Fistula Outreach Camps

For the past two weeks I have been away from Kampala, working with some of Mulago's urogynaecology specialists who were conducting VVF outreach camps. The first of these was in a small town called Kiboga, which geographically is not far from Kampala, along a well paved road. In reality, there are many constraints faced by women afflicted with fistula - who will pay for transport and food, who will farm the land, who will care for the children - that prevent them from accessing definitive treatment at Mulago. The second camp was in a larger town called Mityana, along a rougher road but still within reasonable distance of the capital. The camps are endorsed by the Ministry of Health and funded in part by an organisation called AMREF.

We arrived in Kiboga, me, two specialists (Mwanje and Alia) and a scrub nurse (Alice), on a sunny Monday morning. Just before we entered the hospital grounds, Mwanje leaned out of the window to talk to someone coming out of the hospital.

'We're here to do a fistula camp'.
'Oh, er, do you have an anaesthetist with you, because we don't have one'.
'What are you talking about? You ARE an anaesthetist'.

And so we met 'Uncle' the resident anaesthetist, whose excuses as to why we couldn't work were many and varied and would be a constant theme over the next few days. 'We have no instruments', 'We have no linen', 'We have no linen', 'It's too much work', 'I worked all night, we did two sections' and so forth. Fortunately, our humour and patience were as limitless as his excuses and so we did manage to get some work done.

We spent the first afternoon screening patients. Radio announcements are made about the camps in advance. Almost everyone has a small wireless radio, or knows someone who has one, so this is the best way of achieving maximal publicity. Prospective patients turn up on the first day, and the plan for the rest of the week is made from there. We saw around 20 patients and operated on 13. While the majority of women attending do have a fistula, we also saw women with prolapse, stress incontinence and pelvic infection. One patient had lived with a vesico-vaginal fistula (communication between the bladder and vagina) for 24 years. It proved impossible to get theatre space the first day, Uncle was dodging us, there was an emergency case and then it was too late in the day to start.

On Tuesday and Wednesday, we managed to get through our 13 patients. We acquired a second theatre table, and after cleaning and oiling the table and topping up the hydraulic fluid it was semi-functional, despite one episode when the head of the table collapsed while the patient was being prepared for spinal anaesthesia - fortunately without the needle in her back, and with the gas man to catch her.

There were several very complex fistula cases which were repaired, third degree tears that had not been repaired which we operated on, ureteric implantations performed and an exploratory laparotomy and adhesiolysis. There was one emergency section performed while we were in theatre, resulting in a neonatal death due to severe hypoxia. I spent 45 minutes ventilating in vain. There is no special care baby unit in Kiboga, or indeed before Kampala, and so even if resuscitation is successful, there is no facility for supportive care. The hospital itself is a decent building, but it's not being used optimally. There was no running water during our stay and very few staff - 3 doctors in total. It was, however, fairly clean, all things considered.

At the end of Wednesday afternoon, our work in Kiboga was complete, and no new patients had attended, so we returned to Kampala with the aim of spending two days operating there, if we could get an anaesthetist to work with us. Unfortunately there was no-one available, and in fact there was no-one for the elective list in the fistula theatre that would normally be running until 3 in the afternoon. We repaired a fistula in a 4 year old who had fallen onto a tree branch some time back. The cause of the fistula was confirmed by the discovery and removal of two pieces of wood lodged within the tissue, one around 2cm long and the other about half a centimetre. We went from here down to the main gynae theatre to perform a bilateral ureteric re-implantation and bladder repair on a woman who had had a section 2 days previously and who had not passed urine since. It was a complete mess, but surgery was successful. Friday was a day of running around organising and doing admin.

I worked the night shift on labour ward on Saturday, spending the night in theatre, getting through 8 sections. The SHO on the shop floor managed to do 3 more sections in gynae theatre. The cases were varied. A woman had pushed for 12 hours before being referred from a clinic to the hospital with a stillborn baby and a difficult section due to severe impaction of the head in the pelvis. Three women had uterine scar dehiscence and all of their babies survived, simply due to us luckily eing able to move them through theatre fairly quickly and avoiding complete rupture. One woman had an undiagnosed placenta praevia. At 4am we ran out of fluids, had no catheters, no venflons and there was only AB +ve blood in the hospital. We had to stop theatre with 3 sections still pending. In that time we had a cervical tear which I repaired on the ward with no light and no sponge holders, kneeling on the floor. We had a number of severely anaemic women, and I spent a merry hour running around the various wards trying to find fluids and gear, with minimal success. All things considered, it was a fairly successful night shift. Sunday, naturally, was a write off.

The following morning, myself, Barageine and Sister Rose piled into another pick-up to venture to Mityana for the week. After a protracted departure, involving paperwork and diesel fuel, we bumped along the road to the hospital. The hospital is in fact best described as an assortment of shacks in varied states of dilapidation. Cows, dogs and ducks roamed the compound freely, whilst chickens strutted through the wards oblivious to anyone. Bags of blood hung from improvised drip stands made of branches. The theatre was small, filthy and clutteres, plants growing in through the windows and insects populated the inside of the semi functional theatre light. There were no overhead lights, no running water and no proper linen - drapes were made from ripped up scrub shirts. The patients were screened in an office, and listed for theatre. We saw a woman who had a catheter which had been in for over 6 months, having had her fistula operated on in a private clinic and then being discharged without follow-up or instruction, and another woman who was operated on at a previous camp and had gone home with the gauze pack still in-situ 4 months earlier. Many of the fistulas were extensive and complicated.

We worked on 27 women, over 4 days in theatre. At points we would be operating, while another patient has a section in the same theatre on a flat bench with no drapes and in the 'anaesthetic' room a child would be being circumcised or having a dental extraction without anaesthetic. The conditions were shocking. After 4 days of operating in the theatre, I was glad to be leaving, amazed that the staff can work week after week in such conditions, and yet dismayed that no-one pushed for change and improvement. I will be glad to get back to Mulago next week.

I took some photos, I don't think words can do justice to the conditions that patients and staff are existing in. You can find them here and will note the striking difference between the two hospitals.

Planes, Trains, Automobiles, Dhows, Boda Bodas and Tuk Tuks

Things at Mulago calmed down after surviving the week on labour ward. Urogynaecology is refreshingly quiet. The set up is very different. Mondays and Tuesdays are ward round days, and so, since most of the patients are electively admitted and for the most part relatively well, the round is usually finished by 11am. Wednesday and Thursday are theatre days and Friday is clinic. There is a dedicated fistula theatre, with the capacity to run 2 tables at a time. Most procedures are done under spinal anaesthetic. The week I started, there had been no list the previous week, and the specialists were upcountry on an outreach fistula repair camp. This meant that the ward was even quieter than usual, and so I had the opportunity to go to theatre for the family planning list, performing two sterilisations by mini-laparotomy, under local anaesthetic. This was a first for me, since the vast majority of elective female sterilisation is done laparoscopically at home.

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

Hard Labour

Mum and I had a few days together in Kampala. She wanted to go and visit the hospital, so we went. I showed her around the midwifery led unit, ward 14 first. A woman had just given birth in the corridor, but the ward was otherwise fairly quiet. Still she was a little shocked at what she saw. We then went to the main labour ward, chaotic and overrun as usual, women in various stages of labour strewn about the place, on mats on the floor, some in beds, some on benches. I don't think she really knew what to make of it, and I don't think it reassured her about the decision I had made to come here. But I think that when I return in August, with tales to tell, she will at least understand them better than most people, for having witnessed the hospital first hand. Our time in Kampala was otherwise spent with friends, barbecuing, eating and drinking good food and wine and doing very little else. We spent an afternoon exploring Owino market and the new bus park, but after the time we spent on the road, we were both tired, and fed up of being 'tourists'. And so much of the day was spent hanging out in the garden being tormented by the dog, and chatting with Doris, our housekeeper, who took a special shine to Mum, probably because they both had motherhood in common. She left in the early hours of Saturday, and I felt a little bit empty after her departure, having been constant companions for 3 weeks.

We had decided as a house, that since most of the 'original' housemates had left, it was time to upgrade the chipped and cracked plates, bent cutlery and plastic tumblers with stuff to make the house more homely. We also decided it was time to upgrade the cleaning stuff for the house too, much to Doris's delight. She admitted to us that nothing had been replaced in the 6 years she has worked at the house. Doris is much happier and upbeat, with a new enthusiasm for her work. And we felt good for doing something seemingly small and routine, that it some way showed that we value Doris and her work. So, we're a happy house! Of course, on our spending spree it was also deemed necessary to buy some 'fun' house stuff. We returned from our shopping spree laden with a volleyball, basketball, 4 badminton racquets and shuttles and a universal net. Ravi and Adam spent a bit of time putting the net up, and the following afternoon, the Inaugural Naguru Lawn Sports Society Meeting was held. Of course, no sports day is complete without a bit of beer and a barbecue, and it seems that our weekends have taken on a whole new meaning.

My first proper week back at work was taken up with meetings, teaching and administrative tasks. I spent time making edits to some of the documents I produced prior to going on holiday. I walked around the department, to see what was happening in the various different areas, saying hello to people and conscious that I hadn't been visibly present there for a number of weeks. I decided to follow-up on some of the things we put in place right before I went off travelling - I had put whiteboards up, providing pens and a small amount of money for replacement pens, and had given brief instructions on their use. It was a small experiment on my part, as I was curious to know whether even something as simple as replacing a sheet of paper with a board to write the theatre list on, giving a static point that would help improve prioritisation, would be implemented without me having to push it. Similarly, having given a tutorial on the whiteboard on 14 as a tool and having seen the initial enthusiasm of the staff, I had been hopeful that they would get it off the ground off their own backs. I was dismayed to see that the examples I had used to demonstrate how to fill the board in, were still there, and it was clear to me that the boards hadn't been touched. But I wasn't really surprised, and a little redeemed from my own cynicism. It led me once more, to question the sustainability of the work I have done here so far. And I now need to think about maybe taking a different approach to the projects I have been trying to get going. We have had a change of guard, so to speak, with staff - particularly effective senior midwives - being rotated. This will hopefully bring an injection of renewed enthusiasm to many of the clinical areas which will hopefully translate into improvements in patient care.

The weekend came round quickly, good old St Valentines day looming, Avner and Ravi were both out of town and myself, Adam and Elizabeth needed some down time together to catch up on each others' lives. We decided to treat ourselves and spend some time at a hotel on Lake Victoria's shores, taking advantage of their weekend Valentines special offer that sounded too good to be true... and was. We arrived to discover that it wasn't as cheap as the flier had suggested. But it was a bloody nice place, so we decided to stay anyway. We persuaded them to put an extra bed in our twin room, and managed to obtain a corporate rate for it too. We then settled into the terrace bar and had a long deep and meaningful while gazing out at Lake Victoria as the sun set. We spent the night under duvets in our air conditioned room - extremely decadent and a real treat by our standards!

Saturday was a pool day, catching rays, reading and messing about in the water. It felt a million miles away from Kampala, a holiday to recover from my recent holiday. Avner and Ravi's plans for the weekend had changed, and we persuaded them to come and join us. Av arrived first with supplies for Bloody Marys, took a shower and shaved his face, leaving a moustache that wouldn't have been out of place in a top shelf movie, and proceeded to prance around in a towel for a bit. We then went for dinner - Av had dressed by now, thanks goodness - and Ravi came from the airport to meet us shortly after we finished eating.

We had to walk past the pool to get back to the room, where there would now be 5 of us staying in 3 beds. It seemed only natural to swim, in the dark. I dived in in my dress - I suspect that a full day of imbibing alcohol may have been responsible for my behaviour - swiftly followed by the rest of the gang, wearing various amounts of inappropriate swimming attire. It was fun, childish, but fun. We went back to the room, threw some drinks together and chilled on the balcony into the small hours. Sunday, we travelled back to Kampala, feeling relaxed and refreshed, and not too hungover, all things considered.

Back at work, I was still feeling a little bit out of the swing of things, and the familiar feeling of dread and paralysis that affected me when I first arrived was washing over me again, less intense, but still palpable. I realised that I needed to face it head on, and really throw myself back in. And so began my week on labour ward, which was to be challenging and at times surreal. Throughout my time here so far, I have tried to write the blog as diplomatically as possible. I apologise if this is not the case with this posting.

I spent the Monday in theatre, tackling the emergency section list. We had a woman with a bad uterine rupture that had gone right through the back of the bladder. I managed to repair the uterus, but struggled to deal with the damage to the bladder and called the specialist in, who in turn called in the urogynaecologist. Uterine ruptures are common here, some much worse than others, but I am still not at the point where I am confident enough to 'just get on with it', as I don't feel that I have the experience of repairing a uterine rupture, or performing caesarean hysterectomy to do it independently and safely. This is considered an alien concept by some of my colleagues here, having been indoctrinated in a different system, but I can't subscribe to the 'see one, do one, teach one' philosophy. While I came to Uganda to gain experience of these types of things, I refuse to approach my patients any differently to what would be expected of me in the UK. It might hold me back a little, but I can sleep at night.

On Tuesday, I met with the head of department and two of the specialists to work through the applications for the exchange programme that runs between Mulago and Liverpool Women's. We spent several hours poring over the applications and discussing them. We selected two midwives to go. I returned to labour ward around 1pm, and was told that there was a destructive delivery happening. I have seen one before, quite early on in this job, and while they are brutal and unpleasant, they still have their place, especially in this setting. It was thought the the baby was in a face presentation, badly impacted and no longer alive. In this situation sometimes a destructive delivery and achieving a vaginal delivery rather than performing a caesarean delivery is a safer option for the woman, if not an especially pleasant one. The specialist was struggling to come to a decision about how to proceed, the landmarks being difficult to determine. The patient was pushing well. An episiotomy was performed. At this point it was noted that the breech (bum) was presenting. A breech extraction was performed, legs then trunk then arms. The head was stuck. Fast. What happened next will stay with me for the rest of my life. as the specialist tried to deliver the rest of the baby the head separated from the body. We had to take the patient to theatre to deliver the baby's head by caesarean section, the thing we had been trying to avoid in the first place. It was one of the most traumatic things I have ever experienced. The rest of the week on labour ward was busy, the usual mixed bag of eclampsia, massive bleeds from undiagnosed major placenta praevias, uterine ruptures, hysterectomies, severe malaria, severely hypoxic babies and so forth. Everything else that happened that week was eclipsed by Tuesday's horrific experience. But I managed to complete the week on labour ward, and I was proud of myself for managing to do that, but also astounded with myself for being able to compartmentalise my experience in order to function.

The Friday of that week, Ravi left us, his 6 week placement at Mulago finished, ready to go back to the States, graduate from medical school and take up his residency post. We had a big barbecue send off, which was a welcome antidote after the week's events. And we packed him off in a taxi a 3 in the morning, bound for Entebbe airport. One of the nicest people I have ever met, and someone I feel privileged to have spent time with, I know he will be a superb doctor, and I wish him well.

Sunday evening, walking away from the labour ward felt like a release from incarceration. I'm pleased to have finished there for a few weeks, but glad that I'm back in the swing of things once more. I am reminded, once again of how lucky we are to have the NHS, how lucky we are to be born where we are born, and how that affects our destiny. I also think this is the first time I've looked forward to doing a block of urogynaecology too!

January...Part 4 - Hippos and dirtroads and birds, oh my!

The morning after we had been tracking the gorillas, the world started falling out of my bottom. So it was a good thing that we hadn’t planned on doing anything for the day, as I quite literally couldn’t have left the lodge. We spent the day watching the birds in the valley – sunbirds, sparrows and the like – brightly coloured on a backdrop of blue sky. After lunch we decided to try and get an idea of the size of our hotel bill, and it was at that point the lodge manager announced that it wasn’t possible to pay by credit card, despite being reassured by the office in Kampala that we would be able to. We had a minor panic at this point, having literally just enough cash to cover the bill with none left over for emergencies. We spent around an hour unsuccessfully trying to work out a solution. The nearest ATM was more than an hour’s drive away. We called Eddie, who had disappeared up a mountain somewhere, to take us to the ATM. When he arrived an hour later, he reminded us that it was a public holiday, and should the ATM be empty, we were stuck. We decided it was probably most sensible to take our chances with no rainy day fund to speak of. It was a day of doing absolutely nothing, that turned out to be fairly stressful. All in all, the ‘splurge’ turned out to be a true disappointment.

The next morning, we left at around 8, driving to the next decent sized town, where the cash machine decided that it initially wasn’t going to dispense any money for us, and then 5 minutes later after having no success inside the bank, decided that actually it would give us some funds after all. We were relieved. We then set off for Ishasha. Arriving at around 10, we hoped to catch a glimpse of the tree-climbing lions. As it turned out, the lions were not feeling particularly tourist friendly and had abandoned the branches of their fig trees. We didn’t spot a single one. Disappointed that nature had won the game that day we carried on through the park in the direction of the Kichembwa Lodge, which was to be home for two nights.

Queen Elizabeth National Park is very different to Murchison Falls. The hot, dry savannah continues as far as the eye can see, with bits of scrub here and there, and the occasional damaged tree, providing evidence of the presence of elephants. We saw hundreds of Ugandan kob, a sort of antelope, and numerous elephants on the horizon as we drove along the dusty dirt track, baking in the blistering sun. The lack of game meant that the drive was fairly dull, with little to grab our attention or capture the imagination. As we got out of the park and onto slightly better roads, Eddie picked up the pace. Along the way were brightly coloured butterflies. Wherever there was a puddle, the butterflies congregated and as we drove past, they fluttered up from the ground like handfuls of wedding confetti, streaming out from underneath the back of the car. Beautiful. We arrived at the lodge, which was a series of round thatch-roofed huts, reminiscent of Hobbiton. We got to our hut and were greeted by a breathtaking view of the plains below, reaching what seemed to be the edge of the world. It was a really special place. We reflected on the day’s game drive and the arid landscape that we had seen, and decided to change our plans. We’d originally decided not to go up to Murchison Falls, but Mum wanted to see giraffes, and we figured that we would probably have more luck seeing big game up at Murchison. We decided to spend one night at the lodge, game drive the next morning, head to Fort Portal for 2 nights and then spend 2 nights at Murchison.

Our game drive the next morning was again, fairly fruitless, save for watching male kob sparring with each other at dawn, and group of mongooses/mongeese/mongice/mongoose (exactly what is the plural of mongoose?!). There was a disappointing lack of most of the big 5. We were out in the park before the sun came up, but as it rose it was seemingly too hot and dry for the animals. I was glad that we had changed our plans. After eating a breakfast of fruit, bread and eggs while gazing at some salt flats, we began our journey to Fort Portal, and I started a series of phone calls to rearrange our accommodation. Unfortunately the guest house we had already made a reservation at was unable to accommodate us a night earlier, and so referencing our ‘trusty’ lonely planet, settled for a place called the Y.E.S. Hostel. We drove round some of the crater lakes which sit outside Fort Portal proper. on the way there We saw endless numbers of men pushing bikes impossibly laden with bunches of green matoke, up dirt tracks in the midday sun, and women and children tilling and farming the land. We were in very fertile country, on account of previous volcanic activity in the area. The fields were full of coffee, tea, matoke, papyrus and other crops.

We stopped for lunch where we got rid of the packaging from breakfast. My Swiss Army knife was wrapped up with them, and was inadvertently disposed of, without either of us realising until the next day and by which time it was too late. From here we continued to the sparse, prison like hostel. We were the only guests. Mum was incensed, ‘I stayed in a place like this in Afghanistan in the ‘70s, and there was shit up the toilet walls there too’, I suggested that our options were limited but we could check out the posher – and even more soulless – hotel just up the road. On balance, we decided to stay put and grit our teeth for 3 dollars a night. On walking to the posher hotel we became surrogate parents of a random dog, who followed us all the way there, entered the ground with us and sat next to us while we drank cold beers in the shade. The dog found the rest of the customers fascinating and whiled away a few hours making a nuisance of itself. At one point the bar manager came and asked us if the dog was ours, and we quickly denied having any connection with it. As we left, the dog decided it had probably best go home and followed us back to where we had found it. We had concluded quite quickly that Fort Portal itself was a place to pass through and use as a base for exploring the area, rather than a place to have a holiday.

We went back to prisoner cell block H, spending a bit of time playing table tennis, without actually using the table at all. In a desperate attempt to make our evening into something we went to a nearby guest house with a roof bar, containing a pool table, a couple of TVs showing football and a noisy parrot. One beer and we decided the best thing we could do was go back to our room and try and get our heads down. This was delayed by Mum's discovery of the lonely hearts page in The Red Pepper, Uganda's quality rag. 'Married man seeks woman for fun times' and ' Man seeks woman from North for marriage, must have untilled land upcountry'.

The following morning, we couldn’t have escaped faster than we did and checked in to Rwenzori View, which was lovely. We headed off to Amabere Cave, just outside of Fort Portal. We met Robert who was to be our guide for the morning, and set off, first on a ridiculously steep hike through burned fields to a vista point from which we could see three crater lakes. He pointed out birds and plants on the way and we had some interesting discussions about religion and politics. Like most Ugandans I have met, Robert talked around the subject matter, including the Anti-Homosexuality Bill of 2009, without actually giving us his personal opinion on any of it. On the way back down towards the falls themselves we met a couple of girls, who can't have been any older than 10, one carrying a bunch of matoke and the other carrying a pumpkin and a machete. Child labour is all too evident outside of Kampala, where less than 60% of kids attend school. We headed to the cave from here, fighting through sinewy forest to reach it. Here, stalactites and stalagmites continue to form, supplied with minerals by the milky coloured water dripping from the cave roof. Robert regaled us with the legend of the cave - full name Amabere ge Nyinamwiru, meaning Breasts of Nyinamwiru. Nyinamweru was the King's daughter, the most beautiful woman in the land, constantly plagued by budding suitors - a feeling I know only too well ;). The king had heard prophesy that he would be killed by his Grandson. The King had no grandson, but the attention of suitors towards his daughter now worried him. In an effort to reduce her beauty and hence the attention of menfolk, the king chopped off her breasts - and in Robert's version of the tale, poked out one of her eyes too - to reduce the chances of her becoming pregnant. This still had no effect on her charms, and so the King threw her into a tower - Robert's version - or into the caves - Bradt Guide version. Either way, she was impregnated and gave birth to a son. In Robert's version, word reaches the King that Nyinamwiru has produced a son, and the King takes the child and throws him into the cave, where he manages to survive by drinking the milky water running from the cave, grows up, learns of the events surrounding his birth and abandonment, meets the King out on a hunting trip and avenges his misfortune by killing him. The guidebook version is not so elaborate, basically stating that the child and his mother took shelter in the caves, and she, having no breasts, replaced the milk with the water dripping from the caves. I know which version I like better. We spent a happy hour scrambling round the caves and behind the waterfall there, and on the way back to the car, Robert pointed out a bald cow, born with no hair, which has to be one of the strangest freaks of nature I've ever seen.

Adam, my housemate, met us in Fort Portal that afternoon, and we went back to the guesthouse to shoot the breeze on the porch with a few beers. We met a Dutch surgeon and his wife, who had trained one of the guys I work with at Mulago, and it was interesting to talk about the differences between Mulago and Kisoro hospitals. We shared a communal dinner around a large family table at the guesthouse, with about 15 other people.

The following morning, we embarked on the long drive from Fort Portal to Murchison Falls. The day was scorching hot and the roads incredibly dusty. We sped along the dirt roads, kicking up the dust that flew through the car and covered us in a thin film of orange particles. I looked like a Scouser with a bad St Tropez tan. As we drove along, the scenery was similar the whole stretch, fields of Matoke, coffee and tea plantations, papyrus springing up from the marshes. Most of the vegetation was also covered in orange dust. Each village we hit was a collection of similar looking huts and shops, some painted with the colours of mobile phone companies, others displaying signs such as 'God is Able Grinders', 'Second Chance Salon', 'The Breath of God Ministries', 'God is Good Barbers' and so on. We saw a man wobble along the road on his bike, so drunk that when he eventually fell sideways into the ditch, he just went to sleep there. There was a brief moment of excitement when a wasp entered the car and Mum nearly had a fit of hysteria, demonstrating the 'Dinsley Wasp Dance' to Eddie and Adam with a modicum of style and finesse. After 8 hours on the road we stopped in Masindi for lunch. They had nothing on the menu we asked for 'It is finished', 'It is over', 'We don't have', so we settled for Chapatti and avocado salad. We were caked in orange dirt and must have looked stunning.

Eddie bundled us back in the car, and drove into Murchison Falls National Park. The scrub had been destroyed by wild fires, sparked by poachers or carelessness. Much of the vegetation along the main road in was blackened, the trees stripped of leaves, their bark scorched, looking eerie in the smoky air. We couldn't get a space at the backpackers campsite and had booked a banda in a lodge. It was more gross than the hostel in Fort Portal and at least 20 times the price. We decided to upgrade to a cottage, which wasn't much better but at least had a shower in it with hot running water. It had been a long and tiring day, and having to spend much more money to get a decent bed made me grumpy for the first time on the trip. We did get a good night's sleep, but I reflected on how the best places we had stayed had been some of the cheaper places.

Eddie collected us at around 6.30 ready to pick Adam up from his campsite and catch the Paraa ferry across into the park proper. The sun was rising over the misty Nile, hippos wallowing in the water like giant rocks with ears. On the other side, we didn't have to drive for long before finding an abundance of giraffes, buffaloes, kob, hartebeest, oribi, warthogs, baboons and hippos. Eddie managed to spot a shoebill stork on the far side of the river, one of the rarer birds here, with a face that looks literally like someone stuck a clog on the front of it. We went to the hippo mating ground, and if hippo foreplay is anything to judge by, all I can say is that I'm glad I'm not a hippo. We saw a solitary lion and a few elephants too. On the way back to the ferry, Adam spotted an upturned, decomposing hippo, a fair distance from the water. Not something the UWA mentioned we were likely to see in the brochure. Quite how it ended up on it's back, all four legs up in the air is beyond me. Perhaps it fell out of a tree.

We spent lunchtime at the Red Chilli Hideaway, kicking back with our books. The tranquility was only disturbed by an octogenerian canadian man using a chair to fend off a warthog that was just standing on the opposite side of a ditch minding its own business. His shouts of 'You might just get more than you bargained for, sonny!' while thrusting the chair towards the hairy pig had us sniggering into our plates, and when he turned to address the rest of his group after the warthog got bored and walked off, with the line 'You just need to make a threatening gesture', I had to leave the table for fear I might embarass myself. After lunch we took a boat trip to the bottom of the falls, watching the hippos pop up from underneath the water with a look of surprise that seemed to say 'Oh 'ello!', and spotting all sorts of colourful birds. There were many more elephants around compared to the last time I was here. It was a really lovely afternoon. We got back to the banda, and helped Adam to pitch his tent outside. We headed over for dinner, and despite us all having headtorches on, Adam still managed to trip over a sleeping warthog. I'm not sure which of them was more surprised.

The next morning we took a hike to the top of the falls, the last leg of our adventure before heading back to Kampala, and again were blown away by the sheer power of the water. We got back to Kampala mid afternoon, and after showering, throwing the dirty washing in the laundry and finally properly unpacking, caught up with the gang. It had been an amazing journey.

Photos can be seen here

January...Part 3 - Gorillas, in the midst

Part 3 of a 4 part summary of January...

Our road trip around Uganda began with an early start and frantic unpacking and repacking of bags after our Zanzi trip. Fast Eddie arrived early in his Landcruiser, and we sped off through the go-down away from an overcast, drizzly Kampala. We stopped en route at a place called Mpambire, where the Royal Drum Makers make and sell African drums. When we asked Richard, the craftsman, exactly what they were called, he replied 'Drums'. So that was us told! A beautifully crafted large cowskin drum can be had for sixty thousand shillings - approximately £20. We elected to consider going back following our return to Kampala, as the idea of transporting one round the whole south west of the country didn't seem sensible. We continued from here to the Equator, for cheesy tourist photos, coffee and breakfast before plodding on down the Masaka road, passing through Masaka, past Lake Mburo to Mbarara, where we broke the journey with lunch. From here we continued to Lake Bunyoni. Arriving at around 5, we checked into our treehouse safari tent on stilts, overlooking the lake. The sun was beginning to go down by the time we got ourselves square, so after a cup of tea and a quick walk we decided to relax at the camp. After eating the worst pizza I have ever encountered, we decided to get into the tent and read to the chorus of frogs and insects that was coming from the waters edge. After deciding on an early night, I was woken by the loudest clap of thunder I think I've ever heard, and a heavy shower of rain. In a tent, in a treehouse on stilts, in a thunder storm... Safe. I decided I was too warm where I was, and being struck by lightning is one of the more exciting ways to go, so I stayed put. The next morning the entire lake was shrouded in mist. Eddie picked us up at 10, ready for the long slog to Buhoma, in Bwindi Impenetrable Forest. We wound around the lake's shores, high up on the hills, affording spectacular views of the mirror-like water. Soon after leaving Bunyoni, we hit bumpy dirt track, which continued through the hills. Looming ahead in the distance was Bwindi, noticeable because of the sudden density of the forest canopy. We drove through the forest for around 3 hours before arriving at the lodge, with its spectacular view of the forest. The lodge was comfortable, although not as nice as we had expected it to be, given that it was our splurge on the trip, but nevertheless, we made ourselves at home with a couple of beers and chilled out watching the valley and the birdlife. We were looking forward to gorilla tracking so much that I don't think at that point we'd have cared where we slept.

We woke at 6am the next morning, excited, full of trepidation about the unexpected. We would have to trek through Bwindi ‘impenetrable’ forest, were warned that it would be strenuous, that we might not find the gorillas, but that it was ok, because if we didn’t, we’d be entitled to a 50% refund on the tracking fee. We arrived at the UWA headquarters at 7.30 after a slightly hairy moment where it seemed that perhaps our driver had slept in/was still out drinking and shooting pool/had decided he just couldn’t be bothered. Fast Eddie tore up the drive in a billow of dust at 7.25. Phew.

After being shown two interestingly produced videos about the gorillas , dubbed with a commentary in the Queen’s English, we met our guide, Kathy, outside. We counted two of us in our group – me and Mum. Assuming there must be more to come we waited for around 10 minutes before Kathy said it was time to go and that she’d brief us once we got closer to the gorillas. We were to track Habinyanja group at Buhoma, a group that now contains 18 mountain gorillas since the young Silverback overpowered the older silver back, who had left the group taking 3 females with him.

We drove for 45 minutes to the trailhead, where we picked up two porters, Moses and Wilson. These guys turned out to be fantastic help, not because the bags were heavy, but because we’d have struggled to keep balance carrying a load – I struggled enough with my camera – and pick our way through the steep, thick, slippery forest.

We walked for around 40 minutes through farmland, taking in the vast valley view, teeming with tea plantations, banana trees, terraces and children vying for a ‘How are you?!’ from the two Mzungus in silly hats with walking poles. The pace was slow and steady, and we had regular radio contact with the two advance trackers, who had gone ahead of us to find the gorillas, based on where they had left them the day before.

The forest edge loomed ahead, an abrupt border to the farm terrain. We entered, and suddenly the ground was soft underfoot, nervously stepping and unsure as to where the true forest floor lay. Impenetrable. We thrashed our way through branches, ferns, thistles, nettles, webs and goodness knows what else. The forest, a thicket of every shade of green and brown imaginable, pierced every now and the by the occasional shaft of bright sunlight, as the weather had deigned to be kind to us. We slipped and slid down through the trees, zigzagging round obstacles, with the help of the porters holding back and snapping branches as we moved. After 50 minutes of battling with the forest, hands and bums muddied from falling over, we met the advance trackers. Kathy then said to us ‘There are no gorillas in the forest today’… WHAT?! ‘Just kidding’, she said, beaming. We were briefed on the rules – ‘No flash photography, no food or drinks, no sudden moves or pointing, no spitting, farting, swearing or petting in front of the gorillas’ and we were off. We traversed down the slope, and up ahead, just visible through the trunks and branches, lay a black back, keeping watch over the other gorillas, amassing 13 in number, just a bit further down under the forest canopy.

They were grooming, swinging from branches, the small ones beating their chests at each other in an effort to prove their strength while the adults cuffed them round the head when they got too boisterous. It may sound like a cliche to say that we felt privileged to be there, observing them in their natural habitat, such gentle giants. There was a real sense of family and community. The silverback was separate from the group initially, being groomed by two of the ladies. One adolescent female was crouched about 10 metres from where we were. As I crouched to take a photo, she stared directly at the camera lens, and I realised that she was going to charge. I stepped back at the guide's instruction and she galumphed past us, grabbing the back of my left calf as she went, reminding me of exactly who was in charge. I know that if I had been any closer, the force would have knocked me over. Awesome.

The silverback joined the rest of the pack, who were now basking in sunlight, eating leaves, nesting in trees and rough and tumbling, taking branches down as they went. They moved down the hill and we followed them to their next nest site where they continued with their antics. It was amazing watching the interaction between the group members. They moved off again, this time through the trees rather than on the ground, at an astonishing pace. We reached a dip in the forest, needing to climb uphill to get to the next area of flat groud from which we could leave the forest relatively easily, rather than trying to negotiate our way back along the route we had come. Moving uphill was tricky, with very little to grasp, the ground wet and slippy. We reached the top of the hill and the porters moved from where they had been waiting with water. William, one of the advanced trackers, suggested we continue down the next hill into a clearing in the forest canopy, which would allow us to leave the forest through terraced farmland. We followed him through a dense growth of thistles, nettles and other spiky plants, tearing at our feet and clothes and tripping us over. We were sweaty, knackered and covered in thorns. As we started to climb through the farmland, Kathy pointed out a black back down the hill, separate from the rest of the group. We waited amongst the vegetation for him to move, out into bright sunshine, and he lumbered past us up the hill to join the group, providing the best photos of the day.

We plodded back out of the forest, in awe of what we had just experienced. Something that was really special, truly magical. I don't have the words to describe how it felt at the time, but it was definitely up in there with the top 10 things I've ever done in my life. Worth coming to Uganda for on its own.

Moses took us to his house on the way back down the hill, a mud hut with three rooms, sparse with no furniture to speak of apart from a mattress. It was very humbling, especially to know that here was a man doing a job that pays him relatively well by Ugandan standards, that had very little in the way of material possessions. It was another raincheck on just how much we overvalue possessions. We were greeted at the end of the trail by a group of children from an orphanage project who performed some songs and dances, tapping into the tourist trade in their own way. We swiftly ran out of shillings.

We headed back to the lodge for a well earned beer, to reflect on what we had just seen, exhausted but elated.

Photos can be seen here

January... Part 2 - On Earth as it is in Heaven

Mum arrived on January 17th. It felt strange meeting her at an airport in a hot country - normally I'll collect her from the perpetually freezing arrivals terminal in Manchester, on a dreary, drizzly day. We had an overnight stay in a motel in Entebbe, since we were leaving early the next morning for Zanzibar, and after introducing her to the local beer we hit the hay. Fearing being bumped off the flight - flights to Zanzibar are routinely overbooked - we decided to head to the airport early, only to find that we couldn't check in until an hour before the flight. This meant we had to settle for 'coffee' - lukewarm brown liquid with no flavour - and a 'croissant' - stale butter infested bread - in the only cafe before the departure lounge. Not the ideal introduction to the culinary delights Uganda has to offer, but we were hungry. Check in was smooth in the end, and we began an epic 9 hour journey, flying to Nairobi, then to Dar es Salaam passing Mount Kilimanjaro en route, and finally making a 30 minute leap across the ocean in yet another plane to Zanzibar itself. The airport at Dar provided a few comedy moments, since we had to check in again here. After having our passports and $100 taken from us by a man in uniform who then disappeared into a throng of people, we were a little bit concerned we would be stranded in no-man's land, however they were returned pretty swiftly. We then spent 15 minutes being passed from one person to the next to try and get our boarding passes. After confirming 4 times that our luggage definitely hadn't come off the carousel, we were shepherded down a narrow corridor to a desk where we were presented with boarding passes, only to be shepherded back the same way, bypassing security altogether. When we finally made it to the gate, they scanned our bags, producing a few suspicious looks from the woman operating the x-ray machine. It turns out that Mum had a cigarette lighter in her bag. What was amusing about this, was that the bag had been scanned at Newcastle, Amsterdam, Entebbe (twice) and Nairobi, and no-one spotted it. What was even more amusing, was that when we finally arrived at the hotel, she found another one in the same bag!

Having left our hotel at 7am we finally arrived at Coral Rock Hotel in Jambiani, Zanzibar, following a hard sell 'I'm a tour guide too' taxi ride across the island, at 7pm. It had been a long day. And what a wonderful place to end it. The evening was warm, the sun had set and there were a pleasant breeze wafting from the ocean, towards our beach front cottage. We met Daniel, a South African who had gone travelling, and never quite managed to leave Zanzibar behind, who showed us around. Mum and I ended up in the honey moon suite - a little incestuous, I know - but it was nice. We headed to the restaurant, desperate for a proper meal, after our last in flight gourmet offering of Spam and mustard in a flat bread. The fish, bought on the beach that morning, and served up with a Zanzibari sauce, was phenomenal, and the atmosphere great - the sea lapping onto the rocks below and that warm sea breeze blowing in through the window. I felt like I had died and gone to heaven. I sort of hoped I had! After dinner we were invited to join a group who were embarking on a drinking game - flipping a coin into a glass. It's not often that you meet hotel staff that truly interact with their customers, but Neil, Daniel and Sibs were up there heading the stakes. It was a late night.

We decided on a chilled out beach day for the next morning. I love arriving somewhere after dark, so that the next morning, after you've rested and you can take everything in, you really appreciate what is in front of you properly. We opened the cottage door to the most stunning view. Crystal clear sea, with every shade of blue, turquoise and green imaginable, on a bed of white rock and sand, as far as the eye could see, punctuated occasionally by a Dhow, or a fisherman wading out with his sails and nets on his back, or a woman going to check her seaweed harvest. We spent a number of hours sitting by the pool, absorbing this view, reading, relaxing and in traditional Alldred style, getting sunburned - despite the factor 40, I hasten to add!

After more fish for lunch, we decided to walk down onto the beach, and out for a kilometre or two to the channel which had revealed itself at low tide, protected from the ocean proper by a coral reef. The sand was blindingly white, the landscape surreal in its piercing clarity, and vast. Absolutely colossal. There were shallow pools of water, heated by the sun, and small plots where women had set up seaweed farms made of sticks and twine. It was almost lunar. As the sun beat down we eventually found the water's edge, and had to wade a further 200 metres until it was deep enough to swim. The sea was beautifully warm, but the current too strong without fins, so after a very quick dip we beat a retreat back to the hotel, followed by the rapidly advancing tide.

The next day we went on a boat trip. After all, what is a holiday without a boat trip? We drove to Fumba, a group of 12 people in the bus, armed with snorkels and fins, high factor sunscreen and plenty of water. Told we would arrive at the beach at high tide so the boat would be almost on the shore, it seemed that there had been some mistake, and we waded out for about 400 metres across sharp bits of dead coral, navigating round jelly fish and all manner of other plants and creatures, to the boat. We cut through the water for around an hour before stopping to snorkel. There were shoals of hundreds of brightly coloured fish - black and white striped, electric blues, yellows and oranges - with a wall of several thousand sheltering behind a huge hunk of coral, avoiding being washed towards the shore by the tide. There were huge urchins, anemones and brightly coloured coral. The visibility was perfect. And of course after an hour of snorkelling, I had gained a branded back.

We continued our journey around the bay, stopping on a sand bar in the middle of the water for fruit and beer, where we got chatting to a South African couple, Jen and Alan. It turns out that Jen was bridesmaid for the sister of a guy we know in Hartlepool. As they say, it's a small world. We sat and watched crabs dig sand out of holes, got back on the boat to the next island where we ate yet more seafood, climbed a Baobab tree and then got the boat back to Fumba. Back at the hotel, the party was just warming up as we arrived, and many shooters, including the local spirit, made for a bunch of merry travellers who danced until the small hours.

The next day we had opted to take a guided tour of Stone Town. Normally we'd explore a city with the help of a map, but given the state of the pair of us, hungover and sleep deprived, it was better to do it this way. We drove to Stone Town and were met by Abdul, the most acharismatic tour guide I have ever met. It was going to be a long afternoon. We wandered through the narrow streets and passageways, lined with crumbling whitewashed buildings, and weathered ornately carved Arabic and Indian doors. Women in headscarves and kids in Kaftans weaved through the streets, while guys on bikes and scooters dodged pedestrians around blind corners. The sheltered maze provided welcome relief from the baking sun. We visited the local produce and fish markets, seafood festering in the heat of the mid-afternoon sun while locals bid for it at auction. The spice market was a bit disappointing, everything having been pre-packaged for tourists, and I suspect not where Zanzibaris buy their spices from.

From here we went to site of the old slave market, functional right up the abolition of slavery was effective here in 1873 - although there was continued illegal trade from the island after this time. We visited two small holding cells, the cell for women and children having a capacity of 50-70 people, in what must have been a 15 by 10 feet in maximum dimension, with two small slits allowing in tiny shafts of daylight. It was harrowing. In the old marketplace itself there now stands a statue to commemorate those sold into slavery, next to the site of the old whipping post, where slaves were flogged to determine their worth. The thought that this barbaric practice had ever been acceptable is sickening. From here we visited the Fort, and stopped for a drink at Africa House, which had been the British Club in colonial times. It made the visit to the slave market all the more sobering, to think that we had probably followed in the direct footsteps of British perpetrators of slavery - from the market to the bar.

The evening was spent watching the sun go down, and sampling the wares of street hawkers selling barbecued seafood at the night market, while watching kids pull somersaults off the seafront into the water. Stone Town had been interesting, but there wasn't anything that made me think 'Wow!'. Perhaps if we had had the time to explore it at our own leisure, I would feel differently about it. Our final morning on Zanzibar felt a bit strange, we said our goodbyes to the staff who felt almost like new friends and headed off to the airport to make our way back to Uganda for the next leg of our journey...

(Photos can be seen here...)

January...Part 1 - Back to the grind

January has proved to be a whirlwind month. This posting has the potential to be very long so I will probably split it into several smaller postings for ease of digestion.

Having arrived back from a bitterly cold Christmas break, I struggled to get back into work, knowing that I would be on the road in another 2 weeks. I had a lot of loose ends to tie up on some projects that I didn't manage to finish/polish before I went home, and focused my energy on these. Administrative tasks seem to take a lot longer here in Uganda, and it's very possible that you might manage to achieve one or two things in a day that would take an hour or two in the UK, but you literally don't stop running round sorting for a full 8 hours.

It was nice to see friends and colleagues at Mulago, the midwife in charge of Ward 14, Sarah, greeted me with a hug, and the exclamation of 'You look well, you've gone all pale and you've put on weight'. This, I think, was meant as a compliment! Others seemed to think that I had run off and left them forever without so much as a goodbye 'You are lost! Eh!'.

My industrious fortnight consisted of arranging the printing and laminating of posters, which I spectacularly failed to achieve while in the UK, completing the first draft of the normal labour guideline, completing the work on the AMEWS charts and policies, advertising for the next round of applicants to go to Liverpool in April and making printed flowcharts for ward 14. I did a midwife teaching session on Eclampsia and Premature Rupture of Membranes, and while on ward 14 mid-tutorial got involved in some neonatal resuscitation that involved a fairly swift and extremely bump 4x4 ambulance journey down the hill to SCBU. Trying to perform bag and mask in such a situation is no easy feat, especially when you're sitting sideways on a makeshift bench, and sprinting up 3 flights of stairs - especially when running is against your religion - makes for a very sweaty Mzungu.

We used some of the Magic Whiteboard that Clare Fitzpatrick brought over in December to make a prioritisation whiteboard for the emergency caesarean section list, which went up and was being used the same day, with much excitement from the SHOs. I made a decision to appear not to have any involvement in the implementation of this, to see if the acceptability and uptake is any different. I have been reading a lot about volunteer involvement in Africa and the lack of sustainability once volunteers leave. I'm concerned that much of what I may start here will not continue once I leave, and after my recent break am also aware of the importance of conserving my own energy and sanity levels and spending a little bit more time focusing on gaining personal clinical experience - particularly in theatre. Mark Muyingo, who has recently been in Liverpool, put the whiteboard up and announced it, so I hope that he will continue to drive it.

I'm keen to get whiteboards up on the central delivery suite, but I'm not sure how easy they will be to implement. There are times when patients go missing, as we don't have a way of keeping tabs on who's present on the labour ward. They may sit outside with their attendants while waiting to go to theatre, get missed, and end up being found the next day with a more significant problem than they started with. A geographical whiteboard would help to improve patient monitoring, and ultimately might help everyone manage the women better. It may also improve partograph usage. The number of patients and the current lay out of the labour ward would not be easy to manage even with a whiteboard system, but it would be a step in the right direction.

By contrast, ward 14 deliver around 20-25 women a day, and it is a much more ordered place. We put a huge whiteboard up there, the staff numbered the beds and we then laid the board out methodically, with an example patient in the far corner. We're hoping that this whiteboard will improve the pick up of women heading for an obstructed labour or who are failing to progress and facilitate earlier transfer, hopefully resulting in better outcomes - fewer sections, stillbirths etc. The staff seemed very enthusiastic, and after putting a couple of women's details on the board we had a Post Partum Haemorrhage on the ward. I put all the details on the board, real time, including drugs given, estimated blood loss and the time the ambulance was called to transfer her, to illustrate just how useful the board can be. I left it in the hands of the co-ordinator, along with some money for extra pens, and departed the hospital, ready to disappear off travelling for a few weeks with my Mum...

2009... same difference?

What did 2009 bring? Indulge me here, while I get a bit deep and philosophical... I have had some time for reflection whilst I've been home over the Christmas period. I've been able to catch up with old friends and family and for the first time in ages, check my head. The nice thing about coming home after being away for 4 months is the realisation that despite the fact that many things have changed, everything's still the same.

2009 was the year when I grabbed the bull by the horns, bit the bullet and faced all sorts of other metaphorical perils and hazards face on. 2009 was the year that I decided to fulfill a life career ambition of doing obstetrics and gynaecology in Africa. The decision to take a year out of program to work in Uganda is probably the biggest and most uncertain that I have ever made. Having never travelled on the African continent, I was charting unknown territory, on my own. It still scares me if I think about it for very long! Having thought about it a lot over the last few weeks I have come to the conclusion that it is the hardest thing I have ever done, the most frustrating thing I have ever done, the most acute learning curve I have tackled, at times fantastically rewarding and an experience that has taught me more about myself than anything else ever has. It has made me realise just how many people touch your life, in so many different ways. Mulago has challenged me in more ways than I thought possible. It has tested my resilience both as a doctor and a human being, and will almost certainly continue to do so for the next 7 and a bit months.

Lots of things happened in 2009; people got married and engaged, some had children, some are still waiting to hatch, a lot of people loved and a lot of people lost. And me? Well, I just plodded on, business as usual until August 13th. And then I stepped into the (metaphorical) abyss. I remember someone once read a verse out at a conference, referring to uncertainty, written by Guillaume Apollinaire. I distinctly remember it because I had a stinking hangover after an evening of wine tasting and subsequent shenanigans in Melbourne that resulted in my laptop drinking a glass of wine and ending up in hospital. The quote was ;

'Come to the edge, he said. They said: We are afraid. Come to the edge, he said. They came. He pushed them and they flew.'

That quote rang very true to me as the time came to leave for Kampala, and it was my pride that did the pushing, because when it actually came down to it, I didn't feel brave enough. Sometimes being proud and stubborn can be a good thing. I'm pleased I went to the edge, and I'm pleased I was pushed, although I'm not sure that I am flying with any grace or finesse just yet.

So what have I learned?

I've learned that one person doesn't change things, but that little by little you can begin to change the way people think, and changing the way people think changes the way things get done. Changing the way things get done maybe, possibly might change the world. A little bit.

I've learned that one pair of hands can only do one thing at a time.

I've learned how to reflect. Not in the way that our portfolios do, but in the way you sit on the theatre floor, head in hands, crushed because you couldn't get hold of any blood, and that a unit of blood might just have made the difference. And the way you change how you do things because this time you were just lucky, the way you learn from not having stuff that you take for granted to hand, or not having a team of 6 people working and focusing on one problem together.

I have learned the importance of having colleagues that will go the extra mile, but also the importance of acknowledging those colleagues, and appreciating them. When the propellor and the proverbial are having a meeting, it's a lonely place to be on your own. So to all of you who go the extra mile on a daily basis, thank you, you're stars, whether you're in Mulago, Liverpool Women's, Arrowe Park or Leighton - and not in any particular order. That extra mile might be running to Nakasero Hospital just to see if they've got another unit of blood at 4am, or making a shift of knackered people a tray of much needed tea, or being kind to someone when inside you're broken and you don't feel like it any more. But the little things sometimes make as much difference as the big things, so please keep doing them , they are appreciated.

I've learned that we probably don't need all those shiny silver things with obscure archaic names that look a bit scary that live on the section tray in theatre... but they're nice to have! Sometimes you don't even need a blade handle.

I've learned what all the fuss is about catgut... 'If only I had a length of catgut...'

I've learned that I am stronger than I think I am, and yet I am more sensitive than ever before.

I've learned that the things you think will get to you don't at the time, but come back and hit you when you're least expecting it.

I've learned that we should all talk less and do more. In the words of the late, great Elvis Presley, 'A little less conversation, a little more action please'.

I've learned lots of other things too, so many that I'd bore you. I'm the same as I was when I left, but I'm different too.

What else? I know that being able to write this blog keeps me afloat, being able to email people and vent has kept me sane, and the support that I have received from friends and family has been immense. I was overwhelmed by the number of people I saw over Christmas, braving the snow and ice, before and after nightshifts and long days, operations and the dreaded lergy to come and say hi. I guess you don't really appreciate what you have until you leave it behind. Thank you to each and every one of you that has listened, advised, encouraged and pushed me. You know who you are, and if I try to mention you all by name I'll miss people out.

So, now I'm back in Kampala, and it's a new year. My New Year's resolution? To appreciate what I have more, to appreciate the people I love more.

Brrrrrrrrrrrrrr!

Well, I knew it would be cold back in Blighty, but snow?! A definite shock to the system. I was grateful for my big snuggly tracksuit bottoms, base layer and fleece, and even more grateful that I had taken them to Uganda with me despite cries of 'What do you need those for?' when I was packing them back in August. Coming through the arrivals door was the best feeling, three familiar faces beaming back at me, followed by 'You're not going out in public dressed like that!' It's good to know that nothing changes!

My last week at work felt very long and was a mixed bag of challenges. I didn't go in on Saturday, choosing to spend the day doing some Christmas shopping and chilling with Adam. He's been in Mbale for the last few weeks so it was good to catch up and pretend to be a tourist for the day, hitting the craft markets after breakfast and bargaining for tacky African Christmas presents. The best thing I found was a massive wall hanging of the late Michael Jackson, badly sketched and even more badly printed, featuring, in Luganda, the timeless slogan of 'We will never forget you'. At 22,000 USH (about £8) I thought this was a bargain, but Adam disagreed, so it will not be adorning our dining room wall in the near future. Perhaps it will be in the sale when I get back...

On Sunday I went to work, putting myself in theatre on labour ward. The washing machine in the hospital laundry was broken, and we had no sterile linen. One of the senior consultants managed to acquire some brand new linen from stores, but we were unable to use it until it had been labelled in gloss paint, allowed to dry and autoclaved. We started our list of 13 pending caesarean sections at 2pm, managing to do four and a normal delivery on the theatre table by 5.30. Linen continued to be a problem throughout the week, with the operating obstetrician going from labour suite theatre to gynae theatre, depending on where the current stock of linen was situated.

I spent Monday sorting out the Midwife of the Month award, packing my stuff to take home and tying up last minute loose ends. One of our senior anaesthetic officers sadly passed away on Monday, which had an impact on morale amongst the rest of the staff. Work continued, albeit at a slower and less enthusiastic pace.

Tuesday, Wednesday and Thursday were again spent on labour ward, in and out of theatre. I seem to be having a run of arm prolapses, badly impacted heads which I have needed to deliver by the breech and sub-total hysterectomies - the second one in a week was for a bad uterine rupture. We were due to present the Midwife of the Month award on Friday, however we lost a further 3 anaesthetic staff in a car accident on Thursday, ironically whilst they were travelling to their colleague's funeral. It was felt to be inappropriate to celebrate people's achievements while the department was in mourning and so it has been postponed.

We had some farewell house drinks on Friday evening. It felt a bit strange that the surrogate family were heading off in different directions for Christmas, but we are all badly in need of a break from Kampala. On Saturday, my regular Boda Boda guy Alan was a bit miffed that I hadn't asked him to take me to the airport, and couldn't really understand why, carrying 25 kilos of luggage, I didn't fancy taking the 45km journey on a motorbike, opting for the far more sensible car. I managed to sunburn my left arm by hanging it out of the window, and arrived home sporting two totally different coloured arms and a very attractive watch strap mark, which I have avoided for the last 4 months! The flights were unremarkable for the most part, although I had a very luxurious 8 hour sleepover on the floor at Dubai.

It's nice to be at home, nice to have the creature comforts that I have missed, nice not to have to sleep under a bed net and nice be with my family. But it's a bit of a shock to the system too, and I think that I am probably becoming more of a Muganda than I have realised. That said, you can't beat a pint of real ale in your favourtie pub in the world - The Crown Posada - and a kebab, which is exactly what we had last night. All I need now is some fish and chips, some pease pudding and a parmo...not necessarily at the same time either!

So, a Hippo Walks Into a Bar...

So, it's been a while since I've blogged. I've been crazy busy here, I'm not even sure where to start!

Prior to the arrival of our colleagues from Liverpool I had a hectic few days on labour ward, spending a fair bit of time in theatre, delivering arm prolapses by the breech and other such exciting things. It has been a testing time for me recently with lots of difficult cases and difficult deliveries, not all ending in good outcomes. A lot of the time I feel very surreal and detached when they happen. I think this is a coping mechanism of sorts, but it's not something I'm comfortable with if I think about it too much. Many of the difficulties we experience here are due to resource constraints, meaning that it can sometimes be impossible to manage patients in a timely fashion, for example a woman waited for 24 hours to get to theatre for a third degree tear repair. We are extremely lucky in the UK to have the capacity to get women to theatre within 30 minutes of a decision to deliver.

The team who had recently been to Liverpool presented their work, including a slide show of their touristic activities. A picture of Joy Acen freezing to death, wearing all of her clothes, standing on Crosby beach tipped me over the edge and I sat in the meeting blubbing away, feeling suddenly very homesick! Adam and I had a really nice Thanksgiving meal at a swanky restaurant, as Elizabeth abandoned us and went to Rwanda to celebrate. It was sedate but I was shattered so it was nice to chill out.

On the Saturday I did 6 sections, battling through 5 power cuts. I will never complain about the theatre lights at home again! Thank goodness for Ketamine! I met Adam afterwards to watch the rugby and walking towards a restaurant, I fell down a storm drain. One minute we were bounding down the street and the next I was flat on my face, one leg down a massive hole and the other flat on the pavement, with no idea what had just happened to me! A few cuts and bruises but nothing too exciting.

The team from Liverpool; Andrew Weeks, Carol Porter, Louise Ackers, Sarah Jarvis, Clare Fitzpatrick and Sarah Ryder arrived on 28th November. On the Sunday I excused myself from Labour ward to go to Mabira Forest with them for lunch. By the time we got there and ate, it was time to head back to Kampala, so we didn't get to appreciate the rainforest and wildlife. While there I got a phone call to say that someone had broken into my Mum's house and taken my car - he's currently missing in action. I'm gutted, but at the same time, it made me realise how much I have changed while I've been here. I think when you see as much severe disease and loss of life in difficult circumstances, material things become just things. More importantly, no-one was hurt.

We headed back to Kampala, and had a barbecue at my house. I asked our Ugandan colleagues to contribute typical Ugandan dishes to the otherwise Muzungu style barbecue. I was not expecting someone to bring a box of fried grasshoppers - and neither were the Liverpool lot! Still, they were certainly 'interesting' to eat, although I don't think they'll be stocking them in the international food aisle in Tesco any time soon. We had a great night and a beer or seven. Sarah had carried an SOS parcel for me containing new clothes, M and S goodies, wellies for theatre, Turkish Delights, more Marmite than you can shake a stick at and amongst other wicked things, a Rubik's cube! Louise brought me some face and foot goodies so I will pamper myself when I get a chance.

On Monday we hit the hospital, attending the morning meeting and the report from the Sunday which had been a bad day - including a woman jumping from the fifth floor window - and a shocking introduction to Mulago for our visitors. We then went on a tour of the hospital, starting with the main delivery suite. It's an overwhelming experience even just to be present there, and Clare and Sarah were no exceptions to the rule. They got a good overview of the hospital and by the time we finished the tour it was mid afternoon. We left for the evening and went out for dinner, while Andrew travelled off to Mbale on a bus.

On Tuesday, the two Sarahs went up to Ward 14 and Clare went off to theatre. I was covering labour ward off and on, and went up to check that all was well on 14. A patient was being transferred down to the main labour suite and the girls were following her down as the baby was undiagnosed breech. We got down to labour ward and were there for around 30 minutes before a woman on the floor began pushing.

How many Muzungus does it take to deliver a baby?

One to deliver (Sarah, medical student), one to direct the medical student (Sarah, Midwife), one to shout in broad scouse 'Go on sweetheart push down, right down in your bum, that's it, go on, go on' (Clare, Midwife) and one to translate the scouse into Luganda 'Sendike Nyabo, sendike!' (Me).

Anyway, the baby was delivered, followed by a swift flurry of three more deliveries on the floor in the corridor, and a quick round of neonatal resuscitation. On Tuesday evening we continued our culinary tour of Kampala, heading for Turkish washed down with a few more beers and a debrief. Wednesday morning was spent on labour ward again, and in theatre. In the afternoon we had a meeting to talk about the Liverpool Mulago Partnership and the way forward. I think it's a really worthwhile exchange and essential to drive initiatives and keep momentum, and change attitudes.

On Thursday morning we did emergency skills training for 19 midwives from labour ward, covering cord prolapse, PPH and neonatal resuscitation. The session was a bit disrupted by the lack of space but it was enjoyable and I think they learned some stuff. In the afternoon, we visited an orphanage for children whose lives have been affected by HIV/AIDS. It was a really humbling and emotional experience. The orphanage houses around 30 children, and also pays the school fees for a further 90 from surrounding villages. We had a great afternoon, Clare and Sarah brought bubbles, stickers, crayons, colouring books, felt tips and sweets. My SLR camera was kidnapped by one of the boys who had a great couple of hours wandering round taking pictures, with me following closely behind, petrified he was going to drop it, but he was so content I didn't have the heart to take it off him. By the end of the afternoon the kids all looked like they had some sort of pox, having put the stickers on their faces, the bubbles had been used up, with a few kids getting soap in their eyes, many having learned to say 'That's lush Clare' in a scouse accent and there was not a flat surface that hadn't been covered in crayon and felt tip! We decided to walk to the village to buy sodas for everyone, and Enid the orphanage manager said she was sending two strong kids with us to help carry the crates back with us. We ended up feeling like the Pied Piper, with about 15 kids in tow, and carried two of the babies who had fallen asleep on the journey! I did a couple of medical assessments, one on a child with asthma and another child with a possible appendicitis. All in all it was a really rewarding day. We had a big meal in the evening at Khana Khazana, where the curry was so hot that Clare said she was 'sweating like a glassblower's arse', which she then had to explain to Joy, the Ugandan midwife, eliciting loud cackles from their side of the table. Avner, who has recently moved into the house, and is a lawyer from New York came down and joined us with Elizabeth. A thoroughly good night all round, and the Ugandan midwives got a doggy bag - also an unfamiliar expression - to take home with them.

Myself, Clare and Sarah then went off to the Red Chilli Hideaway ready for our safari trip to Murchison Falls. We had a noisy night in the dorm there - with me apologising profusely for the budget accommodation - and an early start the next morning. Naturally we ended up on a truck with two Finnish women who talked literally non-stop for 7 hours all the way there, and one angry scouser with a migraine. After a long journey up there, we got to the top of the falls as the heavens opened, Claire having been eaten alive by mosquitoes. Walking up to the top of the falls was an awesome experience, the power of the water was immense. After taking some photos, and helping two stuck trucks out of the mud, we made it to the camp, where we stayed in semipermanent tents, falling asleep to the sound of scavenging warthogs.

We started the next morning with a game drive, crossing the river as the sun rose. We were greeted on the other side by a breakfast robbing baboon, before driving off through the bush in search of the big five. We found giraffes very quickly, then elephants. I will never forget the abundance of wildlife that live alongside each other in that space. We then happened upon a lioness who was sitting in a tree which seemed a bit bizarre, until we realised she was watching an Oribi - a small antelope. She climbed down from the tree, stalked across the grass, and in one swift stealth move, grabbed it by its throat and killed it. An incredible and rare thing to see, we felt blessed. After finding some more elephants, buffaloes, giraffes and crested cranes, we headed back to the lodge for lunch. In the afternoon we took a boat launch to the base of the falls, spotting hippos, crocodiles and kingfshers, drinking Nile on the Nile, catching some rays and chilling out. For three hours, Sarah didn't even have to evacuate her bowels! In the evening we sat in the bar, in a roaring thunderstorm, when in walked a hippo. Well, into the beer garden at least... incredible. It shuffled round a bit, sniffed the ground and then buggered off back to the river!

On Sunday, we went to Ziwa Rhino sanctuary, tracking the rhinos on foot and getting within 5 metres of a male and female. It was a gobsmacking, and slightly pant browning experience, but a real experience. We got back to Kampala, exhausted but really happy.

On Monday we threw our noses back onto the grindstone, working on adapting the Maternity Early Warning Score for Mulago. Amusingly, we're going to call it AMEWS. Using the magic whiteboard that Clare brought with her, we constructed charts using colour coded pens to stick on the wall in the recovery area. On Tuesday we bumbled round on labour ward, putting the AMEWS stuff up on the walls, creating a flurry of excitement. We then arranged to have two blood pressure machines which had been bought for the hospital by two friend mounted on the wall. I took a trip to the workshop, bracing myself for the long paper trail that's usually involved in these things, found a guy called Robert who came back up to labour ward with me. He drilled holes in the back of the machines that afternoon and mounted them onto the wall the next day. I was amazed! We put one up in the post-op recovery room and one in the admissions room.

Within around 30 minutes of Robert finishing the work, a woman came in with a massive antepartum haemorrhage and a stillbirth, bleeding profusely. We couldn't get her into theatre immediately and there was no blood available, so Sarah and Clare monitored and resuscitated her with fluids in our newly created room, using the AMEWS chart on the wall to keep track of her condition. We managed to get her into theatre and delivered the baby by caesarean, but unfortunately had to do a subtotal hysterectomy. She eventually got blood, and thanks to a good team effort is doing fine.

On Thursday morning we ran our second training session, this time on the midwifery led unit, Ward 14. 15 midwives attended, many coming in on their day off, and we trained them on cord prolapse, shoulder dystocia using a Pringles tube, neonatal resuscitation and postpartum haemorrhage. We had a great morning, the staff were really enthusiastic and asked lots of questions. It was good to try it out, with the midwives rotating around each skill and everyone having a go at hands-on. In the afternoon we went to the pub to work on some guidelines and stayed for the quiz, which we were dreadful at, but it was great to have an injection of scouse fun and humour into the evening, Clare at one point taking the mike from the MC and singing at the top of her lungs.

Yesterday morning I was in theatre, and in the afternoon after running a flat baby across to special care attended the Hospital Christmas party, a terribly formal affair to begin with. I was shattered and left early but I believe it turned into the usual drunken debauched evening that you would expect from a hospital bash. I left with a bag of goodies, including the stock of Peperami that Sarah had brought with her in case of famine... I think the dog will end up eating them. Gutted that the girls have left, it was great having them here to help keep me sane at the point where I was becoming more exasperated than I have ever been. Still, it's only a week until I head home for Christmas. I'm ready for a break.