Wednesday, 25 August 2010

Full Circle

Since we were unable to get home from Rwanda in a timely fashion, I missed the first day of the neonatal resuscitation training. It felt right to be finishing off my year at Mulago in the same way that I'd started. Following our recent 3 day programme, we had cut the training down to 2 days.  We planned to run 3 courses back to back.  Domalie and Agnes were willing and eager as ever, and so my missing the first day was no great shakes, especially as only 7 candidates turned up for the training.  The numbers on the first of the 3 sessions were very disappointing.  Fortunately by the end of the week, they had picked up significantly, and we trained a total of 60 midwives in a week.  Several midwives from outside of the hospital attended for training, and so hopefully this will help spread knowledge to other clinics and healthcare centres outside of Mulago.  While Domalie and Agnes delivered lectures, practical demonstrations and critique, I had my head down, wading my way through the maternal death audit case files, determined to finish before leaving Kampala.  It took a lot longer than anticipated, and I was still beavering away the morning that my flight was leaving Entebbe, but I managed to collect data from all of the files available.  I felt guilty that I had not spent my last remaining weeks doing clinical work, but was also determined to tie up my loose ends and fulfill a numbers of pledges.

We had BP machines attached to the walls on Ward 14 and also ordered and took receipt of 17 mattresses, which were bought with money raised by Heather, Lorraine and Rebecca, and their friends and family.  I met with the matron to discuss her vision for the future of the department from a midwifery perspective.  I had a good nose around the new labour ward too, which is a fantastic use of the space available to put it in,  and a much more pleasant environment than the current labour ward.  The medical students finished off their SSM project. 

I bought enough African souvenirs to sink a ship, and then realised that I might not be able to get them all home.  I decided that I was going to sacrifice many of my clothes in order to get them home - I was prepared to abandon all of my possessions entirely to get a painting home which I had bought, by an artist named Edison Mugalu.  It typefied for me everything about the year I had spent in Uganda, and more broadly East Africa.  The easiest thing to do was to divvy up the spoils between Alan, the Boda guy, for his wife, and Doris.  Now, I'm not a waif, but Doris is a tad larger than I am.  She managed to wedge herself into one of my poisoned pink bras that had seen better days, and over the following few days turned up to work in a selection of my clothes.  My possessions almost became a free-for-all, 'Your bag is nice, can I have it?'.  Doris was fantastically happy.  My Mum asked me to give Doris a small gift from her, to thank her for looking after me.  She was overjoyed.  When I asked her what she would spend it on, she exclaimed 'Laundry and shoes!'  By that, I think she meant clothes.  I hope that she enjoyed it.

I spent time with the boys in the house, chilling, eating, chatting - although not about our impending leaving dates.  It felt strange that time had suddenly crept up and I was in my last week of being in Kampala.  I caught up with friends and bid them farewell.  Frequented my favourite haunts for the last time.

My last day at Mulago was Tuesday July 28th.  I took in a couple of cakes to the morning meeting, as is customary.  I was unable to say very much to accompany the cake, other than thank you.  There was too much to say to too many people, and I was choking the tears back before I'd even opened my mouth.  But I think the sentiment was understood.  I was then presented with a number of very unexpected gifts - baskets, bowls, pestles and mortars, straw mats and carvings.  Having already packed my stuff, and with a modicum of concern about the weight I was already trying to take home, I had to pass them on to Shireen and Amelia, and Carol and Louise to take back for me.  I said a lot of goodbyes.  There were some people that I missed, that I really wanted to thank, and bid farewell to.  But I also wanted to leave quietly.

I spent the next couple of days finishing off the audit.  On the Wednesday, I was invited to the launch of the Ugandan Parliamentary Scorecard, the project that Adam had been working on throughout the year.  There were rumours that the President would be there to launch it, however he was unavailable, and so the Prime Minister came instead.  We sat through several lengthy presentations before Adam stood up and said his piece about what the scorecard actually means.  Then followed another lengthy speech before the Prime Minister stood up to speak, prompting a fit of giggles from me as he attempted to clear his throat while shouting the word 'capture', at the same time. The presence of several TV cameras didn't do anything to help matters, and I was helpless for a good ten minutes.  It is not uncommon for me to get a fit of giggles in inappropriate places -weddings, masses, first holy communions, funerals, formal dinners - but rarely have I done it on camera.  We were on the news.  I just hope that the Prime Minister didn't see me.  My giggling was avenged by one of the heaviest rainstorms I've seen in Kampala, and the heavens opened, as if on cue, almost the second we left the hotel.  By the time we got to Garden City, we looked like drowned rats.  I was so cold I had a hot chocolate.

The day I left was hard.  I had some photos printed for Alan, who insisted on walking to the mall with us as it was our last day.  I wandered through the go-down taking photos, trying to capture the place in all its glory, and not succeeding.  Maureen came round to say goodbye.  I showered and changed.  James, the driver, arrived early, as predicted.  I said goodbye to the dog, who put his head on his paws as we loaded the cases into the car, and he whined.  I couldn't speak to Adam, we just hugged each other.  We didn't need to say anything, it was hard enough already.  I will always be grateful to Adam and Elizabeth for their unswerving friendship and support.  Without them, I am sure that I wouldn't have lasted the year.  They were my rocks.  I said goodbye to James and Maureen, and George the guard, and after cuffing Pasha round his ears one last time, got in the car and headed to Entebbe...

Tuesday, 17 August 2010

Um Bongo, Um Bongo, there is none in the Congo!

The day after the girls left, I took Sunday to rest and recuperate.  Elizabeth, Adam and I went off to the spa for an afternoon of pampering.  Adam and I opted for the couple's massage, since it was cheaper, resulting in much hilarity as neither of us wanted to witness the other in the buff.  There was much theatre with towels and sheets in order to avoid any unnecessary flesh exposure.  It was much needed, and after the masseure let loose what felt like an elephant on my back, neck and shoulders, I felt significantly less tense than before I'd started.  We finished off our girlie day by subjecting Adam to Sex and the City 2 at the cinema, which he endured without too much whinging.  Meanwhile, Shireen and Amelia, medical students from Liverpool, who had an SSM project planned at Mulago, landed at Entebbe.

On Monday morning, we began what was to become the very frustrating process of applying for ethics approval for the project.  The project itself was a very simple straightforward proposal, which involved taking routine vital signs observations and equating them into an early warning score, which would trigger when patients were becoming ill.  The plan was not to use these scores to guide care, but simply to see firstly whether it was feasible to collect such information, and secondly to use it as a pilot for a larger validation study to see whether the scoring system actually worked.  The girls were not planning to take any measurements that the patients should not have had done already, and were not planning to use the information to alter patients care.  It had been approved by the University of Liverpool's ethics committee, and so we were hoping for a straightforward process.  Simples?  Not so.  The first time it was knocked back was because it was not in the standard format for the hospital's ethics committee.  Frustrating because we had asked before we submitted it whether the format was acceptable, and the secretary had said yes.  It was knocked back a second time because the information sheet was not in the local language, and various other spurious reasons.  This wouldn't have been quite as annoying, had we not already questioned whether the information sheet needed to be in Luganda.  The process dragged on for the whole time that the students were at Mulago, and so unfortunately we had to adapt the project and they ended up doing retrospective and prospective audits, looking at compliance with the current post-operative care protocol.  This yielded interesting, if not surprising information about post-operative care in women who had had emergency caesarean sections at Mulago.  The information will be shared with the department and hopefully this will provide evidence that will help to influence the care that the women receive.  It's just as likely to sit in a filing cabinet and never see the light of day, which would be a shame.  Louise Ackers and Carol Porter arrived on the Thursday to work on some stuff for the Liverpool Mulago Partnership and experienced similar frustrations with a project that they were trying to get off the ground.

Meanwhile I finally got round to wading through the patient case notes to complete the maternal death audit for 2009.  I managed to get hold of 180 of the 186 sets of casenotes for women who died last year.  It was much more difficult and took much longer than I had anticipated, but I was determined to complete it and get good information so that I had a fairly accurate picture of why the women that die at Mulago die.  The causes of death range from women who have complications of induced abortion - sometimes performed by themselves - to women who die because there is no blood available.  Eclampsia and hypertension, sepsis, complications of HIV, burst abdomens and obstructed labour were all culprits as well.  I still need to process the database to write a report.  For the first time ever I felt like I'd done a really useful audit that will be informative - I even enjoyed doing it!  It took me the best part of 3 weeks solid work, but was worth it.

The weekend was spent relaxing with friends, and on Sunday morning, Alan, my boda driver invited me to his house to meet his family.  He lives with his wife Joyce, and their 3 children Sly, Lydia and Lilian in a small mud walled house about 7 feet wide by 10 feet long.  It is divided by a piece of fabric and the walls lined with dismantled cardboard boxes.  The bike is kept in the yard, where Joyce prepares and cooks the family's meals.  I spent an hour or so playing with the kids and watching bad Ugandan music videos on TV.  After having photos taken, which I printed out for Alan as a keepsake, I went back to the house to get ready for a poolside afternoon at the house Carol and Louise were staying in, a lasagne and way too much gin.  Which turned out to be a pretty safe place to watch the world cup final.

We were totally oblivious to the fact that 3 bombs had exploded in public places where people had congregated to watch the match, until Alfred collected Amelia, Shireen and myself from the house shortly after midnight.  The explosions happened at Kyadondo rugby club, which is less than a mile from our house in Naguru, and at the Ethiopian Village in Kabalagala.    The morning after the bombings the roads were eerily quiet.  On arrival at the hospital there were crowds of people outside, red cross workers everywhere and lists of the dead and injured posted on the walls outside of casulaty.  The rest of the hospital seemed to operate as if it was business as usual.  It was quite surreal really.  Fortunately nobody I knew directly was in either of these places, but several people I work with lost friends or family.  Suddenly Kampala was on alert, and armed guards, soldiers and police emerged outside every public place in the city, scanning machines installed and searches instituted.  People were worried, and stopped going out to socialise.  Somali Islamic Militants were swift to claim responsibility, which prompted something of a backlash by Ugandans in the city against Somali immigrants and refugees.  With many Africn leaders due to descend on Kampala for the AU summit, the atmosphere was tense and nervous.

Three days after the bombing, I was sitting in the departmental library with Shireen and Amelia, working through our respective audits when pandemonium broke out outside.  I went out to see throngs of people running and shouting to one end of the hospital, on each of the floors.  The words 'Bomb scare' swiftly spread through the crowd like a wave.  There we were, stood on the 5th floor, with the stairwells jammed with people panicking.  It was the first time I had felt genuinely frightened in Uganda.  And then, almost as quickly as it kicked off, it all settled.  It turned out that someone was running amok, snatching mobile phones out of people's hands, and had grabbed the attention of several onlookers while being chased by security.  I didn't want to be in the hospital.  I realised how vulnerable we were, in such a large institution that lacked the capacity to properly screen every single person who walked through the door.  I decided to get out of town for the weekend.

Adam, Elizabeth and I took a trip to Lake Kivu, Rwanda.  Elizabeth was already in Kigali, so the gruesome twosome took the Jaguar night bus from Kampala to meet her there.  We had been on the bus, sitting at the bus station, for about 5 minutes before a man stood up, puked in the aisle and behind one of the seats, and got off.  The bus crew came on with a bucket of water to swill it around and a sheet of cardboard to cover it up and hide it, before the bus departed from the depot.  Sleeping in moving vehicles is not my specialty, so I spent an uncomfortable, very cold night trying to rest my eyelids, lying across two seats, while Adam sprawled himself across the three seats in front of where sickyguts had let out his rainbow yawn.  About 8 hours later we reached the Rwandan border where we were required to get off the bus and go through the necessary formalities.  By this time, Adam is wearing a kagoul, shorts, beige trouser socks and brown flipflops, and looked like someone who should not be allowed contact with vulnerable people.  After getting our stamps and having our luggage searched for contraband plastic bags, we were allowed back on the bus.  As we were about to settle back into our spots, Adam discovered that he had spent much of the night lying in a small puddle of vomit.  Much to my amusement.

We arrived in Kigali whortly afterwards, stopping for breakfast on the way to Elizabeth's where we had a shower and got changed.  While Elizabeth went to a meeting, Adam and I went to the Kigali Genocide Memorial.  I can't describe the impact that the museum has on you.  It's almost impossible to comprehend the scale and brutality of the massacre that happened in 1994. The museum is divided into three parts, the first devoted to the Rwandan genocide, the second to other genocides that have happened and the last part of the museum is dedicated to children who were victims of the Rwandan genocide.  There are a number of large photographs of happy, smiling girls and boys, many of them toddlers.  Beneath each photo is a small plaque with information about their name, their favourite food, their best friend, their favourite toy, how they died and their last words.  The effect that those little bits of information had on me was something I'll never forget.  By the time we left the museum, the pair of us were snivelling, puffy eyed wrecks.

We took a bus to Gisenyi.  More of a van with many seats in actually, and much difficulty was encountered trying to find the right place to get the bus from in the first place, but once we had a ticket secured, we had time for a cold beer before boarding.  We left Adam to watch the bags, since he doesn't like beer, and when we returned he had stocked up on crap food from street vendors to help him survive the 3 hour journey.  We took an unhealthy taxi from the bus stop to the hotel, which appeared to run out of petrol as we pulled up to the gates, checked in and ate some fish.  I was absolutely exhausted, having had no sleep the night before and spending a ridiculous amount of time sitting on buses.  My head hit the pillow and I was out like a light.

Lake Kivu is beautiful.  Peaceful and quiet.  We ate breakfast on the lakeshore and relaxed to the sound of nothing.  I sat on the beach and read my book, enjoying a bit of downtime, and glad to be away from a city that had suddenly become a very stressful place to be.  Beer o'clock came early - at around 3 - and went on until around midnight.  Two friends of Elizabeth, Giorgio and Dudu came and met us at the hotel and tried to persuade us to cross the Congolese border for a night of partying in Goma, which we politely declined.

We headed to the border with the DRC the following morning.  As usual the Rwandan side of the border was fast and efficient.  It seemed that the boys had not made it back from the DRC until morning and we saw them having what looked to be a very fraught conversation with a number of official looking gentlemen.  We elected not to try and find out what the problem was, hoping that they weren't on their way to a police cell.  

The bureaucracy on the Congolese side of the border was something else.  We were standing in the queue, when the girl in front turned round, and I recognised her as a medical student from Kings who had been at Mulago almost a year ago on elective.  It was a bizarre happening, of all the places in the world we could have both been.  Once we eventually got to the front of the queue, our passports and money disappeared goodness knows where, which left us nervous for a good 10 minutes.  Once we had our stamps we were ushered round the back of the building to have our yellow fever certificates checked.  I have carried my yeallow fever certificate all over the world, and ordinarily it doesn't leave my passport wallet, but for some reason, I had taken it out and left it in my bag, which was 6 miles away back at the hotel.  Elizabeth didn't have hers either, and she had a rapid, slightly heated conversation in French about how the certificate was elsewhere with the woman behind the desk.  After much discussion, they demanded that we pay a $20 fine to compensate for our lack of a certificate.  I couldn't help but point out to them that charging us $20 was not going to stop us spreading yellow fever, which in hindsight probaby didnt help.  We refused to pay the bribe, at which point they said that we could try and cross the border.  So we did...

I have never experienced such a change of atmosphere between two places as between Rwanda and the DRC.  Almost as soon as we crossed into Goma we received verbal abuse and unwanted attanetion from bike taxi drivers and random pedestrians on the street.  There was a sinister atmosphere about the place, the streets were pretty empty and nowhere looked welcoming.  We got as far as the roundabout in the centre of town, when a group of 4 men began to follow us.  We decided to cut our losses and leave.  We were in the Democratic Republic of Congo for exactly 58 minutes.  I was glad it was no longer.  It was the worst $35 I've ever spent.  Nice stamp though!

That evening we headed back to Kigali, to discover that the night bus we were supposed to take back to Kampala was cancelled.  We caught the early morning bus, and spent the journey sweating, being covered in dust that the bus kicked up as it screamed through Rwanda and Uganda, watching Ugandan and Tanzanian music videos, badly choreographed and danced by pelvis thrusting dwarves in ill-fitting velour tracksuits, interspersed with clips from a Westlife karaoke DVD.  It was truly awful.  10 hours later, and looking more orange than we'd started, we were home.

Sunday, 25 July 2010

Misadventures in Mombasa and beyond

The girls travelled off to Nairobi, the night we got back from Murchison, leaving Kampala at around 2.30am in order to catch the first flight to Nairobi.  The plan was that they would follow the route we had taken when we went to Mombasa some time back.  I received a text message to say that the night train to Mombasa wasn't running that night, and so I put my travel agent hat back on...  After several hours of frantic phone calls to bus companies and airlines in Nairobi, and hotels in Mombasa, flying round Kampala on the back of a boda boda to the airline offices, the girls had tickets to Mombasa and an extra night's accommodation at the Castle Royal Hotel.  When they arrived at the Castle Royal, it turned out that there had been no running water for 3 days, and their room was a dump.  It also transpired that there was no other accommodation available in the city.  Travel agent hat went on once more, and although they had to spend the night where they were, the Serena beckoned the next night.  

I flew out to meet them, arriving at the hotel on Saturday morning.  The Swahili coast was as breathtaking as I remember it being, the suntan lotion was slapped on and I thoroughly enjoyed soaking up the rays - it felt like I had been in the hospital for so long without having a weekend to properly relax.  Heather and Rebecca took a ride on a camel, and I wandered along the beach, chatting to the touts.  Miriam sells Kangas to tourists.  It was the usual 'look at my stall' in the beginning.  I rarely buy stuff when I'm away, I seem to get it home and it's never quite as nice as you thought it was when you bought it.  And so I plugged my usual 'I've been here for a long time, I have a lot of this stuff and I don't need any more'.  Then I got the 'I have to feed my family' line.  I asked Miriam whether she was married... She said that her Kanga stall was her husband, 'Much less hassle than a human one, doesn't argue, answer back or drink my profits away'.  I agreed to consider going back and having a closer look the next day.  In the distance, somewhere in the direction of the camel, I could hear the girls, now with an entourage of beach boys, singing 'Jambo Jambo' and smiling to myself, I wandered and found a place to sit and breathe in the fresh sea air.  

That evening we had planned to revisit the Tamarind Dhow for a dinner cruise, but learned that both boats were in the work shop for repair.  We settled for dinner at the Tamarind Restaurant instead, that was delicious, oysters, crab and prawns being the order of the day.  Returning back to the hotel, sleepy and sated, I fell asleep swiftly and had the best night's sleep in ages.  The girls had an early flight via Nairobi to Zanzibar, I had a direct flight mid-afternoon, and so took the opportunity of a lie in...

Arriving at the airport in good time, excited about the prospect on being in the tin can for less than an hour, I walked up to the check in desk and presented my passport to receive the dreaded words 'Your flight has been cancelled'.  'What?!'.  'We can fly you to Nairobi tonight, there are no more flights to Zanzibar today'.  'You're going to fly me to Nairobi?  I don't want to spend a night in Nairobi'.  It seemed, however that I didn't have a choice.  And so, off to Nairobi I went, on my own, feeling very pissed off and a little bit sorry for myself.  I had been so excited at the prospect of sitting in the cliff top restaurant at Coral Rock in Jambiani, with a glass of Kilimanjaro as the sea breeze blew in through the open terrace.  

Instead I found my self in the Panari Hotel, a gaudy business hotel with as much atmosphere as a vacuum and decor to match.   I settled myself into a striped black and white faux leather chair and wept into my beer as Germany thrashed England in the football.  Since Kenya Airways were footing the bill, I decided I wasn't going to pay extra for an a la carte meal, and settled for the buffet.  Big mistake.  I woke up at 3am with cramp.  By the time the bus came to collect us and take us to the airport I had become very friendly with the hotel toilet.  As I sat on the plane, I realised that it was not going to be a pleasant flight.  Unable to stomach any food, I really fancied a sip of orange juice.  As I took my second gulp, the captain pointed out Mount Kilimajaro on the right hand side, which I was unable to appreciate as I reached for the airsick bag and emptied my stomach of the previous night's meal.  The woman sleeping next to me didn't even stir, and the stewards ignored the bell.  I was grateful that the bag was wax lined as I carried it up the middle of the plane to dispose of it, chuckling at the message 'If this bag is used for airsickness purposes, please hand it to the steward'.  For a minute, I had contemplated depositing it in the seat pocket.   

The girls came and met me at the airport, with a day of activities planned.  Feeling slightly less peaky, we drove to a spice farm.  Having no sense of smell, is a drawback on this sort of tour, but I was interested to see the processes involved, and what spices actually look like before someone dries, grinds, bottles them and ships them off to Tesco.  Our guide showed us nutmeg, cinnamon, berries for making lipstick, hacking stuff down from trees and putting them into a banana leaf funnel to take home.  We got to the cloves... 'These are cloves'.  'That's lovely, where's your toilet?', as I was gripped by the familiar rumble, accompanied by a profuse cold sweat.  'Now?'.  'Now, now!'.  I was shown to the thatched toilet hut, knowing full well what was I was going to find inside.

At the age of 9, we took a family holiday to Scotland.  Having just left the castle that we had paid a fortune to get into, and entered the forest for a walk, I decided that I absolutely had to pee.  So I was instructed to go behind a tree.  As I squatted, my brother leaped out from behind said tree, scared the living daylights out of me, and I pissed all over my own trouser leg.  Since then, I have had major issues with peeing outside, or in squat latrines.  The words 'Asian toilet' send shivers down my spine.  Try as I may, I just cannot master the art of piddling in a hole in the ground.  And this time, I was not worried about urinating on myself.  It was something far, far worse.
I thought I was better, having relieved myself, and attempted to join in the rest of the spice tour, taking in one further spice - could have been bloody anything for all I know - before running back to the hut, making an executive decision to lose the trousers completely and whistle loudly to scare off other would be toilet users.  20 minutes later, I emerged and parked myself on a bench, lying still and wanting to die, while the rest of the group finished off the tour and had lunch.  They were deposited in Stone Town and I went to the hotel.

I was greeted by Pedro at Coral Rock, who gave me the option of 2 rooms.  'N2, that's the honeymoon suite right?'.  'Yes'.  'I'll take that'.  'Do you want to look at the rooms first?', 'No thank you, I'd like to go to the toilet, get into bed and feel sorry for myself', 'Oh, OK'.  And that's precisely what I did.  When Heather and Rebecca got back from their tour I joined them for a coke, skulking back to my room by 9 and stumbling back into bed.  So much for Island Paradise.  The next morning, I felt significantly better and we took a walk out to the channel to swim in the sea.  I had forgotten how blindingly white the sand was and how warm the water was.  Once more I really did feel like I'd found Heaven on Earth.  A tentative bland lunch seemed to be the way forward, and the afternoon was spent chilling by the pool and reading.  Remembering how good the food was the last time I was there, and craving some real sustenance, I opted for fish, which was delicious.  

My stomach begged to differ, and I was back to square one.  Once more my Zanzibar odyssey becoming a bed bound adventure.  Along with the bad weather, it served to sabotage our planned boat trip.  I can think of worse places to have gastroenteritis, but it's a bloody expensive place to do it.  Coke and water arrived at regular intervals, and by 4.30 I was feeling well enough to decamp to the pool for a quick dip in the water.  I was not much of a fun travelling companion.  Fortunately we rearranged the boat trip for the next day.  Once more, however, stormy weather off the coast, was to meddle with our plans again.  Instead, we headed back to Stone Town, this time I was feeling much better.  We meandered through the maze of streets, stumbling across little boutique clothes and craft shops, enjoying the leisurely pace, bartering with shop keepers and soaking up the atmosphere.  We found the Persian baths, a crumbling testament to former Stone Town days, stunning in their own way, but in need of a little TLC.  We stopped for a coffee before plodding onwards past the markets in the hunt for 'Two Tables' restaurant.  Down a back alley, this place is actually someone's house, that opens  in the evening for dinner.  Consisting of two tables in a conservatory of sorts, it's a gem.  We rang the bell, and heard someone shout down from an upstairs window.  We shouted up that we wanted 3 places for dinner, and were told to return for 7.30.  We continued on to Africa House for a leisurely lunch on the terrace, overlooking the harbour, in the company of 3 menacing monkeys that were trashing the bar with the help of 3 unruly children.

We wandered and shopped a bit more, calling into the Old Fort, and unsuccessfully bartering for some bowls, our final stop of the day was the 'House of Wonders'.  The first house in Zanzibar to have electricity and an elevator, it had clearly seen better days.  The hand stitched Dhow was interesting, but in reality, the Museum is badly laid out and badly maintained.  Which is a real shame, as it could be wonderful.  We wandered into the night food market, sampling some sugar cane juice and grilled bread fruit, watching boys jump into the water from the harbour walls, with varying degrees of acrobatic skill.  We stopped for a beer, before heading back to Two Tables.

On arrival, we were greeted by the head of the household, and invited to take a seat downstairs, and a small living room full of bric-a-brac, that would give any British Antique shop a run for its money.  After a short while, we were invited upstairs to the dining room.  We were served soup, followed by lentil curry and the most delicious Mandazi I have ever eaten, a portion of vegetable croquettes witha  spiced coconut dipping sauce, a small meat kebab, Marlin in coconut curry and fried Elephant bananas to finish.  It was gut busting, delicious, a wonderful experience - the family sat and watched TV as we ate - and incerdible value for money at $15.  Thorooughly recommended and worth hunting for.  Stuffed, we found our driver and headed back to Coral Rock.  We were greeted by a drunken Neil - the owner - who wanted to know what had happened to me since my last visit and why I wasn't being savage.  I explained that I'd been unwell, whereupon he insisted on buying us a drink and made us do the pub quiz which we'd missed.

Suddenly it was our last Zanzibari day.  The weather was dreadful, and plans to snorkel in the channel off the beach thwarted by torrential rain.  No sooner had we set off for the airport at midday, than the skies cleared.  It was a long day of travelling, arriving in Entebbe at around 8.45pm, as our plane was delayed.  James dropped us at Emin Pasha, where we met back up with Lorraine to hear about her 2 weeks at fistula camp, and travelling around South West Uganda.  We decided on a take out curry, which we ate in the hotel room on Emin Pasha's finest crockery, washed down with a few beers.  It was a late night in the end, I got home at around 1.  The following morning, Heather, Rebecca and Lorraine flew back to Blighty.  Having them around for a month had been great fun, it had been fantastic to share Mulago and some experiences there, but also the things we had done together outside the hospital.  I realised I was going to miss them all immensely, and that at the same time them leaving also indicated that with 4 weeks left in Uganda, my time was coming to a close too.

Photos are here

Thursday, 22 July 2010

A Bad Case of the 51's

Heather and Lorraine spent a further week at Mulago.  On the Monday morning I learned that we would not be able to move the HDU project any further forward due to building works happening elsewhere on the ward.  This was disappointing news as I had been reassured that the space we had created the HDU in was not going to be affected by the works, and a number of people had put a lot of time and effort into what we had managed to achieve already.  This news has unfortunately dampened my enthusiasm to push the project forward - which is a real shame as I felt I was going to be able to leave some sort of lasting legacy.  C'est la vie, as they say.

We ran a skills training morning which we opened up to all staff.  Disappointingly, only the midwives attended, but there were 15 in the group.  We covered Eclampsia, PPH, shoulder dystocia, neonatal resuscitation and vaginal breech delivery.  It was a really fun morning and I think that the staff enjoyed it as much as we did.  

We spent a drunken night making a poster illustrating cervical dilatation and positions of the fetal head...  I haven't had the guts to look at it again, as wielding a ruler, pencil and Pritt Stick after a third of a bottle of gin cannot possibly bode well for a professional looking product.  We were mostly on labour ward - and for the most part it was reasonable, apart from one day when I had been to meet a friend for lunch, and arrived to find Heather and Lorraine muttering curses as they ran from patient to patient.  The theatre was not up and running, the list was overspilling and there were several women who were causing concern.  Finally we got moving, and stayed around until the last patient that we had been involved with had been delivered - baby and Mum both did well.

Rebecca Smyth joined us that Friday, and the girls all moved out of Mulago Guest House and into Emin Pasha - a far superior abode.  I met them for dinner and drinks.  We made the mistake of eating a salad...

On Saturday morning, we hired a driver for the day, for our grand tour of Kampala.  Alfred collected Adam and I from the house, the three girls from the hotel and a radiotherapist called Kate from the guesthouse.  We then travelled to the Kasubi tombs, and important historical site, which is the burial place of four Kabakas (Buganda Kings).  The tombs were destroyed by fire back in March, but the site is still very interesting.  The tombs are tended by the wives of the Kabaka and subsequently their descendants.  Around the central building - ravaged by fire, covered in tarpaulin and a mess of mangled metal - are small thatched huts where the tomb attendants dwell.  As we entered the complex, we met the Prime Minister of Buganda, and spoke to him about how work was going on to reconstruct the tombs.  It turned out that there was a Buganda Princess with an entourage at the tombs that morning.  We wandered round, receiving snippets of information from our guide and meeting various people.  

We met an elderly lady who was responsible for looking after the tombs, sitting outside her hut wrapped in a large piece of barkcloth.  Our guide introduced the ladies in the group to her, and we each greeted her.  Because women are considered subservient, Adam was not permitted, due to custom, to greet her.  However, she let him know, that even though she couldn't greet him because of tradition, she 'loved him just the same'.  Our brief tour of the site concluded with our guide showing us a list of the different Buganda clans.  Heather happened to notice that clan 51, known as the Ekitibwa, was translated in the list as 'Shit'.  This obviously appealed to our inner schoolchild, especially since it is not permitted to eat the thing your clan is named after, and you're not allowed to marry a fellow clan member.  In other words, if you're a member of the Ekitibwa clan, you can't eat shit, and you can't marry shit.  I think I'd be ok with that.

From here we travelled to the Kabaka's Palace, to visit one very specific part of the site.  The Kabaka's palace itself, is not accessible, but the grounds contain an important and sinister piece of history.  Idi Amin constructed a concrete bunker here, where he and his soldiers incarcerated people and tortured them.  The chamber itself is accessed down a slope, flanked by imposing concrete walls.  The doors of the bunker are no longer there, nor are the sliding doors covering each of the 4 large cells, but it's complete enough to give you a sense of what it must have looked like.  The cells are raised up off the ground by about 3 feet, and the open part of the chamber was filled with water.  On the walls are bloody handprints and smears, and graffiti, inscribed by prisoners, and latterly by family members who suspect their relatives were victims.  It is a dark, dank, oppressive place.  In the far corner is a cockroach nest, and there's a colony of bats that move from one chamber to the next to roost.  I was glad to get back out into the fresh air, even though the heavens had just opened.

After the oppression of the torture chambers, and lunch, we headed to the National Museum, to examine the dust coated relics, paying particular attention to the educational text accompanying the exhibits.  For example, if you didn't know much about paleontology, a fossil is something which has been dug up.  Thanks for that.  I am now much wiser about what fossils are.  We stopped for a drink and a spot of craft shopping before heading back to the hotel to meet Judith Ajeani for a farewell drink.  Heather managed to miss the entire farewell session, in favour of spending time visiting the bathroom, and my stomach also decided that I couldn't participate for long.  We both ended up with a severe attack of the '51's'.  I headed home and spent the night burning up with fever, as the world fell out of my bottom.
We were due to head to Murchison early the next morning.  I felt like 51.  I called the girls and by this point Rebecca was also unwell.  And so instead of spending time journeying to visit the wildlife, the day was whiled away drinking flat coke and eating rich tea biscuits.  Having been relatively fortunate in my time here, I realised that complacency had got the better of me, where food was concerned.  Fortunately we were able to rearrange our Murchison trip, thanks to good old Fast Eddie.  Taking Monday to fully recover - and utilising the time to take Rebecca round the hospital and buy some more Africrap (read: souvenirs), finishing with a barbecue and copious deviled eggs - we started our trip to Murchison bright and early on Tuesday morning.

Fast Eddie excelled himself - literally - by making it to Masindi in 3 hours flat.  We ploughed on to the top of the Falls, where we took a leisurely stroll around.  What initially started out as 'This is a pleasant walk' swiftly turned into 'Kate Alldred, when I get my hands on you...' as the heat and terrain took its toll on a certain group member (Smyth).  Fast Eddie was on hand to help - thankfully - and everyone made it back to the car in one piece, nobody having been murdered, albeit sweatier and dustier than when we'd started out.  

We moved on to the Red Chilli Camp, and the boat launch.  Eddie had booked us onto a tiny boat, that carried no beer on board.  Not what I had requested and I told him so, in a fit of childlike tantrum, demanding to go on 'the big boat with the cool box'.  It worked.  I think it was my outburst that caused karma to break my camera, just as I was about to get a National Geographic head on shot of an elephant by the water.  The beer, however, was ice cold and delicious.  The usual assortment of game were out playing, with a particular abundance of elephants this time, and a good trip was had by all.  After a refreshing cold shower, dinner and a bottle of Nile, I was knackered and in bed by 9.  The game drive the next morning was great, with a tentative sighting of a leopard - which was a black silhouette skulking between two bushes - and a shoebill stalk.  There were dozens of giraffe out too, and a lot of the game was quite close to the track whereas previously ithe animals have usually kept their distance.  On the way out of the park we had 15 minutes of being attacked by Tsetse flies in the car, and a mass execution of trapped flies - using a copy of the Bradt guide as a weapon - ensued.  All flies out of the car we travelled to the Ziwa Rhino sanctuary, stopping for lunch in Masindi on the way.

At the rhino sanctuary, we tracked a family of rhinos, Baby Obama, who is just a year old, was stomping around with Mum and dad keeping a close eye on him.  We had a slightly hairy moment after Mum got annoyed with Dad and Obama's play fighting and charged him.  Dad then contemplated charging us and stood pawing the ground, facing us, as the rangers talked him down.  It was a privilege to see the family interaction and a worthwhile detour on the way back to Kampala.                                                                                                                                                                                                    

Wednesday, 14 July 2010

Doris Days 2

Two further conversations that have occurred with Doris in the past couple of weeks - slightly out of sync with the blog, but I have to write them down before I forget...

Doris; 'James, I have been seeing on the television, the thing that picks the football, youu know, you eat it sometimes'
James; 'What?'
Doris; 'You know, the thing for dinner, that picks the winner'
James; 'The what?!'
Doris; 'On the television, the thing with the legs like the spider'
James; 'Oh, the octopus!'

And then last night...

Doris; 'I saw it again, the thing like the flower, that lives in the water'

Today, on returning from work...

Doris; 'Kate, is Adam around?'
Me; 'Not yet, he'll be back, but later'
Doris; 'You tell him he needs to pay the cabbage for 3 months'
Me; 'The what?'
Doris; 'The cabbage people, they need the money for the cabbage for 3 months'
Me; 'Cabbage?'
Doris; 'Yes, you know that you put outside'
Me; 'Garbage?'
Doris; 'Yes, cabbage'
Me; 'OK, I'll tell him.  So what about the water, we were supposed to pay them weren't we'
Doris; 'Ah, I don't know when they are coming back'
Me; 'You don't know when they're coming back?'
Doris; 'No, it's because they're Indian'
Me; 'Right.'
Doris; 'Also, the liquid soap.  It is finished'

Can I bring her home with me?

Tuesday, 6 July 2010

How Many Ugandans Does It Take To Get a Midwife Down a Mountain?

Heather Nunnen and Lorraine Dinardo arrived from Liverpool one drizzly Saturday afternoon at the beginning of June, which seems such a long time ago.  I was excited about them arriving and about working with them at Mulago, but also nervous about what they would think of Mulago, and also about how I have adapted to the environment here and how that reflects in my clinical practice.  We had a very action packed 2 weeks at the hospital, and an equally action packed social calendar.  Which started almost immediately on arrival, with several beers and a curry, and confirmed my suspicion that we would be working hard, and playing hard too.

We spent Sunday doing the leisurely tourist intro to Kampala, including an obligatory trip to the craft shop 'Banana Boat' and met up with Alice Alum, who is the manager of the midwifery led labour ward here at the hospital.  Sunday evening kicked off with 7 of us piling into a car made for far fewer people, and as the resident hobbit, I drew the short straw, sprawling myself across the girls in the back seat, wedging my head up against the window and bracing myself for the potholes.  We arrived at the Ndere Cultural centre for a night of traditional dancing and entertainment.  We went on a cultural journey around Uganda, with most areas being represented in varying forms of colourful hip shaking, bum wiggling dance.  A number of staff from Mulago joined us, as well as a team from Canada and my housemates.  It was a fantastic show.

Monday started in earnest with the morning meeting, introductions to notable people within the department and a tour of the hospital.  The labour ward was fortunately quite quiet, although at the end of our tour round, we came across a flat baby that needed quite a lot of resuscitation, taking him to special care and commencing CPAP.  He recovered reasonably well, but it highlighted some of the problems that we face here.  We debriefed over a few beers and an Ethiopian in the evening.

Tuesday was a day of bureaucracy, and Heather and I trudged to the Nursing and Midwifery Council in the searing heat, to collect her registration certificate.  And got sunburnt.  We wandered back to Mulago, stopping to buy grilled sweet potatoes, and taking in the scenery of Wandegeya - coffin makers, cabinet makers, stalls selling everything from shoes to bath taps - before returning to the hospital.  I hosted a barbecue in the evening for everyone involved in the partnership, which went down well.  The star of the evening, however, was Alice's one-year-old daughter Anneke, who caught and held Heather and Lorraine's attention for much of the night.

Wednesday was a national holiday - Heroes Day - and so after some craft shopping at the National Theatre we went out to visit Enid at the orphanage in Buddo.  It's some time since I visited Enid last so it was nice to go back there and see how she and the children are doing.  Enid prepared a simple lunch of matoke with g-nut sauce, greens and beans, which we ate in her home with her mother. At Enid'e request, Agnostic Alldred, managed to stumble through something resembling a prayer, dragged from the back of my catholic educated mind, and we were then able to share our meal.  It was delicious.
After lunch we met the children, and Heather and Lorraine gave the stickers, books, pens, crayons, balls, parachuting men and a whole other selection of goodies to Enid for the children.  It was less of a free-for-all than the last time we went.  Enid told us a bit about her life, and how she got to where she is now, what life at the orphanage means to her and about her family.  We mucked around with the kids for a while before they migrated to their rooms, or towards the TV, and after a farewell prayer we headed back to Kampala and settled down for a Ghanaian meal.  It had been an emotional afternoon, which manifested itself as a need to have 'just one more beer'.  And for once, it was not me doing the encouraging!  We met my housemates at the casino - Avner was due to leave town and was having a blow out - which made for a late night.

On Thursday I pottered onto labour ward at precisely the wrong moment.  In the space of an hour we delivered 3 stillborn babies and dealt with a woman who had what we thought to be an eclamptic fit.  It was total chaos and by the time it started to settle we were knackered!  The day continued in the same sort of vein.  On Thursday, Norfolk Enchants hosted the best/worst pub quiz (delete as appropriate) ever conducted in the history of the world, at Bubbles O'Leary.  The major advantage to having to write and present the quiz is a free bar all night.  Which we took advantage of, since it would have been rude not to.  Friday was an admin (hangover) day for me, Lorraine stayed on labour ward and Heather went up to ward 14 for the day.  I arranged for the carpenter to return to measure up for the mosquito grilles on HDU. On Friday night, we had a leaving party for Avner, who has finished his time in Uganda.  Was gutting to see him leave, but we have many fond memories of the hairy Mexican/Egyptian/Israeli/Khazakstani Jew wandering round the house in nothing but pornographis moustache and a small towel.  I can hear him say 'Antisemite' at that sentence.  It was drunken, and ended at some ungodly hour of the morning.  And then we got up to drive to Sipi Falls the next morning.

Fast Eddie arrived at the house at some horrifically early time after the party.  Chi had slept in so we were a bit late staring out but Adam, Chi, Mbarara Mike and I piled into the van and picked up Heather, Lorraine and a random dude called Jason, from the guest house.  Eddie lived up to his name and before we knew it we were in Jinja, eating rolex for breakfast.  On the road out of Jinja, we were leafleted through the van window, much to Adam's annoyance.  The leaflets were advertising a Dr Brown and Professor JK, and claimed to be able to cure diabetes, improve your sex drive and get rid of the Tokoloshe (a dwarf-like water sprite or zombie), amongst 26 other wild claims.  I kept the phone number, just in case...  The journey was otherwise uneventful, apart from a torrential rain storm breaking just as the mountains came over the horizon.  We reached the Sipi River Lodge at around 2pm, and had lunch of sandwiches and locally grown, roasted and ground coffee.  After sorting out who was sleeping in which banda, we decided to go for a hike to the top two falls out of the three that make up Sipi Falls.

And so the fun began.  It was steep and it was slippy, and our guide didn't quite know what he'd let himself in for.  We got to the top of the first waterfall, before we started collecting people.  A number of children began to crowd around Heather, one or two at first and then a whole throng.  We heard lots of giggling, and at each corner when she caught up with us, she had more flowers about her person - in her hair, shirt, behind her ears - than before, and seemingly more kids.  We were almost stampeded by a crazed cow that came hurtling down the track, but veered off into a field and crashed through a farmer's fence instead.  We reached the base of the second fall, by now with around 12 children in tow.  We spent a few minutes taking photos in ridiculous poses before starting the trek down hill.  It turns out that our newly found troupe of children came in handy for steadying 'Grandma' as they had affectionately named H,  on her descent, as the track was slippy.  Ahead of the group this time, slips were usually preceded and followed by a loud 'AaaghAAAghArgh!', from Heather, and the accompanying infectious cackle of one of the kids, with or without a crash through  the undergrowth.  Naturally this set the rest of us off laughing and in some instances a domino of slips too.  We made it down from the mountain as night fell, covered in mud and soaked through from falling.  A welcome beer and a home cooked meal awaited us, and after a hearty feed and more coffee, we stumbled back to our banda and fell asleep to the sound of rushing water from the falls, and the creaks of the bunk beds as people shifted around.

The next morning we had a leisurely breakfast and then set off to tackle the lowest and largest of the three falls.  Heather elected to stay behind at the lodge and write postcards.  She definitely chose the sensible option, and I envied her choice as we slipped and slid down to the bottom of the falls only to get absolutley soaked on the way back up.  The views were spectacular though, and it was a great way to work off the previous night's dinner.  We had lunch before departing, getting 5 minutes down the road before Mike declared he had left his watch in the dorm.  We turned back to pick it up, I got paranoid and decided I had left my ipod - which I hadn't, it was in my bag all along - so frantically rummaged through my bags and the dorm only to find it in the last place I could possibloy have looked.  Chi jumped out of the van declaring that she had left her brain behind, at which point we realised we were all being ridiculous, and we set off back to Kampala for the second time.

We reached Kampala late, had dinner and headed home, ready for another week at Mulago, refreshed after a fantastic weekend in the great outdoors...

Photos are here

Sunday, 20 June 2010

Doris Days

Wow, the weeks seem to go by more and more quickly.  And my blogging seems to get less frequent.

We successfully completed the neonatal resuscitation course, and trained 11 midwives - one suffered a bereavement mid-course and didn't complete - despite one of the instructors getting malaria.  It was generally well received, although there were complaints about the food.  People complain about the same things, wherever you are in the world.  The three day format worked very well, although for subsequent courses we plan to run it for 2 days to keep the group sizes down.

The SHOs had exams for 2 weeks, so I covered the labour ward.  The first week there was me, one specialist and 1 to 2 interns.  Despite being extremely short staffed we managed pretty well I think.  I spent the Monday and Tuesday on the shop floor, while the specialist was in theatre with the intern.  I sutured cervical tears using the light from my mobile phone, kneeling on the floor.  I did some manual removals under pethidine sedation.  I ran around struggling to get blood, and then having to decide which of the three moribund patients - one massive APH with a live baby, one massive PPH and one severe malaria in pregnancy - who were O +ve to give the single unit I could get hold of, to.  We gave it to the woman with the APH.  All three women and the baby survived, fortunately.  I also resuscitated babies, dealt with complications of HIV, severe malaria in pregnancy and severe PET.  

I spent 3 days in theatre, battling with the usual frustrations - no catheters, no cannulae, no gloves - the patients had to bring their own, which created its own set of disasters, since it seemed to be those most in need of an urgent section that didn't have money to buy the consumables we were lacking in or didn't have attendants to go to the pharmacy and buy them.  We had  a retained twin, delivered by CS, the mother had delivered twin 1 at 1am and rocked up to Mulago at 3pm, from less than a mile away.  Baby was fortunately OK.  My section mix consisted of 1 woman with 5 previous scars in labour, 4 genuinely obstructed labours - one of whom I had to deliver by the breech - an impending rupture, a cord presentation, 4 other women with previous scars, 1 HIV +ve woman with PROM, a PG with contracted pelvis and one severe PET.  Numbers wise it wasn't a huge amount of work, but when the list often doesn't start until at least 11am - sometimes later - and with all the other rate limiting factors, on a good day in one theatre most people don't get more than 7 sections done between 9 and 5.  I had the weekend off, which cover had been arranged for, and gathered my thoughts, relaxing in the garden with a good book and plenty of coffee.

The second week the staffing numbers were a little better, 3 SHOs - including me - and two interns. This meant that we were able to run 2 theatres.  We still had issues with gloves.  We had the added problem of the student anaesthetic officers being examined on the emergency list.  This meant that the choice of anaesthetic was dictated by what they needed to be examined on rather than the clinical indication for caesarean.  It also meant that the list shifted very slowly indeed.  I spent 2 days on the labour ward shopfloor, the highlight of which was an undiagnosed multiple pregnancy, twin 1 breech, twin 2 cephalic.  I was called to assist as the arm was not deliverable on twin 1 on account of it being extended above and behind the head.  After a lot of manouvreing, I managed to hook the arm down and deliver the baby, resuscitated it, only to find that twin 2 was a compound presentation.  I managed to push the hand back, rupture the membranes and she delivered vaginally, so all was well that ended well.  

I had a challenging few days in theatre.  The first day we had 3 sections for fetal distress, a transverse lie, back down, with a previous scar and oligohydramnios at 32 weeks, who I had to do an inverted T incision on, a badly obstructed labour and 2 women with 2 previous scars.  Aside from the glove issue, the list ran fairly smoothly.  The second day, I walked into labour ward, past the admission room and spotted a woman with 2 previous scars, behaving like she had an impending rupture.  We managed to prioritise her to go in first but the anaesthetic students refused to start the list as they were waiting for their examiner to arrive.  I ended up getting annoyed, since I had expressed my concern about the likelihood of this woman rupturing.  They brought her through, and put her on the table to start the spinal, and I knew from the change in her behaviour that the uterus had ruptured.  Fortunately the baby was still alive, and although the uterus had ruptured posteriorly,  managed to repair it.  She had a PPH and required blood but subsequently did OK.  

The next patient that came in was transferred from another unit, severely anaemic, having been delivered by section the day before in another unit. I was dealing with the PPH on the corridor, so one of the other SHOs went in to start the laparotomy, finding that the bladder had been sutured to the upper lip of the uterine incision, and she had bled from the lower lip and into the broad ligament.  Again, there was no need to do a hysterectomy.  Unfortunately, because of this referral taking priority over other cases, the next woman with a severely obstructed labour ruptured anteriorly, and the baby was stillborn.  I managed again, to repair the uterus and she did OK.  We then managed to get through two more sections - 2 and 3 previous scars in labour - before finishing for the day and handing over to the night team.

The next morning I walked into theatre to an almost identical scenario - students awaiting examiners, another impending rupture - who again, ruptured on the table, with a live baby.  Unfortunately the rupture also involved the bladder and I couldn't confidently find the apex or the ureters, so I called the specialist in.  That day we also had 2 undiagnosed praevias, a breech with a cord prolapse, one CPD and a severe PET.  It was nice to hand the house over on the last evening, knowing that I wouldn't be taking it back again the next morning.

The next week was dedicated to finalising some stuff for the upcoming Liverpool Mulago exchange, putting the finishing touches to the HDU paintwork and completing some of the paperwork that we need in order to get the HDU running.

Being so busy at work meant that I wasn't at home very often, and had particularly missed relaxing in my own space, and also spending time with my housemates.  Doris, our housekeeper has been a constant source of interesting conversation recently.  She's a formidable woman with a hatred of men - for reasons we are not sure of - and is inherently suspicious when new people, particularly of male gender, move into the house.  She collared me in the living room when I got home while she was still at the house...

Doris; 'Who has been feeding the bones of fish to her?'
Me; 'Who has been feeding the bones of fish to who?'
Doris; 'Someone has been feeding the bones of fish to Pasha'
Pasha is a male dog.  Doris is forever confusing gender, and will refer to Adam, Pasha, Justus and George as she or her, while referring to me and Elizabeth as he or him.

Me; 'I don't know who has been feeding fish bones to Pasha'
Doris (accusingly); 'It must have been Justins [Justus] or George.'
Me; 'I doubt it was Justus, it may have been George'
Doris; 'You need to speak to her, in my country when they are trying to kill a dog, they feed her the bones of fish'

Or another conversation a matter of days later

Doris; 'She has been stealing plates and bowls and knives and forks'
Me; 'Who has been stealing?'
Doris; 'Justins [Justus].  And she stole my pegs'

When Doris settles her mind on something, it can be impossible to change it.  We have a new housemate, Chi, a Tropical Medicine SpR from London. 

Chi; 'Hi Doris, my name's Chi'
Doris; 'Cheese?'
Chi; 'No, C-H-I. Chi.'
Doris; 'Yes, Cheese.  Welcome'

Doris recently found 70,000USh in my trouser pockets, which I'd abandoned in the washing basket.  She is a woman of the utmost honesty and integrity.  Having discovered the money she spoke to Adam who was the only one home...

Doris; 'Whose are these trousers?'
Adam; 'I don't know'
Doris; 'I think they are for Kate sometimes'
Adam; 'I don't know Doris'
Doris; 'Yes, they belong to Kate sometimes.' (Long pause, Adam looks around room uncomfortably) 'I found this money in them'.

I don't know who my trousers belong to the rest of the time, if they're only mine sometimes, but hey ho.  I admire Doris.  She grafts to school her kids, as a single mother, strong, stubborn and doesn't take any sh*t from anyone.  I will miss her when it is finally time to leave.

Thursday, 13 May 2010

A Chimp Off the Old Block

Things have really picked up pace.  With only 11 weeks left here I have so much to complete.  I'm in that pre-amble phase of writing lots of lists and making pretty coloured timelines, which is somehow reminiscent of revising for any set of important exams.  'We need the induction of labour guideline urgently' and 'When can you set up the HDU?  This weekend?' suggested to me that the head of department is also conscious of my nearing departure.

Induction of labour is at best haphazard here.  We had a case of uterine rupture in a woman, who had an induction which had been carried out in line with FIGO recommendations, that made the department collectively twitchy about the induction process.  There are no true written rules, and while everyone sort of does the same thing, it's not uncommon to come across women who seem to be undergoing an eternal induction.  So rapid action was required and Prof Lule was quick out of the starting blocks to get something put together on induction , while I worked to pull together the evidence for use of Misoprostol throughout obstetrics and gynaecology, and summarise it in a presentation.  We presented both pieces of work together in the morning meeting and there was a lot of debate and discussion about exactly what we should do here to induce labour.  Different people have different opinions about what works, based on personal experience.  The difficulty is consolidating that with what is in the literature and what is deemed to be safe.  I think this will be one of the most difficult guidelines to ratify here - there are a lot of strong-willed people with differing opinions.

Big things have happened with HDU.  I've mentioned it previously here, but there's a definite need for some sort of high dependency care.  I have felt strongly about this since arriving at Mulago, having discussed it with my predecessor, and the idea gathered momentum after Mark Muyingo went to Liverpool and identified a need for a high dependency area for postnatal women.  We unsuccessfully bid for funding to set it up, learning we had not won the money in early February.  The idea for a 'shoestring' HDU has been floated around and I finished the first draft of the concept paper.  The Friday before last the Head of Department, the Ugandan LMP team and I went to ward 5C and identified the latent phase room as the best place to put it. 'When can you start work?  This weekend', was no joke, although it was too short notice to co-ordinate painting.  'Next weekend' was my reply.

Working on guidelines has allowed me to eat lunch away from the hospital with my housemates.  I was sitting waiting for Adam, Avner and Phoebe to join me one afternoon.  Adam came bouncing into the restaurant, clearly quite wound up.  He had had an altercation with a taxi conductor over 400 shillings (about 12p), in which the conductor had snatched a packet of photos from Phoebe's hand as a way of forcing them to pay more than the usual fare because they were Mzungu.  It seemed to get out of hand, and culminated in Adam slapping him, grabbing the photos back and running away.  There's a degree of racism here, when it comes to paying for stuff, and the 'Mzungu price' often gets hiked way above the local cost.  This gets very wearing at times, when you live here and you know what goods and services are supposed to cost.  I guess Adam had reached the end of his tether.  Time to leave the country - he's currently chilling in Zanzibar.

I joined my housemate Avner for a march on labour day (May 1st).  We were marching against child labour.  I was under the impression that this would be a huge organised thing.  We turned up at the roundabout by the Northern bypass at 8.15 ready to march en masse.  The few of us in our group were the only people there apart from a group of security guards.  It turned out that the march had been cancelled, but that not everyone had been informed.  All the other groups were already at the shcool where the march was supposed to conclude.  So we walked for 5 km to get the, in the beating sun, to find that in fact, the majority of people that were there were from large corporate firms, present to keep the politicians happy.  The only other group that was even vaguely similar to us was the Ugandan Nurses Union.  So there was I, ready to chant and burn stuff in protest, only to find that I had to plod round the parade ground in front of the powers that be, and be on my best behaviour in front of the mayor and various other invited guests.  We were on TV that evening, but I don't think we got our message across! 

Phoebe and Mark left to go back home to Canada last week.  Our small group of close friends is ever decreasing in size.  We had a lot of fun with them, but apparently Sescatchewan was calling them.  Great opportunity for a Canadian break though!

On a different note, I have a regular boda boda driver who brings me to work in the morning.  Alan is dependable, obliging and above all, a safe driver.  We don't talk about much, but I like him.  He had come to the house one afternoon, with a problem.  Driving a boda boda is a way of making ends meet.  Most of these guys don't own their bikes, but rent them from shrewd characters who know how to snare people into a rental agreement that is difficult to break away from due to financial constraints.  On average, Alan earns 80k per week (about £25).  He rents his bike for 50k a week, and puts around 20k worth of fuel in on top of this.  He therefore has a take home of 10k per week, and this has to pay his rent and feed his wife and 3 kids.  He has rented his bike for 18 month, having previously worked in a photography studio.  He gave this job up because he wasn't paid for 4 months and driving a boda boda was the only option available to him.  The guy he rents the bike from announced that he had sold the bike, and had bought a matatu, and that the bike would no longer be available to rent, but he could buy it for 1.8 million shillings.  Alan's livelihood was at risk, and he was asking us to help him out with a loan.  None of us had the capital sitting round to do this.  I went to the bank with Alan, but the loan situation was impossible, and microfinance companies wouldn't make a loan big enough to cover the cost of a bike.  Alan had decided that rental was a mugs game and that buying a bike was a way of sealing a future, with his goal of being able to buy land to farm and to school his kids.  I really wanted to help him out.  Then my housemate Avner mentioned a hire purchase scheme set up by an American journalist.  The boda driver gets a brand new bike, he pays back over a period of 17 months with interest, but the papers are in his name and he walks away at the end of it with a good bike and 50k extra a week in his back pocket.  I made some calls, arranged for Alan to meet the scheme manager and I put the deposit up for him, which he'll pay me back by bringing me to work for free.  He turned up at the house with his brand new bike, beaming, ready to start a new chapter in his life, that will enable him to make a better future for him and his family.
Louise Ackers and Carol Porter arrived from Liverpool last week to present the findings of the evaluation they have done on the Liverpool Mulago Partnership.  They have done some awesome work looking at patterns and trends in morbidity and mortality, including some really interesting work mapping out where the women that die at Mulago come from.  This will perhaps allow us to address some of the logistical issues that contribute to maternal mortality here, such as transportation, referrals, functionality of referring hospitals and clinics and so forth.  There is more data to collect and add to what has been done so far, but it's incredible to see everything collated and analysed in one place.  I'm excited to read the final version.  We attended a grant proposal writing workshop together with Judith Ajeani, one of the specialists here, for another funding bid to help in setting up the HDU, but more importantly to evaluate the impact that it has on care here.  If we can get this funding, it will be a huge milestone for the partnership, and will strengthen the links that the team have worked so hard to forge.  It will allow us to see whether what is actually a relatively simple intervention does make a difference in this environment.  I'm keeping my fingers very tightly crossed.  It was great to spend time working with them.  I met a Liverpool palliative care consultant at the workshop, Dr Merriman, who had been a care of the elderly consultant at Whiston Hospital back in the day, and who set up Hospice Africa.  It's a frighteningly small world.  

We have finally unravelled what was happening with the maternal death audit data, which we need as a detailed baseline from which to measure the impact that various initiatives are having here.  The data has simply disappeared.  So I have 184 files to audit from 2009. They also brought a heap of donated equipment for the department.  We had a nice meal with the Ugandan members of the exchange on the Friday evening.

On Saturday we travelled to Ngamba Island chimpanzee sanctuary.  I had forgotten how rough Lake Victoria gets, and by the time we had made the 45 minute speedboat crossing in the lashing rain we were soaked to the skin.  We spent a happy hour watching the chimps at play, socialising, chasing each other and interacting.  We share 98.7% of a chimpanzee's DNA.  The resemblance is scary.  The chimps are all orphaned or rescued from injury, or from being kept as pets.  We got back slightly less damp than we arrived.

On Sunday we deep cleaned the HDU and painted it.  7 of us - me, Louise, Carol, Mark Muyingo from Mulago, and my housemates Av, Eric and Carine - set to it with wire scourers and brushes, tackling all the surfaces and washing off years of grime.  We the covered the room in soft white, managing to get three coats on before we ran out of energy.  We need to go back and put the finishing touches to it, but it does actually look like we mean business.  Once the painting's finished, we'll get mosquito grilles up and start to put the equipment in.

Andrew Weeks arrived on Monday morning, so we had a few drinks and dinner on Monday night.  We'll spend a bit of time working on the HDU proposal while he's here.  Carol and Louise left on Monday afternoon.  The rest of the week will be spent training the midwives in neonatal resuscitation.  We have 12 candidates this time, due to problems with staffing and rotas.  The good news is that I have enough money to run a further three 3 day courses in July.  It will be my swansong before heading back to Blighty.

Photos of the HDU so far are here and chimps are here

Saturday, 24 April 2010

Chicken Run

We travelled to Arua the day before the outreach camp was due to start. Arua is in the far north west corner of Uganda, near the border with the DRC and Sudan. We knew we had a long day ahead of us, and so we set off at 9.25am - not bad considering we planned to leave at 9. Armed with the Sunday papers, myself, Barageine, Alia and Rose set off with our driver in a Landcruiser. Once we escaped the clutches of the jam - even on a Sunday morning - we made a fairly good pace. We stopped along the road to buy skewers of beef muchomo, barbecued plantain and maize from the throng of vendors at the turn off for Masindi. Not a bad breakfast, and much cheaper than chips! We continued along the road, skirting along the edges of Murchison Falls National Park. We spotted baboons patrolling the roadside, donating the remains of breakfast - at high speed I might add - to them. We crossed the Nile - awesome as always - and carried on west through Pakwach and beyond.

Not far out of Pakwach, the car suddenly veered to the right side of the road, into the path of an oncoming bus, which was screaming down the road like something possessed. The driver managed to get the car back across to the other side of the road before we were hit, but it was a little hairy. We came to a halt, and got out to check the cause of the problem... a punctured back tyre. Which would have been fine, except that the jack for the car wasn't big enough, and while we could get the wheel off, we couldn't get the spare on. And so ensued the search for a flat rock, to place under the jack, and a series of improvisational measures were employed to keep the car elevated enough for us to take the jack out from under it, and place a sturdy and big enough rock under the jack, so that we could lift the car high enough to get the wheel on, in the baking heat, with no drinking water between us, on a deserted road, in lion country. We succeeded in completing the task at hand, and piled back in the car, a tad sweatier and dustier than we'd been when we got out.

We stopped in Nebbi to visit Rose's family and to drop off some bread which we had bought in Kampala - bread's very expensive in the north, so it's a rare treat shortly before stopping for lunch, which after the tyre fiasco was welcome. We travelled for around another hour, passing IDP camps made up of round huts of mud and straw. Some of the buildings were pockmarked with bulletholes - evidence of the still relatively recent struggle with the LRA. We hit Arua, a big, bustling market town, full of pedestrians and cyclists. We checked into the Hotel Pacific - which, in a landlocked country is surprisingly nowhere near the pacific, nor did it seem to have any features to suggest a tie with the pacific ocean. Either way if was fine, comfortable enough, apart from the howling scrapping dogs in the alley behind the rooms and the roosters that crowed incessantly from 4am, in a manner suggesting that they were being skinned alive. We settled down in the hotel for a beer or 2, and had a bite to eat.

Alia wanted to go to his Dad's village to pick up some chicken that had been killed and cooked for us, but there was an issue with taking the Landcruiser. The chicken arrived, by boda boda, with a pan of matoke and some sugar cane, right after we had finished eating dinner, so we loosened our belts and tucked in.

Next morning, we got to the hospital. The patients had been screened by Alia and Barageine shortly after we arrived in town. We got to theatre around 9, and I was pleasantly surprised by the theatre, which was a far, far cry from Mityana's. The first patient was waiting, drip in hand. The day got off to a flying start. The staff were motivated, and apart from the anaesthetist who repeated the phrase, 'That's next to impossible' regarding our request for a fan to help survive the heat were very positive. We got our fan - which was just as well, or else I'd have melted. We got through all 5 scheduled patients by 4pm and screened the new arrivals. We headed off for a well earned drink - which swiftly turned into 6, plus fish and chips, Alia insistent on 'just one more beer' for all of us - makes a change from me saying it anyway!

This camp turned out to be the best so far, everything ran like clockwork, we had good light, running water, instruments and proper linen, a motivated team, the hospital's own doctors got involved and there were even medical students around! The fistulas were among some of the most complicated I've seen so far, which was interesting to see. In the end, however, we only operated on 13 women. This was a question of people not coming to the camp to be treated - everyone we saw that needed surgery got it. We left Arua on the Wednesday afternoon. Prior to leaving, Alia went off to collect a chicken from the village, which was bundled into the car, clucking manically.

We hit the road on what was to be a long drive. We stopped not too far outside of Arua to buy Mangoes from kids on the roadside, prompting stories from the guys about how they used to scrump for mangoes. They had kids running up and down the road buying plastic bags. Fruit purchased, we continued on our journey. We stopped at Rose's village to collect another Chicken to keep the one we already had company, which doubled the noise asince they decided to peck at each other. Loading the car up with more mangoes we set off again. In Pakwach, we stopped again, this time to invest in wooden milking stools with phrases etched into them. My particular favourite was 'Remember Pakwach'. What?! After politely explaining to the 20 people flocking around the 4x4 that I didn't need any wooden crocodiles, cars, crested cranes, innominate birds, balancing objects, bows and arrows or drums, and everyone else satisfied with their purchases we drove across the Nile. On the other side were tens and tens of Elephants. Alia hypothesised that they were all going down to the river to drink. Barageine disagreed, stating that they had almost certainly already drunk from the river and were heading in the opposite direction. Rose and I looked at each other and burst out laughing, suggesting that since they were all facing in different directions it was difficult to tell what they were doing or where they were going, and either of them could be right, but that they were arguing for the sake of it. After an hour we stopped again. Alia bought 4 more chickens and Barageine bought 6, bringing the total to 12, making for a bloody noisy car, and reminding me why sometimes having no sense of smell has its advantages. The rest of the journey was relatively uneventful, apart from a heavy downpour. Getting the chickens out at the other end proved to be a challenge and I finally got through the front door at 10.30.

Since arriving back from Arua, I've spent a lot of time doing project work. I've spent time preparing and co-ordinating stuff for the next exchange visitors from Liverpool Women's - registration, accommodation etc - and also trying to sort out visas for the Ugandans who are hoping to visit LWH. I've been working on a detailed proposal for a shoestring HDU, and have made the final arrangements for a neonatal resuscitation course. Many of you have donated generously, and so far I've collected almost £1000 in donations - THANK YOU! We're also hoping to present on a few new guidelines for the unit next week and so have been putting the finishing touches to these. From here until I leave things are going to be fairly intense, with 3 separate groups of visitors coming who are working on fairly different things, we'll be physically setting up the HDU at some point in the next 6 weeks and there are post-graduate exams, so I'll cover labour ward for 2 solid weeks.

Thursday was pub quiz, the first one we've been to in a while. We had some new additions to the team, Anna, a medical student, and Whiteney and Lisa, 2 nursing students, plus Phoebe and Mark joined us for the first time. We came 2nd. Slowly we're improving - perhaps next time we might win. From here we visited Elizabeth, who has just taken a job in Rwanda - we had left her earlier in a packing frenzy - to sit and drink wine on the porch one last time before she left yesterday.

Yesterday was also Adam's birthday. Phoebe and I went to pick up his birthday cake. I had explained the order, with the appropriate illustration to the lady at New York Kitchen. Rather than a whole cake, I asked if it was possible for them to give me half a chocolate cake and half a carrot cake but to put them in the same box. At some point between me explaining what we wanted and the cake arriving in the shop, somebody interpreted the order as, chocolate cake on the bottom, carrot cake on top with a layer of chocolate fondant between them, iced entirely in chocolate. What part of that combination would be normal in anyone's frame of reference.? So I waited for 25 minutes while they deconstructed the cake - since we needed it within the hour , and there wasn't time to start again from scratch - stripped off the icing, re-iced the chocolate cake and put the carrot cake in a separate box. Armed with our 2 cakes, party hat and candles, we jumped in Alfred's car. And sat in the jam. For 2 hours. School's out. We had forgotten. We got to the Italian Restaurant later than expected but had a lovely evening, and the cake, in the end, was delicious.

This weekend is my last free weekend for some time. I intend to do absolutely nothing.

Tuesday, 6 April 2010

It's Chilling in Kigali...

Returning from fistula camp, I had a mountain of stuff to catch up on. Many of the staff commented on my being 'lost' - read, not around - some thinking that I had abandoned Mulago forever. Not so. I did spend much of the week trying to pin people down to make progress on various things - arranging for the next wave of exchanges, getting protocols moving again and trying to work out how to take the HDU project forward without any formal funding. I managed to meet with the head of department to discuss these and more and feel that we've taken a big step closer to realising some of our ideas. We have enough basic equipment to set up an HDU if we can acquire the physical space and I'll drag my trusty band of painters back to the hospital - possibly kicking and screaming - to spruce it up. We're hoping to acquire a six bedded bay with dedicated staff. I feel perhaps that I spend a lot of time expressing 'hope' on this blog. Speaking of which, we're going to give triage another bash, this time I have permission to get the whole department involved, mobilise the doctors as well as the midwives, who we had focused all of our efforts on the last time we piloted. I'm still hopeful that we can get it working. See, there it is again... hope.

I did a bit of teaching, more interactive which seemed to be well received, and some practical refresher training on vaginal breech delivery and neonatal resuscitation. We definitely need to run another formal course. We have identified over 30 midwives who need to be retrained or trained. Initially we were looking to run a series of one day courses, but having met with Agnes, one of our in-house trainers and talked a bit more, she feels that we should run a more intensive 3 day course so that we can really drive the message about resuscitation home. I've set up a charitable donation page here, and if you're feeling generous, money is accepted in all forms... I'll even take beans if you've got 'em. We're going to do it during the first week of May. Although I didn't do any clinical work, I did achieve a lot in terms of igniting or re-igniting project work that had gone off the boil a bit.

For Easter, the three amigos - Adam, Elizabeth and myself - decided to take a road trip down to Rwanda and back to Kampala via Lake Bunyonyi. We arranged a driver for the weekend, and asked for a 4x4 vehicle. Alfred rocked up the night before departure with what looked like a clapped out Matatu (minibus taxi) and a grin on his face. Fortunately it was fairly plush inside, and since it was the 11th hour and we had no choice paid the deposit. The next morning, bleary eyed at 5.30am Alfred turns up with Dan, and the bombshell that Alfred is in fact not going to be driving us after all. Thanks for the notice, mate. We piled in, and Elizabeth and Adam were asleep before we'd even reached the outskirts of Kampala. Given that I cannot sleep in a moving vehicle of any description I was glad I had brought a stack of books with me and began to devour the first with absolute delight - I don't get to be much of a bookworm these days. We stopped on the Equator for the compulsory naff photo, a coffee and the biggest muffin in the world before continuing through Mbarara - where Dan, not being one to leave things til the last minute, had to stop to buy insurance. We ploughed on to Kabale - Uganda's highest town - where we stopped for lunch. We were pleasantly surprised when the food that we had ordered from the fairly dubious looking menu arrived, and particularly impressed by the avocado and banana milkshake. We ate our fill - eyes bigger than bellies - and proceeded to tackle the border.

I hate crossing borders by land. The process is always ludicrously bureaucratic and a total waste of ink. The Uganda-Rwanda border was no exception. The concept of queuing was non-existent and it was pouring down. Despite the seemingly tight control I am fairly certain that you could easily pass freely from one country to the other without anyone noticing - as one crazy gentleman appeared to be able to do, while muttering to himself and flailing his arms in the air. Having added a new stamp to my East African collection at the much more organised Rwandan side of the border, I got back in the car along with the others and we set off once more. There was a minor moment of panic, when Dan decided after driving for about 70 km that he should probably stop and ask someone if we were heading in the right direction, since I, who had never set foot in the country before, didn't know. We were heading in the right direction, thankfully, and I managed to stop myself from suggesting to the driver that following a random truck from the border in the hope that it was heading to the same place as us was, to my mind at least, a foolish plan. We drove past acres and acres of tea plantation in the flat bottomed valleys. Every inch of the land is seemingly given over to farming, with agricultural terraces tumbling down the hills like a patchwork quilt of every shade of green imaginable.

Eventually we hit Kigali, driving past the taxi park and heading up the hill. The striking thing about Kigali is how well looked after it is - it's clean, there's no rubbish, the roads are paved, it's organised and the traffic's not mental. The perfect city antidote to Kampala in fact. It unsurprisingly transpired that Dan didn't know Kigali at all, and we didn't have a map. So we were driving randomly around hoping to spot a landmark that looked familiar to Elizabeth, who had lived there in a former life. We eventually made it to the Hotel Chez Lando a mere 14 hours after we had left Kampala, and I was wishing we'd climbed aboard a plane and arrived 15 minutes before we'd set off. Elizabeth headed out for a business dinner and Adam and I amused ourselves trying to translate the French menu, with no success, only to find the English version at the bottom of the page.

Elizabeth spent the next day in meetings, and Adam and I decided to see the sights of Kigali. Brandishing our faithful, if not trustworthy Lonely Planet and a map from the local rag which had the landmarks in all the wrong places, we got into Dan's van. We'd furnished him with a wishlist of places we hoped to go. We were not expecting much, as on getting to the carpark, we found Dan awaking from his slumber in the back of the van where he had spent the night. Give him his due, he'd done his homework and had developed a remarkable knowledge of the city's geography.

We arrived at the Kigali Memorial Centre, to be greeted by a firmly shut iron gate and a guard making X-factor signs at us, demonstrating that the centre was closed, rather than displaying his affection for Simon Cowell. We were informed that it would be open the next day, since Easter Saturday generally isn't a public holiday. We decided to visit a couple of churches outside of Kigali, 25 and 30 km south of the city. En route we stopped at a memorial garden, where the grass was being cut by people brandishing machetes, which had an uncanny irony to it. The remains of over 600 genocide victims were buried here, some identified by their first names only, and some simply identified as 'boy'.

Along the roadside, heading out of town were bands of men working on roads or in gardens or on construction sites wearing pink tabards. These uniforms identify them as prisoners suspected of having been involved in genocide on some level - most of whom killed or looted - awaiting trial. They work on civic projects, a useful form of community service. The prisons are overrun with genocide suspects with little hope of a trial in the near future.

We arrived at Ntarama Church in a downpour. Around 5000 people were killed here by Interahamwe militia using grenades and machetes. Most people were sheltering in the church itself when the grenades were thrown in. The church is a humble brick building with rows and rows of simple benches. At one end of the church are shelves containing the skulls and femurs of the dead, many showing evidence of how brutally they were massacred, clean lines sliced through the bone by the soldiers blades. Around the church, hanging on the walls are the victims' clothes, cooking utensils and whatever possessions people brought from home in the few days they took refuge before a neighbour told soldiers of their whereabouts. Outside you could see where the grenades had entered the building, blasting through walls that are 18 inches thick. The steel window frames were twisted and bent where the people trapped in side had tried desperately to escape. The place felt desolate and abandoned. It didn't feel like a church. It was deathly quiet.

We got into the car, feeling sombre. We drove another 5km to the next church at Nyamata. We met Steven, now 24, at the entrance, who was 8 when the killings started. Above the entrance to the church, there is a banner which reads,

"Iyo uza kwimenya nanje ukamenya ntuba waranyishe"

I asked Steven what this meant. He said that it was far more philosophical than the translation

"If you had known me, and if you had known yourself, you would not have killed me"

While waiting to be shown around inside the church, Steven told us his story. They heard the soldiers coming, they were beating drums as they advanced towards the village. Steven fled the village with friends and neighbours. His Mother and Father, Uncles, Grandmother and brothers remained behind. After the genocide was over, Steven was adopted by one of the adults that he had fled with. This man spent 4 years trying to trace survivors from Steven's family. He eventually managed to track down his grandmother, and Steven and his sister were reunited with her. The rest of his family had been slaughtered. The man who had killed his father and 2 uncles turned up at Steven's house in 2003 begging for forgiveness. Steven told us that his grandmother refused to let him in the house. His sister couldn't speak to him. Steven went outside and asked him to leave, and if he felt the same way in a week to come back and ask again, this time bringing details of where the remains of his family were buried. The man returned the following Sunday. He took them to a pentecostal church. During the service, there was a period for free speech, where people took to the altar and spoke to the congregation. The man stood on the altar and asked the deputy pastor and a number of others in the congregation, men and women, to stand. He identified these people as being complicit in the hiding of 32 bodies in a disused latrine. 9 years later, the bodies were still there. Those involved were arrested. The man, along with Steven and others, removed the bodies from the latrine. Steven told us that they were in varying states of decay, the ones in the middle still had flesh and skin. They brought the bodies to Nyamata to rest. Steven told us that he has forgiven the man who killed his family. They drink beers together these days. He's a stronger person than I think I could ever be.

He took us into the church, much bigger than Ntarama. It seemed a lot more peaceful, but I think that was the light. There were piles of clothes on every single pew and the altar. The altar and font were pockmarked with bullet holes, and light peeked in through tiny shrapnel holes in the tin roof, created by grenade explosions. There was an eerie sense of oppression. 10000 lives extinguished. We were told that the Hutu soldiers tied people to the pillars and amputated their limbs one by one, often hours apart. They used the dismembered arms to wave at other Tutsis imprisoned in the church as a warning of what was about to happen to them. Those who had money, paid the soldiers to shoot them dead, to avoid suffering. We went down into the basement of the church where there was a coffin and hundreds of skulls. He told us that in the coffin were the remains of a mother and her baby. Hutu soldiers had sharpened two wooden poles and driven one through the woman's chest and through the baby that was strapped to her back, and a second pole through her abdomen and out through the back of her neck. They were buried as they were found. Out the back of the church were two large tombs. Inside the tombs were stacked coffinsm 5 or 6 high, each containing 35-40 skulls. It is estimated that the remains of 40,000 people are buried at the church.

Returning back to the church entrance we met Charles. He was also 8 when the genocide happened. He was in the church when the Interahamwe arrived, along with his brothers and sister. Charles, one of his brothers and his sister were still alive after the first wave of mass execution at the church. His brother knew that the soldiers were coming back. He Charles that he needed to hide and pretend he was dead. He covered him in blood, told him to lie with his head inside a small hole in the bottom of one of the walls - we were standing next to where Charles had lain while he was recounting his experience - and then piled dead bodies on top of him. His brother told him he was going to check on the rest of his family, but that he would be back. He never came. The soldiers returned to the church and executed more people. When it was quiet and they had gone, Charles came out of his hole. His brother was dead, his sister seriously injured. She asked him to find water. He brought some to her, but while he was fetching it he heard the soldiers returning a third time. He went back to his hiding place. The soldiers moved amongst the bodies, jabbing at them with spears to see whether there were any survivors. One of them put a spear in Charles' leg. There was a pile of bodies between him and the rest of the military. Charles looked him in the face. The soldier asked him if he was still alive. Charles answered 'Yes, please forgive me'. The soldier told him that he didn't want to kill him, and sparing him, went to join the rest of his group. There were 7 survivors from the church. They fled and hid in a nearby swamp. Soldiers came to the swamp looking for survivors. 2 of the 7 died from hunger. It was harrowing to hear his story first hand.

We left the church and headed to Hotel Milles Collines - better known as Hotel Rwanda. If you hadn't read about it, or seen the film, you wouldn't know what had happened there in 1994, it feels like any other business hotel. But it seemed like a fitting place to have a drink and take stock of the places we had been and the stories we had been told. The rest of our day was spend mooching around, most places of interest being closed due to the public holiday.

The next morning, we headed back to the memorial, only to discover that it was still closed. I was sorely disappointed to be leaving Kigali without getting to see it, but c'est la vie. We spent the morning at a craft village, piled high with what I now consider to be the generic East African souvenir tat, although I did buy a wooden statue of a pregnant woman that seems to resonate with my purpose here. We then set off on the brief journey back to Uganda and onto Lake Bunyonyi.

I loved Bunyonyi the first time I went, and I loved being back there. We stayed at Bushara Island camp, a 10 minute motorboat ride from the main land. It's a beautiful, peaceful place with abundant birdlife. We slept in a huge furnished safari tent with views of the lake. We spent two days relaxing, swimming and walking. We spent a merry afternoon attempting to circumnavigate the island in a dug out canoe, failing miserably and wasting a lot of time spinning the canoe around in circles. It was true downtime.

This week was spent doing a variety of things - the usual mixed bag. I had a couple of days on labour ward, we tried to relaunch triage, I did some teaching. Tomorrow I travel to Arua, in the far north-west of the country, 10 miles from the border with the DRC. It will be my last fistula camp during my time here. I'm looking forward to it.

Photos of the trip are here