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