Tag Archives: africa

The ethics of scarce health resources did not begin with Covid 19

A lot can change in a week.

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This little person with big cheeks was not very happy to be admitted to hospital today!

When I boarded my flight in Adelaide on Thursday, travelling to Uganda where the not-fot-profit Hospital my husband and I established 10 years ago is located, I wasn’t overly concerned about Coronavirus. I wasn’t too anxious about what the current state of affairs may mean for my time in Uganda or to be honest, the world at large. The talk amongst my circles was primarily that the media had been ‘sensationalising’ coverage for weeks, leading to a moral panic and in some cases racism. Cases in Australia were low, and my region had (to my knowledge) no community transmission.

By the time I arrived in Dubai, new measures were being put in place. It seemed overnight not just Italy but now the whole of Europe was erupting with cases. On the departure board when I stepped off the plane, people gathered around to see the flights canceled. Going through security, regular announcements were made by staff, alerting travelers who were transiting through Europe to the US to rebook via different routes. The day I arrived in Uganda, the Australian PM introduced self quarantine measures for all people entering Australia.

A few days earlier Uganda issued quarantine measures for people travelling from 17 different countries, leading to a situation where I was 1 of only 3 Anglo-saxons on the very empty flight to Entebbe. Arriving in Entebbe, many Ugandans were surprised to see me. The customary handshakes that last the whole conversation which I have grown to love, were absent. I felt under-suspicion, a potential carrier of this much-feared pathogen.

My choice to use social distancing while here, just in case, has been appreciated by Ugandans but it has also been met with amusement. For this glorious time, the disease has not risen out of deepest darkest Africa. Africa is largely safe, while the rest of the world is plagued (literally) by this virus.

Now, DFAT are recommending Australians abroad to return home, immediately.

Honestly? I have found it difficult to arrive at the decision that I need to come home early. There is valuable work to be done while I am here, and I wanted to use this trip to have as many useful conversations as possible. My heart (as always) is torn between the needs of Maranatha Health, and my own need to be with my kids as the world rapidly changes. I am unsure if flights will be canceled, if airports will be shut. I am hoping that I don’t pick up a simple cold virus while here (which is a distinct possibility considering it is the wet season and I am working in a kids hospital!) because I worry I won’t be allowed on the plane. The idea of further separation – beyond 2 weeks – from my still-young children is like a hovering dark cloud over my time here, yet it feels like an extremely superficial concern considering the state of our world right now.

These are all my own small personal anxieties, none of which effect quality of life to any significant degree for me.

The desire to curb the spread, to ensure our health system won’t be overwhelmed, is a noble one. But listening to discussion happening in Europe (and now Australia) regarding the ethics of treatment when there may not be enough ICU beds – has again exposed the deep chasm in our world, between those who have money and access to health care, and those who do not.

Health economics, and the perplexity of treating patients when there are scarce resources, is not a discussion topic I am new to. In fact, working for MH for the better part of a decade, it has been our lived reality. Uganda has around 0.09 doctors for every 1000 people – compare this to Australia, whose ratio is 3.59 doctors per 1,000 people.  Currently Uganda has 55 ICU beds, mostly reserved for the very wealthy. Whilst for most in the West these conversations about overloaded health systems remind us of surreal, post apocalyptic scenarios we may have watched in B-grade movies, for me they conjure up our dining table in remote Kamwenge, Uganda, my feet tapping with frustration on the cold concrete floor.

The stale air of a warm rainy-season night

The smell of cooking fires from across the valley

The crunch of grass underneath feet as our security guards diligently watch over the hospital premises.

And Michael and I, in our late 20s, in passionate debate over the ethics that confront us in our management of the rapidly growing demand at our hospital: patient protocols and reasonable resources and especially-needed equipment and an overcrowded ward with far more patients than beds.

Should we stand by the ethics of the greatest good for the greatest number, or the dignity of every life, or first in first served, or prioritize the poorest, or the youngest, or the ones with the greatest chance of survival? What is the right thing to do?

These considerations did not begin with Covid 19. And they are not conversations that only happened hundreds of years ago before the introduction of modern medicine. These are the lived realities everyday for the heroic health workers in the majority of the world.

These are conversations that happen in this era, in this world, in this time.

Even today at the hospital, we were discussing some challenges with the MH solar system with an electrical engineer. When mains power goes out (which it does regularly) we have been overloading our solar system, causing some batteries to swell. We need to replace these batteries, and add more, but the costs are prohibitive to us right now. Alternatively, the expense of running our big noisy generator through long breaks in power is also incredibly high. The other option is to cut down on some key equipment when power is off. The options when the power goes out are to cut back on: essential lab machines that help us with accurate diagnosis; a refrigerator that keeps much needed blood required for transfusions cold; or the life-giving oxygen concentrators that are drawing a LOT of power. If we only used one concentrator at a time (we have five) the system wouldn’t overload. But during busy periods, or after surgeries, we might have 4-5 kids who need oxygen.

This conversation lasted 15 minutes, without reaching a solution. A conversation for tomorrow.

The ICU discussions in the media take me back to one of our first group of neonates in Kamwenge. We had received one donated humidicrib from Australia, and had (at the time) only 1 oxygen pump that could connect to two patients. We had 3 neonates, all who were born very early – a set of twins and another little baby. We encouraged kangaroo care with the mothers (a good practice anywhere in the world!) and then offered them each a certain allotment of hours in the crib each day, hooked up to oxygen. If one of the neonates breathing became laboured, we would switch before the allotted time.

Only 1 of the babies survived.

It was tough. Mostly for the mothers, but also for our staff and for me. I was new to this reality of little babies in little cardboard box coffins being carried back down the winding dusty path away from our clinic, balanced on top their mother’s head. It was my first jarring and bitter taste of injustice, swallowed while the world nonchalantly continued spinning around me.

Ugandans are strong. They are resilient. Despite all the trauma of day-to-day life, they seem to be able to rise up, out of the ashes, time and time again – and keep living. I think the living Ugandans do, despite the uncertainly and all-of-life toughness, is extraordinary. Like someone at work said to me today of Coronavirus and everyone’s fears: “these things come and go…but we push on”.

So,

just for a minute

lets press pause.

Think about some of the uncertainty we have faced in the last week. The unknowing. The fear. The confusion around jobs and salaries and school closures and what might happen to the economy. The distrust that the government has our back, that there will be enough food and toilet paper and resources to go around. That our health system (for once in our entire life time) may not be able to cope if Covid 19 swallowed Australia as it has done to parts of China and now Europe.

And imagine, for a minute, that life was always like that.

This fear and risk we are swimming in is a glimmer of what the world’s poor are accustomed to every day. And when Coronavirus hits Africa – there won’t be many ICU beds and I doubt there will be flattened curves to ensure health systems can manage. There will be lots of people with underlying health issues such as HIV and malnutrition, and, well, poverty. But alongside all of this there will be the indestructible human spirit that Ugandans seem to possess in droves.

But may I ask something of you? Instead of fearing for ourselves and running to the shops to stock up – lets use this temporary suspension of the norm to put ourselves in the shoes of those whose lives are always uncertain – and remind ourselves of what we normally take for granted.

And despite the mounting economic pressures and the looming recession, let’s be generous. This world needs generosity now more than ever. Extend generosity to those around you, to those vulnerable in our own communities, to those who find themselves unemployed currently – yes.

But also to the multitudes of not-for-profits around the world (Maranatha Health included!) who are on the front lines fighting for a more certain world for those who have never tasted it.

 

The Spiders of Maranatha

In the western world, I often feel like people look upon Africans and their capacity as two dimensional. They are cast into suitably simplified stereotypes – uninspiring roles created and promoted and published over and over again, particularly by the NGO industry. The same story is retold by the swathes of voluntourists who visit Africa each year, in search of the ‘unique’ African experience to remind their followers how un-ordinary their own stories are.

Do I sound frustrated?

I am. I have heard these stories for a long time now. I am guilty of proudly propagating them myself when I was a young volunteer. And I STILL see them on charity TV advertisements when I return back to Oz.

What are these stories, you ask?

The first – and most common – is the ‘tragedy’ of Africa. Swollen bellies. Faces swarming with flies. Sick, HIV infected mothers. Famine. War. The hopelessness of black-skinned victims, passively waiting for the white saviour to come and give and rescue – whether it be by giving them sponsorship, school fees, peace, a goat, or to be looked after at an orphanage.

The other story is one of only resilience and joy. All the children are so happy. The music is amazing. The laughter. The dancing. The community and parenting that is so natural compared to what we do. But this story is only partly true: it idealises the exotic, and in doing so ignores the deep suffering that takes place when one is poor. It ignores the unjust system that allows for striking global inequality to continue. And it absolves us Westerners of any personal responsibility to work towards transforming the system and redistributing our wealth.

Craig Greenfield (whose reading I am a little obsessed with currently) discusses these two stories, in a fantastic blog on this topic and puts it far better than I can.

“When we name only the tragedywe cast poor people as pathetic victims who can do nothing but wait for an outside savior. And we end up framing all our responses to poverty and injustice around ourselves and the money we can raise….

On the flip-side, when we name only the resilience, we gloss over the very real challenges faced by people living on the margins. We romanticize their lives….we ignore our own complicity in an unjust system. Apathy reigns supreme.”

Craig goes on to suggest that instead, we should be naming the tragedy and the resilience, telling these stories alongside of each other to show both the heart break but also what is happening from within these communities to transform them from the inside.

This story, I think, can actually be quite difficult to tell. It is for me. In the past, I am guilty of swinging wildly  towards one side of the pendulum or the other. This swinging was borne out of my immature but determined attempts to inspire people in Australia to act, but simultaneously rewrite the far-outdated stereotype of ‘deepest darkest Africa’.

Stereotypes are so easy to fall back on. They often suit the narrative that we like to hear about our lives. Real or imagined – I cannot quite be sure – I still occasionally feel pressure from Australians to recount the story of MH with us as the heroes: ‘Michael and Kim Findlay, bravely moving to Africa and setting up MH alone in the face of so many local challenges, bringing health care to the sick, hopeless poor of Uganda’. *shudder* Even now, when we have this incredible staff team actually doing the work, I sometimes feel that donors following at home would prefer us to be the heroes.

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Circa 2009 – young and naive, standing on our newly acquired land in Kamwenge

But in this scenario like in so many others, stereotypes seem to do us an incredible disservice. They take away the beautiful but ordinary complexity of life. And, more importantly, they are simply not real.

Nowadays when I speak about Maranatha Health and our work in Uganda to people back home, I am often lost for words. Not because I don’t have much to say on this topic, but because I am trying to find the words to bring people’s human-ness to life. To be a witness to their experiences of injustice and tragedy, but also their immense capacity for resilience and as agents of change. To combat the natural distance and over-simplification that people tend towards when hearing about another culture.  I so often wish I could transport people from Australia into Maranatha Health morning meetings to show the utter ordinary-ness of it all – the funny stories told by our staff, the times when no-one can be bothered talking, the laughter, the frustration at a patient’s bad decision making, the teasing of each others quirks the way families do, the counter-cultural compassion for their poorer community members, the annoying requests for salary raises, the wisdom from our team when problem solving an issue, the care for each other when grieving an unexpected death, the reminders not to use too much social media at work….

I wonder if this would allow Australians to see our staff as they are: flawed and ordinary and inspiring and skilled humans who are working hard (most of the time!) to improve the opportunities in their community.

In the blog I mentioned before, Craig Greenfield shares the Cambodia proverb: ‘It takes a spider to repair its own web,” making the revolutionary but obvious point that ‘the spider, the insider, is the key player’.

I find this an incredibly useful analogy. A web, like any system, is complex and beautiful and fragile. And repairing it takes time and precision and intention and the efforts of the spider itself.

Our staff, like the spider, are fixing their community from the inside.

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The most recent staff picture (minus quite a few of us). How times have changed!

Of course…

in the interest of being authentic, Maranatha Health didn’t start quite like this.

There was a time when Michael and I, as outsiders to this place, led every meeting. Wrote the details of every policy. Treated every patient. Made every staffing decision. Created every roster. Visited every community and met with every government official we worked with. That was when MH was in its infancy. We were also young and collecting experiences and building an organisation and growing into our roles…

and still learning how to let others shine.

When we were doing all of this, it was our dream for it to be a fully Ugandan organisation. To empower and equip and up-skill and resource and release into the world an organisation – a movement – that would be transformative from the inside and demonstrate to the wider community the kind of health care that should exist, offered by Uganda’s own people.

And now…this dream has unfolded before our eyes.

These days, I am utterly in awe of our staff. They are doing everything.

They manage, they protect, they record, they treat, they implement, they strategise, they improve, they teach. They are Maranatha.

They are the keepers of the vision now.

And Michael and I? We are becoming sidekicks. Technical Advisors. Supporters. Strategic oversee-ers. Learners.

And witnesses to this incredible example of how to be a community and how to transform health culture in Uganda.

And it’s pretty darn amazing.

Kamwenge’s quirks

Arriving home to Kamwenge 2 weeks ago, it dawned on me one of the things I most love about living and working here. The community, my staff, and the Maranatha Health site produce a constant stream of hilarious live entertainment.

Not in a patronizing “this place has lost its marbles because it’s an African backwater” kind of way, nor a “what have I gotten myself into by moving back here” kind of way. I have more developed a simple appreciation for the nuances and quirks that remind me every day that I am living in a rural area of western Uganda. Coming back after a few months away, has certainly allowed me to see the world through fresh eyes, and what last year I may not even have noticed except for a small shrug and a smile, is now on my radar again. It’s a fun time!

So I wanted to share some of the examples I could think of, just in the last week:

Let me start with a classic Kamwenge story that left Michael’s medical mind gob-smacked. Several days ago, a tired grandmother came in with a wailing 4 week old newborn. The grandmother explained the mother had dropped the baby at her doorstep and left her to care for him. She had been giving it cow’s milk, an extremely less than ideal situation since babies that young struggle to even digest the milk enzymes. One of our clinical officers insisted to her that the baby needed breast milk. Reluctantly, the grandmother agreed, than casually fished out her droopy dark boob and offered it to the baby. Even more bizarre – there was milk there and the baby started to suckle!! The grandmother’s youngest child was 9. Only in Kamwenge…

Continuing in the maternal vein, a woman was very much in labour at our clinic the other day, as is the norm. She was told to stay in the delivery suite, since she was almost fully dilated. But stubbornly, she ventured out, walking into the staff compound. I passed her and one of our security officers pacing near our home, and enquired why she was here. The security officer Paul shook his head meekly and suggested quietly “sincerely, you can’t manage [order around] a woman when the baby is ready to come”. Then gave me a desperate, pleading look which I translated as “please for the love of God don’t ask me to order this woman off the staff compound and back to the clinic”. A few minutes later she stubbornly delivered the baby right there on the grass, with the help of our midwife and a plastic sheet from the trusty mama kit!

The work visa issue has reared its ugly head once again. This time we are up to 7 months worth of attempts, but thankfully are not far away from completion. Michael called a contact in immigration the other day to ask if he could check on the file, which was a few offices away in the same courtyard. The response was priceless: “it is raining too much – you call me back in one hour.” Who would’ve thought rain could have such an impact on life’s possibilities!

The sense of community here always makes me smile. I visited the one bank in Kamwenge yesterday to drop off a cheque, and was met with smiling faces and echoes of ‘welcome back’, before people asked how my family and friends were back home. After the greetings, the inevitable moment arrives when everyone (and I mean everyone – from the MH groundskeepers, to our regular diabetes patient at the clinic, to the bank staff) comment on my fatness. *sigh* Here’s hoping that one day big becomes beautiful in Australian culture too.

Then there was the back-up taxi driver who has occasionally (read reluctantly) picked up blood from Fort Portal (2 hours away) and delivered it to the clinic. Kamwenge taxi’s are normally Toyota sedans that carry up to 15 people in their ‘5 seater’ cars. We urgently needed blood this week. So when the blood bank finally gave us the word that they had some ready and packed for us, we begged this guy to help us. He refused, reminding us last time he had to wait a long time for the blood and missed out on passengers. We called again and begged. This time, a pastor had boarded the vehicle, and reprimanded him:  ‘It is the right thing to do and you will be saving lives – God is watching you!’. We got our blood. You can always count on a pastor pulling people into line in Kamwenge taxis.

Then there is the continued obsession with my fertility for most people in Kamwenge, considering I have been married four years and not yet produced. *gasp!* (In Australia it could be argued that that is normal and a decision that is made by the husband and wife alone.)  Alas, I live in Kamwenge, and I think some are actually making it into a hobby. Each day now, our young newly employed midwife at MH asks me the obligatory question ‘Kim, when are you coming for antenatal?’ to which I always reply, ‘My dear, you wait!’…

One part of life I have never been so keen on is the reminder that meat comes from animals (I know, I am soft and should be able to face facts even as a city girl, etc). Visiting the butcher in Kamwenge always provides a solid reminder. We have a staff party tonight, which should be a lot of fun. However, we now have 2 goats and 3 chickens wondering around the MH compound, and I am sorrowfully trying to remain emotionally unattached, knowing that I have a rare opportunity to eat fried chicken and roasted goat tonight! I walked out of my house 15 minutes ago to see one goat being skinned while the other was tethered nearby and forced to watch his fate – surely that is animal abuse!

So there is a snap shot for you for the first 2 weeks of hilarity at home in the ‘wenge. Hope you enjoyed it as much as I did!

The woolworths of Kamwenge: ‘The fresh food people’

Going to the food market is one of my favourite things to do in Kamwenge.  I normally go to the market a few times a week to buy our fruit and vegetables.

The market, with the dusty well-worn path leading to the semi-undercover, crumbling old building full of wooden stalls and umbrellas and loosely hung material shade; with its neat piles of freshly picked garden vegetables and mothers sitting lazily at their stalls chatting in Rukiga; the market that is brimming with life.  The market proudly presents the picture of Uganda that I love the most: the localness of all things, the respect and time for relationship, the placid pace of life, and the now-familiar smells of Kamwenge: the smell of  dust, smoke from charcoal stoves, matooke, boda-boda fumes and most importantly, lots of ankole cows. Now, it has become a part of my everyday life.

When I first started coming to the market, no one knew the story of this strange white girl – she buys her own food from the market? She cooks? She walks? She carries the food in our local baskets? One of the first times I went there I wrote about it in my journal:

“I asked for green pepper. The woman took my hand and guided me past several little food stalls, each selling the same food – matooke, rice, sweet potatoes, cassava, groundnuts, millet, spinach, tomatoes, a million different types of banana, and pineapple. I am careful to avoid the spread of fresh beans, maize and sorghum laid out on sacks on the uneven ground, drying or waiting to be sorted by hard working women doubled over at the waste, ensuring the purity of their produce. Most people would look at me in shock but smile their jovial Ugandan smile, surprised that the Mzungu has braved the food market; it seems this is a rare occurrence.  Mischievous kids follow behind me cautiously, the light pitter-patter of their bare feet drowned out by their chanting of ‘mzungu’. A few are daring enough to come and hold my hand. As I pass one stall, a little semi-naked boy playing beside his mother’s vegetables begins to quiver, then shake, then scream at the top of his lungs and cling to his mother’s legs in a fit of fear at the sight of this strange ghost-like person. It must be his first time. The mother tries to sooth him between her own fits of laughter. She catches my eye and I laugh and shake my head, as a crowd gathers around entertained by the boy’s reaction. This is my first time causing someone to hyperventilate – I feel caught somewhere between a super-celebrity and a school yard bully. But alas, the boy calms as I continue on my way, now loaded up with a limited variety of fruit and vegetables.”

Now when I enter, I am met with familiar faces greeting me in the Batooro pet-name the women there have chosen for me. So much of the beauty and strength of communal living is disrupted and distorted in Uganda these days; but it seems this is one of the places where it stays true to form. And for a brief moment when I am there, I also feel a part of this living, breathing organism. The women allow me to practice my Rukiga on them, free of the laughter and ridicule that I sometimes find in town. They help me stumble over new words, teach me phrases that I didn’t know, and throw in free produce when they have excess, well aware I am a loyal customer. I hear their stories of illness and burial, of the woman at the corner stall who has just lost her daughter because of an obstructed labour, or the struggle of a bad harvest for a particular food due to the never ending dry weather. I also laugh with them now, when they introduce their shy children who don’t quite know what to do about the muzungu that knows their mother…

And in return? I can offer almost nothing, except to buy their fresh food at fair prices.

Bazungu are human beings too!

Most people that come and live in east Africa for longer than a few weeks agree on one thing: being called a Muzungu [white person] all the time is frustrating. Being constantly referenced in conversation (to you or about you) by your skin colour rather than your actual name is a little tiring. Being the centre of attention relentlessly, because of your colour, is exhausting. When I arrived, even professional people would sometimes address me as Mzungu in conversation. Men would call out ‘Mzungu’ and laugh at me when I walked by in town.  The Boda Bodas [motorbike taxis] would holler for my attention ‘Mzungu we go?’ Captivated children would follow me in the street as if I was the pied piper, yelling the classic ‘Mzungu, how are you?’, daring each other to run up and touch the strange women in their midst.

When I first moved to Uganda it made me angry, because in Australia this would be considered racism.  I have adjusted a little since then. It also doesn’t happen as often in Kamwenge these days.

People are a bit more used to me, and many know me personally. Men don’t call out as much because they know I am married, and some have been seen by my husband at the MH clinic. Many of the Boda Boda’s are now my friends and greet me with ‘Hi Kim’ (or the equivalent Rukiga greeting). Our staff know it is unacceptable to use that term…

But it continues. However, now that I am a little more adjusted to the African psyche, I try not to get quite as annoyed – at least not in the village [emphasis is definitely on the trying…]. People are often just excited. I am a mystery to them, especially in a place like Kamwenge. Many haven’t had experience with someone who doesn’t have chocolate brown skin. The interesting thing is that Ugandans very commonly refer to people very frankly by their appearance, a characteristic or tribe.

“The fat one”

“The brown one” [the one with slightly lighter African skin]

“That Munyankole woman” [a tribe in west Uganda]

“The mad one” [the one with mental illness – that I will never get used to…]

I must confess that a year in Uganda has influenced me a great deal. While in Australia I will (hopefully remember to) never use these statements, in Uganda I have found myself quite regularly using similar descriptions when speaking with friends and colleagues. It is not offensive here.

The other day I attended a funeral in a very remote area of Kamwenge district. A friend of mine, someone we are working with in our community programs, lost his wife in childbirth. Devastatingly and unnecessarily. I wasn’t sure about going; I was conscious of the fact that my presence would disrupt and bring attention, and I didn’t want to be insensitive. But I’m glad I made the decision to go, as it meant a lot to the community that Bosco (a MH staff member) and I were there.

When we arrived, I went and sat on the ground with the hundreds of other women that were there, refusing the chair in the marquee where the family members and VIPs were sitting. I thought it would detract attention from me, and would be a strong unspoken message about where I see my role in the community.  So many people had not seen a muzungu before. There were many lingering looks, chuckles, whispers, and the occasional freaked out wailing child who perhaps thought I might eat them (??). Many came up and touched me. Others actually shook my hand. People wanted to know if I could speak Rukiga. All in all, there was quite a bit of fuss made.

But then there was a group of wise old village women observing all of this, not that I was aware of their presence at the time. Later, Bosco gave me a rough translation of what they had said to the younger crowd, and it made my heart soar:

“Leave this young girl alone! Don’t look at her all the time, don’t laugh at her! You are making her feel shy, look you can see she is embarrassed…

…Bazungu are human beings just like us!”

Yes, we are.