Normally, the urogynaeology team perform 6-8 procedures a week, and about half of these will be fistula repairs, and the rest will be prolapse repairs, vaginal hysterectomies and sling procedures or Burch colposuspensions. The majority of fistulas here are obstetric in origin, since prolonged labour is common, and access to definitive care limited. There are also women who attend with pathology due to trauma, secondary to sexual assault, particularly in times of conflict. It is not uncommon to meet women who have been victims of rape at the hands of groups of soldiers.
Fistula is a taboo subject. There is difficulty in setting up functional fistula centres, as the perception is that to do so is to admit that fistula is a problem within the population. Until recent times at Mulago, less than 10 fistula repairs were being performed each year. Now the department repair several hundred annually. Women with vesico-vaginal fistula cannot control the passage of urine. They are constantly wet, which causes all sorts of issues with hygiene and tissue viability. They become social outcasts, marriages are destroyed, they are unable to have intercourse, being considered 'dirty'. In some places, women with fistula are shut up in small huts, like dog kennels, away from the family home, unable to stand up straight, clenching their legs together in an attempt to stay dry. They are not allowed to leave these huts, meals are passed in through small holes. These women develop disfiguring contractures of the limbs, necessitating surgery.
Sadly, this happens all over the developing world. Even sadder, is the fact that while fistula is operable - and when performed by someone with significant experience can be extremely successful, and life transforming - access to such surgery is difficult. Whether this is a question of geography, finance, stigma or a combination of all these factors and more, I don't know. The good news is that the team at Mulago are running fistula camps at hospitals in more rural areas of Uganda, each lasting a week. They are running one every two weeks for the next 6 months. Hopefully taking experienced surgeons into these areas for intensive periods, will help to tackle some of the issues, and ultimately transform the lives of these women.
After two weeks on urogynaecology, I was feeling much happier with being out here. The job seems to swing through extremes of nice highs and horrific lows. The other thing about urogynaecology and the way the job is set up affords me time to work on other things. I had run some really good teaching sessions with the midwives, interactive tutorials where we all learned new things. I also spent some time thinking about how to take some of the projects forward that have stalled or have not worked as well as we would have liked. It's a happy medium for now, but I'm sure that in a couple of weeks I'll be bursting for some more labour ward action.
Last weekend was a long weekend, for International Women's Day, which is a national holiday in Uganda. As a spur of the moment thing, we decided to fly to Nairobi and travel to Mombasa, Kenya. The idea was conceived and flights booked quickly, to depart the following morning. Elizabeth, Adam and I headed bleary eyed, to Entebbe airport at 4am. We arrived in Nairobi around 7.40am and after battling to get through immigration, 'You can't pay with this $100 note, it was printed in 1999', we met Moses, who was our driver for the day. Having agreed our price, we headed to Nairobi railway station, where we bought 4 second class tickets for the night train to Mombasa, for the three of us and our imaginary friend 'Boris'. So far, so good. From here we went to the National Museum, which was fab. It was an eclectic collection of natural history, cultural artifacts and good art. We whiled away 3 happy hours here - stopping for obligatory coffee and cake at the museum cafe. Nairobi has a reputation for being extremely dangerous. We were expecting seedy run down streets, but what we saw and experience couldn't have been further removed. Our experience of Nairobi was one of a cosmopolitan city, a city on the up, and quite different from Kampala. We decided to attempt to get to the giraffe sanctuary, in the northwest part of the city. Moses said he knew where it was. We stopped to get fuel. It seemed to take us an age to get there. And then, on a random road, seemingly in the middle of nowhere, the car cut out. 'They didn't put the fuel in'. And so we found ourselves attempting to push the car along this random road, in the searing heat, the boot so hot you couldn't push for long without burning your hands. Moses spent some time on his cell phone, trying to arrange a rescue plan. We had no water, were ridiculously thirsty and had no sunscreen on. We decided to walk to the nearest watering hole, which thankfully wasn't far. We thought we might get some lunch there while waiting for Moses to sort out the transport situation. 'We have chicken, goat or beef'. 'OK, how long will it take?'. 'Probably about 40 minutes'. So we were stuck in a local bar, with no immediate chances of escape, with a train to catch, a broken car, somewhere on the outskirts of Nairobi. But the beer was cold.
About 30 minutes later, Moses rocked up in the car, engine running, and we decided to cut our losses and get back to the area near the station, so that if the car died again, we'd still catch the train. The giraffes would have to wait. The restaurant we chose to eat in was closed. By now it was late afternoon, we were hungry and becoming grumpy. We took our chances on a restaurant called Berber's. It became clear that this wasn't a restaurant travellers stumbled upon very often, apparently it was 'an honour' for us to be there. And we would have felt honoured to be there if the food hadn't been so terrible. But it was all part and parcel of the experience and we were just glad that we weren't still pushing a car along the road in 30 degree heat. After 15 minutes of panicking, trying to get hold of Moses on the phone - who was driving around Nairobi with all our stuff in his car while we ate at the restaurant - who had gone AWOL, thinking that all our worldly possessions had been pilfered, we located him, got back in the car and went to the station.
Nairobi railway station was like something out of a black and white film, except the steam trains of yesteryear had been replaced with spluttering, wheezing diesel engines. We waited on the platform, people watching, until the train drew into the station an hour before scheduled departure. We located our cabin, threw our stuff in and made ourselves at home. We were pleased to have somewhere to lay our heads, and pleased that we had survived the day. The train pulled away from the station bang on time, and we cracked open some Tuskers and watched the outskirts of the city speeding past the window as the sun began to set. The train manager paid us a visit to welcome us on board, informing us about meals and arrival times, and to check we were happy. Good old British Rail could learn a thing or two! The bell rang for dinner and we headed to the dining car where we had stew and rice, washed down with some red wine.
There's something very soporific about the sounds and motion of a train. Leaning out of the window, string at the stars and watching the lightning cracking across the horizon, I felt overwhelmingly content. Around 10pm I clambered up into my bunk, and fell asleep to the clickety clack of the train thundering through the Kenyan countryside.
The bell for breakfast at 6.45 was a rude awakening. We stumbled through the train for a serving of fry-up, and a much needed cup of coffee. At 9.30, right on schedule, we arrived in a very hot and very humid Mombasa. We took a tuk-tuk to the hotel, checking in early for much needed showers and then headed to a beach just outside of town for an afternoon of kicking back in the shade a palm trees, looking out across the white sand at the azure and topaz sea. It reminded me of Zanzibar although the colours were different. Elizabeth took a camel ride, on a majestic beast called Charlie Brown. Adam and I plodded through our books, keen to avoid becoming sunburned. We headed back after a few hours, changing for dinner. We were picked up from the hotel and transferred to the other side of the bay, to the Tamarind Dhow, a traditional Mombasan boat, for a dinner cruise. We ate lobster, while drinking nice wine and listening to the sounds of the band, knocking popular classics with an African twist. There's nothing like eating a good meal with friends, in the open air, floating past the world. It was fab.
The following morning we walked to the Old Town, exploring Fort Jesus, a semi-derelict Portuguese fort, unfortunately badly maintained. We then meandered through Old Town's streets. Since it was Sunday, most things were closed, but it had a lovely feel to it, similar to Stone Town, but not quite as nice. After a leisurely lunch back at the Tamarind - this time on land - it was time to head back to the station. The train back, this time with an imaginary child called 'Prunella' sharing our cabin, who was in absentia due to 'sickness' necessitating an imaginary hospital admission, was just as much fun as the first time. A little drunker and a bit more balmy, dinner was spent being childish and messing around, pretending to be 'Cousin it', for reasons I can't remember. After another sound night's slumber in the sleeper car, we spotted zebra and giraffes from the window of the train. Having not yet seen zebra in the wild, I was over the moon!
We arrived later than expected in Nairobi. We were collected by a different driver, Steve. We visited an art centre, and this time actually made it to the giraffe sanctuary, where we got up close and personal with Laura, a female giraffe. Kissing a giraffe is one of those life experiences that I will always remember, but have no desire to repeat! After a bit more craft shopping we went back to the museum so that Elizabeth could buy a painting she had fallen in love with at the beginning of the trip.
We had a few hours to kill - or so we thought - and after consulting the driver about how much time it would take us to get to the airport, we went to do a spot of shopping. All was well until Steve went missing in the car park, with a mobile phone that didn't work. And so for the second time on the trip we began to panic, knowing we had a plane to catch. We eventually found him, by now all of us a bit agitated. But we were reassured that it was only going to take around 40 minutes to get to the airport. 3 hours later, with 50 minutes to the departure of our flight, we were still stuck in a traffic jam, with what seemed like the rest of the population of Nairobi. Adam got out of the car to try and find out if we could get motorbikes to the airport - 'They are banned in the city centre'. The crowning moment in that increasingly tense journey was when Steve read the number of the radio station as the time, rather than the clock, and then suggested we could 'just get the next flight'. When we explained the cost implication of 'just catching the next flight' I think it dawned on him that we really did need to get to the airport. Creeping out of the congestion, Steve floored the car, in one of the most dangerous journeys I have ever been on. Elizabeth's suggestion of 'At least if we crash, at this speed we'll be killed outright' did nothing to reassure me. We arrived at the airport 29 minutes before take off, to be told that we could probably check in, but at that point there were not enough seats on the plane. The next anxious 10 minutes were spent standing at the check in desk, drawing effigies of the driver on the back of a departure card. Bob, the desk steward then announced that there were seats, and so we tore through the airport, skipping and dodging other passengers to the gate, where we were escorted onto the plane, people staring at us for being 'the ones that held the flight up'. I have never been so glad to put on my seat belt and be subjected to the safety talk. The weekend had been fantastic, but in a way, I was glad to be heading back to Kampala.
Photos can be seen here