A Muzungu looking for answers….

photo-5I asked the very uncomfortable question to Mukasa, a trusted Family Health Educator (FHE) and now colleague, that has been working in the villages for over 18 years: Why do these women keep having more children if they are unable to feed the children that they have? It was a burning question within me, and I ensured I only asked it at the appropriate time.

Mukasa’s answer was simple “God has a plan for all my children, God will feed my children. This is what the people believe.”

How do you argue with that?? The under 5 mortality rate here is so high at 69 deaths per 1000 births compared in the UK of 5 deaths per 1000 births that they perhaps expect one of their children to die, so they continue to have them. Sierra Leone has the highest mortality rate of 182 per 1000 live births (World Bank 2012).

Things are not helped by the fact that the people who are meant to be educating the locals are often plagued with false beliefs such as if you use family planning methods then you will get cancer or become infertile and so they discourage women from using them. This leaves many women, one of whom I saw yesterday, with a child of 9 months of age and already 7 months pregnant with her second! She will have 2 children under the age of 1! Breast milk becomes more dilute and less nutritious with ongoing pregnancy so she brought her first child to the health clinic with symptoms of severe malnourishment. Abortion is illegal in Uganda and therefore education at ANY and EVERY opportunity is the only way things will improve.

There also seems to be strong undertones of male dominance. Women often do come for family planning methods, usually the depot injection and most don’t tell their husbands. There are huge cultural differences here compared with the UK. From what we are being told, men don’t really get involved with pregnancy or the delivery of the baby and certainly not in the day to day care of the child feeling that it is the ‘woman’s job’. These attitudes and beliefs are what FHE’s are working very hard to change, trying to engage with the men to encourage them to help their wives with looking after the children. Male FHE’s are pivotal to this as if they are seen to be receptive to change then others will follow. 

When a child does get sick, it is seen as the woman’s problem. They are sometimes cautious of seeking help from health centres and hospitals for multiple reasons; distance, expense, childcare, and in some cases a mistrust of Western medicine, believing it to be witchcraft. Only yesterday at the Children’s Hospital, a father frustrated at the poor response to treatment and the minimal recovery his child was making from a Tetanus infection, made the decision to carry his child out of the hospital grounds and seek advice from his village doctor fearing we had been using witchcraft on his son.

Trust is a big thing here, trusting the Muzungu (foreigner) can be understandably challenging for the locals. Often it works best when Ugandans are educating and empowering Ugandans and the Muzungus work in the background. From my short time in Jinja that it feels that Non-Government Organisations (NGOs), missionary projects and individual inspiring people like Dr Debbie who we are working with, seem to prop up the government initiatives which don’t seem to have much enforcement. People do feel that the government is trying to make improvements, but actions, especially money, seem to get lost somewhere in the middle.

As I settle in to life in Jinja, I am slowly trying to unpick the subtleties of the Ugandan Health Service. What is clear, even at this early stage, and what my new young friend Michael told me, is that ‘knowledge is power’. Michael was a street kid that has been sponsored by one of the NGO’s working in Jinja. From speaking to him an you can truly see first hand that education is the single most powerful tool we can use to change things here.

Harsh Realities

photo-2We decided to walk home after spending our first full day at Jinja Children’s Hospital. I think this was mostly because we needed time to process everything that we had seen.

Our day started at 8:30am, the first year intern who had been a qualified doctor for a total of 1 week, arrived after us and as she entered, the nurse casually informed her that the baby she had admitted yesterday had died during the night. From the doctors response it seemed this was not an unusual occurrence.

After talking to an administrator about this, she told me that from the data she had collected, the number of child deaths recorded from January – May of this year was approximately 25 children per month, almost one everyday. I was told that this number is likely to be higher as many can slip through the registration process.

The Emergency ward felt very chaotic and is a room no larger than a school classroom and is filled with 10 trolley beds and 5 neonatal cots. The windows are broken, I’m not sure the back door actually closes, cats wonder in and out at their leisure and there is a notable absence of a sink and a bathroom. All of the dated beds with no sheets, are aligned next to each other, with no curtains surrounding them, and leaving very little room for manoeuver. On a quick head count there was 24 children that were inpatients. Most trolleys had 2 children to 1 bed, sometimes there was 3. The mothers slept on the floor, which we guessed had not been mopped at all this year.

The intern started the ward round by herself, rescued shortly by a visiting American doctor, Dr Klein, who was here as part of his honeymoon! It really is all hands on deck here, the hospital is chronically understaffed and anyone with any knowledge is most welcome.

As the ward round progressed a bewildered look passed between Alka and I, recognising that a majority of the children in front of us would be on a Paediatric Intensive Care Unit if at home. In the UK we carry out basic observations on every patient at least every 4 hours and more frequently as required, here, the only thermometer we had was courtesy of Dr Klein. We had no idea what had happened to any of these children overnight as the interns finish their on call shift at 9pm and then from 9pm-9am there is no doctor on call to attend to sick children. The nurses are left to deal with any issues, and ‘survival of the fittest’ are sadly the words that comes to mind.

We next reviewed a boy that was really really sick. This young boy aged 4 had severe malaria which had spread to the brain and he had been fitting overnight. He had a GCS of 6/15 which means he was comatose. First line treatment for severe malaria as per the World Health Organisation guidelines is a drug called Artesunate which is given intravenously. Although a government hospital, which is meant to be free, parents are asked to buy most of their medications, and if they can’t afford it they simply don’t get it.

The mother couldn’t afford the Artesunate, and after a disappointed look by the intern and encouraging words that she really did need to try and find the money, we simply continued the less effective free drug that he was on, and that was clearly not working. This child without treatment will likely die, and soon. I resisted the urge to take out the $3 from my own pocket that it would cost to save this little boy as sadly it’s just not the answer.

The Tetanus room was a side store cupboard off the main room that could barely fit one doctor in to review the 3 patients lying in the dark to avoid a dangerous reaction bright lights and stimulation would bring. It was the first time I had seen a patient with Tetanus, and it saddened me to think these children are suffering from an entirely preventable disease.

There are so many questions flying around my head right now, aren’t government hospitals meant to be free? How in this day in age can children die from not being able to afford simple drugs that will save their life? Where is the investment? How do you increase uptake of immunisations? How do you even start making it better when there is so much to be done?

Source of the Smile :)

photo-3The journey from Kampala to Jinja along the Kampala road, which would take us all the way to Kenya if we so wished, was filled with apprehension and actually quite a lot of anxiety in what the next 4 weeks would bring.

For someone that generally always has something to say, I have to be honest and admit that I am finding it difficult to find the words to describe our last few days here. It has been totally overwhelming. The scale of the problem is huge, which I will detail in parts as we go along, but the positivity and commitment of the locals along with the work of NGO’s is truly inspiring.

Our first morning, and we were straight down to business teaching Family Health Educators (FHEs) on danger signs in the newborn. FHEs are volunteers who visit homes of families with children under 5 years of age to provide support and health education to the parents. One of their key roles is to develop trust and friendship within the community and in turn empower them to introduce healthy practices such as bed nets, dish racks, soap and tippy taps.

They act as a link between the local community and the health system encouraging families to get their children immunised, the importance of good nutrition, child spacing, and supporting them in keeping their children healthy. They educate pregnant ladies in the importance of antenatal care, being tested for HIV, and how to prepare for labour and delivery of the baby.

Of course, implementing change is difficult anywhere in the world, and here is no different. There are many barriers to overcome which we are only just starting to gain an understanding of. Next week we will accompany the FHEs that we have been training on their home visits to give them additional support and I await with interest to see what this will bring.

We also made our first visit to the Jinja Regional Referral Hospital for Children. As we approached the huge white arch, and gates with Mukesh Madhvani Children’s Hospital emblazoned across it, it all looked rather promising. However, on approaching the building, the gates indeed seemed to be deceiving. I’m not sure you can ever prepare yourself for visiting a government run hospital in a developing country, and it makes it just that much more difficult when it is for children.

We have only scratched the surface of what is going on here, there is lots to be done, and we are looking forward to learning, seeing and doing more every day.

Welcome to Uganda…!

imageAs we touched down at Entebbe airport, we were greeted by thunderstorms and a very fresh 20 degrees.  The air steward kindly asked all passengers that had travelled to West Africa in the past 3 weeks to make themselves know to the Health Desk, a stern reminder about the very real and very current Ebola crisis. We passed this small desk in the corner of the airport as we stood in the very leisurely queue to get our visa. The passport control desks had #LovingThePearlOfAfrica and #LaidbackInThePearlOfAfrica written above them and it took me less than a day to realise that they had their country hashtagged down to a tee.

Leaving the airport with over a million shillings in my back pocket (the first and only time I will probably have a million of anything!) we started our journey from Entebbe to Kampala. The landscape is beautiful, lush and green and watching the locals go about their daily business, it started to give us a real feel for the country we were to be living in for the next month.  I haven’t visited Africa for a very long time, and had forgotten just how different it was.

On arrival in Kampala, and minus one of our suitcases, Alka and I decided the best way to explore the city would be on foot. After confirming with the hotel that it is indeed a safe way to travel, at least before 5pm, we left our hotel into the heat. Our first stop was the MTN phone shop in Crested Towers where we spent a full 60 mins trying to get ourselves a local sim. #LaidbackInThePearlOfAfrica definitely sprung to mind, luckily we had Beyonce to entertain us! We then found Garden City mall, and enjoyed some tasty delights in one of the rooftop restaurants. Our one Saturday night in the capital found us at Uganda’s only 360 degree revolving restaurant, where the views certainly did not disappoint.

What has been so striking straight away is how incredible the hospitality is here. The Gujarati speaking restaurant owner took it upon himself to offer us a driver and a place to stay and asked us to contact him if we needed anything at all. Locals and internationals that have local connections have all be so kind to ensure that our stay has been as comfortable as possible. We spent nearly 2 hours chatting to Julie who worked in of the the travel agencies, the same age as me, she shared her stories on growing up in Uganda, the different cultures, her 4 children, 4 Caesarean sections, and her 1 month maternity leave with each of them and so much more!

Just as I feel I have acclimatised first to Africa and then to Kampala, it is time for us to leave for Jinja in a few hours. Moving from the buzz of the capital to a much quieter town will be an interesting transition.  Being here, I have realised that I am no longer 21 and it does take me a little longer to adjust to pastures new!!  We are taking things step by step…. Although it had better not take too long, we start work first thing tomorrow morning!!