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.