Jinja photos

Here are pictures from Jinja.  Jinja is a smaller city about 2 hours east of Kampala by microbus. I took a weekend trip there to visit Reagan who is a child I sponsor through Amazima and got to see the headwaters of the Nile at the same time.

https://picasaweb.google.com/vancefelton/Jinja

Entebbe photos

At long last I have started sorting through my pictures from Uganda. For those of you still linked to the blog, here are pictures from Entebbe.

https://picasaweb.google.com/vancefelton/EntebbeUganda

More to follow . . .

Seattle, Nalgenes and CPAP

I'm back in Winston now after a pretty long trip a week and a half ago that started out in Fort Portal on a Thursday morning around 8AM and ended in Winston on Friday night around 9PM with some extended layover time in Entebbe (where I filled my time by swimming at the Lake Victoria pool and jumping off their 30 ft high dive along with a quick visit to the zoo) and in London-Heathrow (occupying my time by staring bleary-eyed out the airport windows, reading Wind, Sand and Stars and finally giving in and lying down on two chairs). Now it's back to life in the South and almost excessively hot weather already despite only being the middle of March.                                          Picture taken with permission of the mother

After the last post which was pretty heavy, I figure I ought to post a more uplifting post about things I saw in Kiwoko to help balance things out a bit. My last two days at the hospital were spent in the NICU which has the capacity to care for around 30 infants or so. It's actually a pretty modern unit with incubators for all the neonates thanks to support from the ISIS Foundation in Seattle. I hadn't spent much time in the NICU at Wake so it was good to get some exams of these really small babies under my belt. The babies ranged pretty broadly in their acuity and prematurity with the really small ones checking in at under 1 kg and hanging somewhat precariously to life while the ones on the other end of the spectrum were basically hanging out and eating and adding weight every day while they waited to hit the minimum weight needed to be discharged.

There were 22 babies there the first day I was there so examining and writing up the plans along with Jill who was the physician in charge took a while. About the time we had 3 or 4 babies remaining to see, a baby in respiratory distress who had just been born was brought in from Maternity. The baby wasn't particularly premature but had clear signs of respiratory distress (fast rate of breathing, increased work of breathing, nasal flaring, intercostal retractions, supraclavicular retractions). Initially we bulb suctioned his mouth and nose and got a O2 monitor on him which showed sats in the 70's if I remember right (normal would probably be >93% at Kiwoko's altitude.)

He didn't show much improvement so Jill broke out the CPAP (continuous positive air pressure) machine which had just been given to the hospital by the ISIS folks and had only been used once before. It had been developed by some people in the US I believe as a low cost alternative to expensive CPAP machines found in the West. CPAP is designed to help open up and keep open the alveoli that can be collapsed in these little babies. It basically consisted of a Y valve that split the flow from the O2 concentrator and one side went into a 1L Nalgene bottle filled with water and the other side went into the nasal cannula in the baby's nose. The pressure that the baby received was regulated by how deep the tubing was lowered into the water in the Nalgene which had markings that indicated the relation of the depth to the air pressure the infant received. Once the back pressure in the nasal cannula exceeded the marked water pressure, the excess air would flow into the Nalgene and bubble out which operated essentially as a pressure release valve and helped maintain a constant pressure. If more pressure was needed the tubing could be lowered farther down into the water and vice versa.

After only a few minutes of CPAP the baby showed marked improvement, began breathing much more comfortably and had much better O2 saturation. We finished our rounds and went to lunch and when we checked back in after a couple hours he was doing so good that we were able to take him completely off CPAP and off oxygen and he did fine.

It was great to see how such a simple adaptation for the third world could make such a big difference and get the baby over that critical hump in the first few hours of his life. So big props to ISIS and Seattle and the people who designed that basic Nalgene CPAP machine. The one part of the equation that wasn't cheap was the O2 concentrators which are quite spendy and which many poor hospital wouldn't necessarily have. Since this NICU was well supplied, there were a number of them available to use and we actually had to use two in tandem to get the desired pressure. However I just read about a CPAP that uses aquarium pumps that are much cheaper and may be a more affordable solution for many of the third world hospitals out there. http://www.nytimes.com/2011/09/27/health/27breathe.html

HIV

Before coming to Uganda I hadn’t worked with many HIV positive patients in my time at Wake or known many friends who were HIV positive. That changed as soon as I hit the wards in Kiwoko. My first day in the hospital started off pretty routinely as we saw a number of fairly stable patients and discharged a good number before going to lunch. On our return from lunch however, I quickly was hit with the reality of medicine in rural Africa. While we were eating lunch, a 7 year old girl had been admitted with some vague symptoms of fever and diarrhea and not feeling very good for a few days. In this part of Africa, malaria always springs to mind as well as a few other things, one of which is HIV. The mother said the child hadn’t been tested for HIV but that she was negative. We ran some tests and went off to see other patients.

Later in the day, a nurse came up to us and said a patient of ours was ISS positive. I didn’t know what ISS was so I asked Phil, who I was working with, and he explained that it was a pseudonym for HIV positive that made it easier to discuss with patients in front of others. I asked him which patient was positive since we had seen a number of patients and I couldn’t remember who we had tested and what their names were in the busyness of learning a new hospital system. He said that it was the little girl and my heart sank. Her life had changed in an instant with the diagnosis by no fault of her own. Suddenly she was facing a dramatically altered life expectancy, social stigma by some, the need for lifelong daily medications, potential difficulty finding a spouse and facing difficult questions about having kids to name just a few of the issues that accompany HIV. It was tough for me to wrap my mind around the injustice of a seven year old getting that kind of sentence so undeservedly. On further investigation, it was also revealed that her mother and father were HIV positive as well, but the mother had known about her status previously but had been dishonest when questioned.

Unfortunately that little girl is not an exception among our patients here. Since that first day I have seen numbers of patients here who are HIV positive, some of whom are clinging to life by their fingernails while being racked by opportunistic infections trying to take their life. Very commonly in the morning when we round, we’ll hear about another one of those patients who was on the brink who didn’t make it and died overnight. It is really heartbreaking as you see the life and death struggle played out on an almost daily basis with these patients who you get to know as you treat them, pray for them, encourage them and hope strongly that they will recover only to see them lose their battle with the disease.

Not all of the patients who have died since I have been here have been HIV positive but a huge number of the patients seen at Kiwoko are HIV positive (close to 60%) and have an uphill battle when they get sick. This battle is even harder if they forget to take their anti-retrovirals for a few days or don’t have the money or time to get to the hospital to pick up their medications in time and allow the virus to develop resistance to their medications. Once the first line drugs are no longer effective, there is one second line drug that is provided free of charge and after that they are out of options. It becomes a waiting game until they die since there are no free third line drugs available to them.

In spite of this tough reality, circumstances are much better than they were in the early days of HIV when there were zero options for the people of Uganda. Now, if they are adherent in taking their medicines and coming to their clinic visits they can experience a much longer and fuller life as a result of the free anti-retrovirals provided by foreign aid. Still as a health care provider and human being, it is hard to watch these patients die while still only in their 30’s and 40’s because of the effects of HIV.

Africa Time

I got my first introduction to Africa time early on in my stay here in Uganda while I was waiting for my bags to arrive from London. The first hints of the leisurely (lethargic? sluggish?) pace of work came when ordering food at the local hostel. Meals routinely took over an hour to be served even if I was one of the first people ordering food and somehow they still took forever even after I began to alter my orders to try to speed the process of getting calories into my hungry stomach. Eggs and toast can’t take that long can they? How about 1.25 hrs plus or minus a few minutes? In my two days at the hostel, I started to mentally adjust my day’s schedule to factor in waiting at least 1.5 hrs for each meal and tried to decide whether I needed food badly enough to spend that much time waiting.

When my bags arrived, I called the baggage delivery company at 8 in the morning to confirm they were there and see if they could deliver them right away. I was quite ready to get my bags since I had been waiting for two days and was rather scruffy and smelly from wearing the same clothes in the hot equatorial sun and not showering for all that time. Plus I wanted to get a decent start in heading north to the hospital that day. The hostel was only 10 minutes from the airport so I thought it would be easy for them to send a driver over with my bags. They said that they could deliver the bags but told me to wait for the driver to call regarding the delivery time. An hour passed with no call so I called them back and was told again they would contact the driver and he would call me. 45 min went by with no call and as it was now close to 10:30AM I finally called them and told them that I would pay for a taxi and come and pick up the bags myself. So ten minutes later when I was getting ready to leave for the airport, the delivery driver called the hostel to say that he was going to deliver my bags sometime around 11. I told them to not touch my bags as I could see visions of chasing my bags all around Entebbe and dashed for the airport before my bags disappeared.

I was reminded of Africa time today as I was waiting to be picked up for a community medicine day. I was riding along with an HIV counselor on a motorcycle doing home visits with HIV positive patients while he checked in to see how they were getting along and offered nutritional advice, encouragement and saw if they needed to come into to the hospital for new or worsening symptoms. My ride was supposed to arrive at 10 so I went back to the guest house a couple minutes early in case he arrived right at 10. I had a suspicion that it might not be 10 sharp so I sat down on the porch to read the The White Nile by Moorhead while I waited. Around 10:20, I walked over to the office to make sure they had actually told the counselor I was going with him since this was the first time I was supposed to go out. He assured me that the counselor knew so I resumed reading and didn’t concern myself with the time since my book was quite good and I had no idea when to expect him. Right around 11, the motorcycle arrived and the counselor said he was ready to go, so less than a minute later we were off. I was glad to finally be off and excited to get to visit some local people in their homes. The excitement dimmed somewhat when scarcely two minutes into the ride, the counselor mentioned he had some business in town to do so after our rapid exit we promptly parked at a storefront office on main street and proceeded to sit for 20 or 30 minutes waiting for one of the city government workers to arrive.

In both cases things worked out fine as I did get my bags and the community visit went off more or less as planned. We eventually made it to the community and it was interesting to meet the people who lived scattered around the area in their small mud houses and who were facing the daily struggle of subsistence farming while also dealing with the reality of being HIV positive. These events did clearly demonstrate the considerable cultural differences in expectations regarding promptness and work efficiency and it was a good reminder to me to always factor in more time than I think when planning my schedule in Africa and to always have a good book or soccer ball around to fill in the time.

Kiwoko

Got to Kiwoko (“Chuhwoko”) almost a week and a half ago after making my way up from Entebbe via taxi, microbus, and motorcycle. Kiwoko is a small town about 13 kilometers down a bumpy dusty road off the Kampala-Masindi road. It’s an agricultural area with lots of banana and mango trees, skinny cows and a few brick huts scattered here and there. The area is not a tourist hot spot to say the least. It merits zero mentions in either the Lonely Planet or Bradt guides and is primarily known in Uganda for its central role in the civil war in the 1980’s. The Luweero Triangle, where it is located, was the epicenter for the uprising in the 80’s that eventually unseated President Obote (who succeeded Idi Amin) and placed the current president Museveni in power. As a result of being the headquarters for the rebellion, the Luweero Triangle was the site of brutal fighting between the government and rebel forces and many atrocities against the local population were committed. It is estimated that 250000 people died in the area, many of whom were innocent civilians falsely accused by one side or the other of aiding the opposing forces.

Today Kiwoko is known locally for the hospital which provides the highest level of health care available for many miles around. It was started by a Christian physician from Northern Ireland who visited the area in the immediate aftermath of the violence of the 80’s and felt led to establish a health center and provide care to the traumatized and medically under-resourced area. From a small health center, it has grown to a hospital with 230 beds, providing OB, surgical, medicine and Peds care to thousands of Ugandans a year. The physician staff is a mix of Ugandan and expatriates and an ever-rotating group of visiting expatriate med students, nurses and resident physicians. Currently in the guest house where I’m staying there’s a Brit, two Germans and myself.

Internet access has been spotty here but hopefully I'll be able to post a little more regularly this week. Occasionally however the internet goes down in the whole country so that makes blogging a little bit harder.

Splashdown

The flat snow-covered plains of France swept by underneath the plane mile after mile as I gazed out the window on the flight south from London to Entebbe. Suddenly the farmland was replaced by the sharp teeth of the Pyrenees which guarded the passage to the sunny climes of Spain. The Mediterranean next came into view followed by my first glimpse of Africa which was unexpected to say the least. Looking down as the coast came into view, I saw the shoreline rise up to a range of snow-covered mountains that extended many miles from the coast. After all my mental imagery of Africa as the land of the steamy jungle and hot desert sands it was surprising to see North Africa with significant amounts of snow and looking quite wintery to say the least. Eventually though the Sahara won out and the snowy ranges gave way to hours upon hours of sand and darkness fell.

Flying into a new third world country at night is always a bit of a disconcerting thing I have found, whether you experience the unsettled feeling before the fact or when you actually arrive. Coming into a poorer seemingly less safe country alone where you don't know the language, geography, or customs always seems to provoke some moment of anxiety during the preparations for the trip when some of your worst fears float in and out subconsciously and you picture yourself being mugged by thugs as soon as you step outside the door.

This moment came and went a few days before I left on this trip and as our plane banked over Lake Victoria to land in Entebbe I had no apprehension only a desire to get off the plane after too many hours of being stationary. Two hours later, after unsuccessfully searching for my bags that decided to stop and see the sights of London, I was riding in a taxi breathing in the humid air of Lake Victoria with a moon hanging languidly in the midnight sky amazed that I was actually in Africa.