All Roads Lead to Uganda

potatoOn the flight out of Entebbe, as I sit and reflect on all I have seen, I wonder about a lot of things. I refreshed my memory on the United Nations Rights of a Child:

Article 24

Every child has the right to the best possible health. Governments must work to provide good quality health care, clean water, nutritious food and a clean environment so that children can stay healthy. Richer countries must help poorer countries achieve this.

Article 28

Every child has the right to an education. Primary education must be free. Secondary education must be available for every child. Discipline in schools must respect children’s dignity. Richer countries must help poorer countries achieve this.

I have seen that basic human rights are certainly not a given, and I have learnt just how different life can be. 4 weeks is far too short a period of time to truly understand the intricacies of how things work here in Uganda, 4 years probably wouldn’t be enough! Nonetheless, it has been an experience that will change me forever.

I have had a privileged insight in to village life in Uganda, being welcomed in to peoples homes, however simple they may be. Their hospitality has been humbling and quickly made me forget that I was in a mud hut, with no electricity, no running water and no toilet. The locals, without exception, have a thirst for knowledge, which has made everything truly worthwhile.

My time at Jinja Children’s was depressing and frustrating at the best of times. Seeing children fight for their lives in this way is something that will never leave me, and more upsetting is the knowledge that things do not need to be this way, and should not be this way. I have seen pathology that, as a UK trained doctor, I only ever read about in textbooks and it has been difficult to say the least.

I feel fortunate to have met Dr Tenywa, a Paediatric Consultant at the hospital and a true credit to the Ugandan medical profession. He is someone who has re-ignited my passion for wanting to be the best you can be, whatever your circumstances and at whatever you do.

It has been a time to reflect, to learn, to overcome personal challenges and most importantly to give back. Meeting others on their journey and creating our ‘Jinja family’ has been very special, fostering unique and hopefully lasting relationships. Peter, a professor at Colombia University, New York and his wife Delia have spent the past 4 years overseeing HELP School which they have set up in Masese. Rob, the American doctor and his bright, bubbly wife Sarah spent time volunteering on their honeymoon. Alethea, an enthusiastic nursing student from the UK, along with Marie and Sofie, 2 Danish nursing students never failed to put a smile on our sometimes distressed faces.

One of the people I wanted to meet most was Sarah, a Paediatric consultant from Belfast who has been working at Jinja Children’s for the past 6 months. Without her blog, ‘A Brunette in Jinja’, coming up on my hours of Internet searches for charitable projects in Uganda, none of this would have happened. Through her and Dr Kanabar, fate has certainly played its part in bringing me here. Visiting Gabula Road where my mother used to live, gave me a sense of identity that I didn’t even know was missing.

As I was leaving, I was told by Leyla and Pete, a couple who have lived in Jinja for the past 8 years that, “All roads lead to Uganda…” I wonder if this will be true.

Overall, this is a country that has one of the youngest populations in the world. You cannot help but feel a sense of responsibility to these young children to make the world they live in a better place. A few parting thoughts come to mind as I head back to London, and I hope these will not diminish with the busy life I lead back at home…

“Be the change you wish to see in the world”

– Mahatma Gandhi


“Education is the most powerful weapon which you can use to change the world”

– Nelson Mandela

Thank you for reading!


Facing The Facts

photo-7 copyAs I sat with Dr Patrick in the Paediatric HIV clinic, I looked out at the waiting room full of mothers and their children, all dressed in their Sunday best to come and meet the doctor. There must have been over 40 children waiting for their appointment. I felt reassured that most of them looked well, happy and healthy.

Of course, not every child is so fortunate. The previous day a 3 year old boy who has had HIV since birth, was transferred to Emergency from the Malnourishment ward following a seizure. He was commenced on treatment for Tuberculosis, a common opportunistic infection in those with HIV. It was heartbreaking to watch him slowly struggle on and see all the complications this illness can bring.

The mother had not attended her antenatal appointments and had therefore not been tested for HIV, sadly transmitting the virus to her child. She had a second, 8 month old child with her, who she was carrying on her back in a sling. For this pregnancy, she had been tested and found to be sero-positive. She had been initiated on anti-retroviral drugs antenatally, the baby was well and importantly HIV negative.

7.2% of the population in Uganda are HIV positive, that is 1.5 million people of which 190,000 are children. There has been a huge drive since 2006 to reduce the rate of mother to child transmission of HIV. Any pregnant mother who is found to be HIV positive is started on treatment as per guidelines from the Ministry of Health. To have babies born free of HIV is definitely first on the agenda in the National Prevention Strategy.

Supplementing this are initiatives in schools to counsel the youth on the risks of HIV, to not engage in risky sexual behavior and to always protect themselves. Parents are also being encouraged to discuss HIV openly with their children. Thirdly, advising the adult population to test themselves for HIV to find out their sero-status and depending on what this shows, again educate them on ways to protect themselves from the disease. Polygamy is a problem here, and often individuals are not aware of their own HIV status or that of their partner which is the most common way new infections are acquired.

Recent reports have shown that the HIV/AIDS epidemic in Uganda is on the rise again, which is deeply troubling. Working closely with patients and health care professionals towards eliminating new HIV infections and putting an end to stigma and discrimination is crucial. HIV is treatable, and is no longer a death sentence as it was once seen to be. Last year, there were 63,000 reported deaths from AIDS, and it is estimated that currently, 1 million children in Uganda are living as orphans due to AIDS. This is a tragedy.

An equally pressing public health issue in Uganda is Malaria. Over 13 million cases are diagnosed every year. It is an infectious disease transmitted via ‘Mrs Anopheles’ the female mosquito, usually at nighttime. It is preventable and it is treatable but nevertheless it is said one child dies every minute from Malaria in Africa (World Heath Organization).

In 2011 the World Heath Statistics showed that Uganda’s malaria mortality rate of 103 per 100,00 is more than 7 times that of neighboring Kenya of 12 per 100,000!!

Why is it such a problem? Well, for many reasons, all of which would be far too detailed to go in to today. However, what I can say is that prevention is definitely better than cure and the government is tackling this in 3 main ways. Providing Insecticide Treated Malaria Nets (ITNs) for people to sleep under at night is probably the most important. Indoor Residual Spraying (IRS) is also carried out where possible and this is the process of spraying the inside the walls and ceilings of houses and buildings such as schools and hospitals with safe and effective insecticide. It has been very effective, having a large scale impact at an affordable cost. Environmental factors are also being addressed to try and deny mosquito breeding sites where feasible.

Many Non-Government Organizations (NGOs) have found that by simply giving out mosquito nets for free means that people do not use them. Sadly, the years of Muzungu input, foreign aid and charity work has led to somewhat of a ‘Poverty Mindset’ amongst the locals. Often villagers can afford to buy simple things for themselves, however they are aware that if they wait long enough, people will give it to them for free. This is disappointing, but often they are right!

One such NGO, Soft Power Health, who I spent time with, is very well aware of this ‘Poverty Mindset’. Their slogan is “You Can’t Afford Malaria, But You Can Afford Our Nets’’. 

They sell them at a heavily subsidised rate of 3,000 shillings, just over $1. Spending that small amount, people value their investment much, much more. Additionally, the education they receive along with buying their nets, on how and why it is so important to use them increases compliance even further.

HIV and Malaria have not been my main focus on this trip, but nonetheless it is so entwined in daily life that it would be wrong of me not to convey what I have seen and learnt. Both are devastating diseases and in both, prevention is always better than treatment or cure. They have been difficult diseases to see and learn about because they often present very late, with many complications. With our early diagnosis, intensive management and observation in the UK, we often don’t see these late signs. It is yet another reminder of how fortunate we are.

All In A Day’s Work…

ugandaAs I spend my days travelling to the different villages surrounding Jinja, I do not tire of the views and watching the children play. The deep red soil of Uganda contrasts beautifully with the lush, green landscape. I watch the women wash their clothes or dig in the fields, and the men, well if I’m being entirely honest I am still figuring out what most of the men do!

As we arrived at our first house of the day in Nawangoma, most of the children came out to see the celebrity in the village. That celebrity was me! Children here will wave, run and shout after you, “Muzungu, Muzungu… How are you?” They approach you, initially cautiously, call their friends, laugh and want to touch you – the strange person with different coloured skin. To have a Muzungu in their home caused quite a stir of excitement indeed.

As mentioned, the under 5 mortality rate is here is high, and a significant proportion of those that die are babies under 1 month old (neonates). Targeting, educating and supporting mothers in the antenatal and post-natal period is key, and for me, has been an extremely positive experience and in stark contrast to our time at the Children’s Hospital. By the time they get there, it is often too late.

Each village has a number of Family Health Educators (FHEs) who work in different zones within the village. They are lay people with no medical background, and do not get paid for their time. They do it because they want to see a change. Our role has been to accompany the FHE’s in to houses of women who have just given birth and support them whilst they review the mother and teach them how to carry out a newborn baby check.

We have been welcomed with open arms, and as we have taught, the mothers have had no end of questions for us, asking us to come back again so they can learn more. It is an opportunity to gain trust, encourage uptake of immunisations and increase awareness of danger signs in the newborn and in the mother. Most of these mothers are back digging in the fields within a few weeks of giving birth, something I still find remarkable, and so their attention is diverted very quickly to work and their other children. Men will often have co-wives so the women are left to deal with most things alone.

The male FHEs have been encouraging the men of the village to make Tippy Taps as basic sanitation is another huge problem. Enabling people to be able to wash their hands after going to the toilet, or before they handle food or a newborn baby will reduce infection rates massively. Things need to be done in parallels to make a real change.

When mothers do take the initiative to seek medical advice for an unwell child, unfortunately it seems that there is an element of ‘pot luck’ as to the type of treatment they get.

There is a tiered health system here, comprising of firstly the Family Health Educators or Village Health Teams as they are also known who should be the first port of call, followed by Health Centres 2,3 and 4. They are graded according to what services they offer. All offer antenatal care and all have a labour ward, although it must be said this is often just a room with a bed in it.

A Brief Outline of the Ugandan Health System

heirarcy1[1]Health Centre 2 is midwife or nurse led, but the majority of patients they see are those with malaria, chest infections, malnutrition and other ailments. They still see and prescribe for any patient that turns up the same way only a doctor would in the UK. They can test for malaria and HIV using rapid diagnostic kits and manage anything and everything they feel is within their capability, otherwise referring on to a higher tier of Health Centre or to hospital.

Watching a few of these midwife led consultations, it did not surprise me that there is a huge variability in the care patients receive. One of the mothers I reviewed told me she had taken her 2 week old baby to Health Centre 2 the day before I visited with a fever and poor feeding. This is a medical emergency and one that needs admission to hospital for IV antibiotics. She informed me she was given Panadol tablets for the baby, advised to crush them and give them four times a day. I swiftly intervened, explaining not to give the tablets and to take the baby straight to Jinja Children’s Hospital.

Health Centre 3 is run by a Clinical Officer who has completed a 3 year diploma in Clinical Medicine. Health Centre 4 is doctor led and has a laboratory to carry out basic blood tests. Here, patients can be admitted for treatment such as IV antibiotics.

Onward referral from Health Centre 4 is to a District Hospital, followed by a Regional Referral Hospital like Jinja Children’s and then finally the National Referral Centre in Kampala. Distances between Health Centres are large, and to Jinja Hospital it is even further. Many cannot afford transport to other facilities and in the rainy season, as I have seen, travel can be almost impossible.

Medicine here is very paternalistic. Patients are not empowered like they are in the UK and do not question the advice or treatment they are given. The quality of care may be partly determined by whether you see a nursing assistant, nurse, midwife, clinical officer or doctor all of whom prescribe medication.

Consultations in all Health Centres and by all professionals tend to last only a few minutes and usually always result in a test for malaria, a test for HIV and a prescription for either antimalarials or antibiotics. If patients have to be referred onwards, this can be very challenging.

It seems that if anyone becomes unwell in the village, they have to navigate a complex system of Health Centres, which have no triage system. Even the sickest of people sit and wait their turn. Poor infrastructure often hampers the best efforts to get the patient to the appropriate facility, and sadly, if they do arrive there it can often be too late.

I have found educating people on danger signs, to seek help early and where and how to access health care to be a very rewarding experience. A little really does go a long way here.

Walking A Mile In Someone Else’s Shoes…

tuballigation1As I watched the doctor delve deeper into the woman’s abdomen I started to feel a bit queasy. I have spent many hours assisting in an operating theatre and am definitely not one to be squeamish but this was something else. Finally, after the patient vomiting 3 times and 40 minutes of searching for her Fallopian tubes, I breathed a sigh of relief as the second tube was identified. It was neatly cut and the mini laparotomy wound was closed. The patient stood up, put on her clothes and walked out.

It is very important not to show our true feelings whilst learning about what happens here. This is their reality. My reality was I had just seen open abdominal surgery in a room that is normally an office and had no working light. The surgeon, who was only 2 years out of medical school, washed his hands with normal soap, did not wear a gown or mask and injected anaesthetic in to the top layer of skin only. I saw a lady squirm in pain in front of my eyes and I was helpless to stop it.

But need is must. The patients are fully counseled on the procedure and are aware of what it entails. Women often present following recommendation from a friend, so where there is demand there must be a supply. I’m not sure this would pass the ethics committee in the UK, but it is routine in Uganda.

Part of the problem is that there is a chronic shortage of doctors here. They, like us, attend medical school for 5 years but the road after this is very different to ours. The huge lack of resources means they do not have the luxury of time to hone their skills and are thrown straight in to the deep end, head first. Carrying out an operation such as a Caesarean section independently after only a week of qualifying as a doctor is commonplace. They churn out specialists within 3-4 years compared to our 7-8 years and they essentially do anything and everything as required. This is especially so in rural centres where jobs are much less popular. Although Dr Dennis, the operating surgeon, was 3 years my junior, I will happily admit he was far more skilled than I.

He told me that when assessing a patient, they are always taught to imagine that they have been posted to the most rural part of Uganda, with no electricity and no access to blood tests or scans. They need all their knowledge at their fingertips and rely mostly on history and examination of the patient.

This was oddly refreshing for me to hear, back to basic medicine. As a doctor in England, clinical acumen is always supported by a barrage of blood tests, ultrasound scans, CT scans, referrals to specialists and even sub-specialists. To simply treat the patient in front of you based on what you think is actually quite novel and something we were taught to do long ago in medical school. Modern medicine seems to dilute this skill.

We don’t have a TV or radio in Jinja and our Internet is sketchy at the best of times! We have made a little family away from home and it offers some well needed support. Any innocence and naivety I had about what goes on here has been completely taken away, and I say this in the knowledge that there is still so much left to see. Watching or reading things in the media is no comparison to seeing and breathing it. It has been quite a journey so far. I felt a pang of guilt as I decided against doing the ice bucket challenge despite being nominated, water is such a precious commodity here that it would be laughable to waste it in such a way.

I wonder to myself how I am going to go home and tackle obesity, when I have spent so much time working with the malnourished or how I will deal with patients resistant to taking their medication when those here simply don’t have access to the drugs they so desperately need. Every health care system has its own issues and the NHS is far from perfect, but it is free, and considering the demand on it, it does an excellent job. People here would be shocked to see what is complained about at home.

Of course, as GP’s I hope that we do make a tangible difference to at least some of the 35-40 patients we see daily at home, but here, everything is on a completely different scale – life and death scenarios are a constant. Having been exposed to a whole new level of need, you can see and feel the difference you make that much more. It certainly serves to put those cough and runny nose consultations into perspective.

I tell myself that my experience here, although challenging, can only make me a better doctor.