 3. Slight ‘irritation’ developing.

Attempt 5: Begrudgingly, we hand over the file, in folder, with receipt to the same woman. This time she does flick through the file, but it seems we need another letter signed by one of the Ugandan board members. We have one, but it doesn’t say exactly the right thing. I do not do this ‘without complaint’. My patience is clearly wavering, and I show it.

Attempt 6: We arrive the next day, our patience becoming more and more compromised as the days pass us by.  We have the letter, as our Ugandan father who we live with in Kampala is on our board. This time, however, we had the wrong type of folder. Apparently this is a serious concern, and she advises us to go and purchase the correct one immediately. I struggle to remain ‘even tempered’ with our interaction this time.

Attempt 7: We come back armed with all documents, receipts, signatures and of course, the special folder. This time, she is happy to accept it – however, only after the photocopy of my passport is rotated 90 degrees within the file to look more ‘suitable’. It is only at this point that she presents us with the main issue at hand. Currently, there is no chairperson to preside over the Ugandan Visa Board, and so we will not be able to get a work permit until such time as they hire someone to fulfil this role. In the meantime, we must apply for a ‘special pass’ visa. In despair, I take the application form for the special pass. By this time, I am past having a temper. Perhaps that is what patience is all about?

Attempt 8: Armed with the special pass application form, we wait in line, praying to God that He may miraculously intervene in this situation in order to prevent us from taking drastic or violent action. It seems He does intervene. The woman takes our documents, the file, our special pass application – and then our passports. In return for the only identity we have in this country, she gives us a little slip of paper from the Department of Immigration that has scribbled on it our names and nationality:

Our current 'passports'

So with fear and trepidation, no passports, & the vague promise of a special pass visa in a week or so, we leave the Department of Immigration, Internal Affairs.

If you are the praying type, pray! 🙂

*Disclaimer: I am ABSOLUTELY aware of the ridiculous difficulty that foreigners are confronted with trying to obtain work visas in Australia, and think that it is equally ridiculous. I certainly don’t want to single out Ugandan bureaucracy, but am merely sharing my experience.

 

Samaritans and strangers

Ugandans are incredibly generous.

Not in the way that Australians are generous. Most of us volunteer our time to a cause at some point, when it suits us, outside of our own space and family, perhaps with a little of our finances, ensuring that the boundaries are neatly carved in stone from the beginning.

I have resolved that the next 10 years of life in Uganda is going to be one big, challenging, uncomfortable lesson in generosity.

“but a Samaritan, as he travelled, came where the man [who was beaten and robbed] was; and when he saw him, too took pity on him. He went to him and bandaged his wounds, pouring on oil and wine. Then he put the man on his own donkey, took him to an inn and took care of him. The next day he took out two silver coins and gave them to the innkeeper. ‘Look after him’ he said, ‘and when I return, I will reimburse you for any extra expense you may have’….

Jesus told them: “Go and do the same.”

Most of my friends have heard this story and know it well, whether they have an active faith, have grown up in a Christian family, are agnostic, or have no religious background at all. The ‘good Samaritan’ story has found its way into everyday language in Australia and around the world. Law in Australia even dictates that Doctors cannot be sued for trying to help a person in an emergency, under a ‘good Samaritan’ clause.

But who of us actually lives this day in and day out? I know I wouldn’t even have a clue how….

And then I came to Uganda.

I don’t know why or how it is the way it is. But every Ugandan family I know well, has at some point taken in someone (often many) who needs looking after, be it a single mother, a struggling student, an orphaned child, or a grieving window who needs some TLC.

In Australia, we pride ourselves on having ‘sponsor children’ that we pay a few dollars a week to, receive a pat on the back from our chosen donor agency, and continue with our lives unaffected. But actually taking a child into your home? Getting messed up in their lives? Risking the safety and privacy and finances of your own families for the sake of a stranger?

Time and time and time again, Ugandans invite strangers in need into their lives.

Children/teenagers/young adults that are not theirs (often there is no blood relation) are invited to live with them.

They feed the child

They pay the school fees

They become ‘mum’ and ‘dad’

They ensure the child has the same opportunities they would want for their own biological children.

A good friend of ours in Kamwenge has several children of her own. Then she has ‘adopted’ a few extras along the way. She makes no distinction between those that are hers by birth, and those she has met and taken in along the way.

As she was telling us in a matter of fact way the other day, one of her ‘children’ she met in town at the shop where he worked. When he lost his job and had nothing to eat, she invited him to live with her. Several years later, he has had vocational training (sponsored by her) and she is now helping him with capital and resources to set up his very own business. He still lives with her.

We were speaking with a friend recently, about the length of funerals in Uganda. He explained that one of the reasons they take so long (and by long, we mean sometimes a week or more!!) is because the close relatives and friends of the deceased sit down to discuss what will happen to the remaining immediate family members. Especially when there are children involved. They will negotiate who they will live with, who will pay their school fees and medical bills, and who will supply some food for them and when and how. They plan for the child to be looked after until they are an adult.

Now, I don’t want to be unrealistic or fantasise Ugandan culture. There are a lot of people who aren’t generous at all, just like anywhere in the world. And there are lots of situations where this network of support breaks down.

But what a wonderful way to try and live! Now I just need to get over my selfishness…