last few photos...

two chickens underneath my seat on the bus... wrapped in plastic!

Well, I am home safely and thought I owed my readers a few more photos.  Above are the two chickens I spoke of that were a seat behind me on the bus from Kitgum to Kampala.  I guess I should not have been too worried about them coming up to peck my ankles because these guys were wrapped in plastic to prevent running around.  Very civilized!

Below is a picture of the melee that occurs when the bus stops... would you like some goat meat on a stick, or cassava, or fried plantains, or a drink, or some milk in a plastic bag - NO is the right answer.  Unless you carry a lot of Immodium with you.

Below is a picture of the headwaters of the Nile River outside of a city called Jinga, Uganda.

I was lucky enough to get a day or so at a nice guest house right on the shore here - Nice view!  Awesome river and great birdwatching.

The last one is a bike I saw near the river's edge...  It is remarkable that people can make something so worn out and old work so long, patched up but rideable. They make do.

 It kind of sums up Africa.

Winding up...

Sorry for the absence of photos from this post, but I gave my last laptop away to a nice medical student who had his laptop stolen from his room. I can't figure out how to upload a photo from my phone to this blog. By the way - a huge thanks to Clay and Jinny for sending me with 3 Mac laptops to donate! My backpack is certainly lighter as I head home. The travel from Kitgum was uneventful- although there were two live chickens under my seat.. 8 hours wondering if they would peck my ankles- but they were very well behaved! I had a couple of free days so I travelled to Jinja at the head of the Nile River as it starts from Lake Victoria. It was an awesome sight and the bird watching was amazing. I had a a day of rest, reflection and a reminder of how lucky I am to be here. Today, back in Kampala I visited with International Justice Mission staff- their work is amazing and I am proud to be counted as one of their "Freedom Partners". See ijm.org - you will be impressed. I then visited the Uganda Ministry of Health, Hospice Uganda, and the African Palliative Care Association. I am trying to get an understanding of how hospice is done here in the big city, what the government supports, and what are the challenges. Some of their challenges are similar to the US, but others are unique to Africa - like regulatory and government barriers to opioid prescribing and HUGE numbers of AIDS patients. I was also surprised to hear that dementia is growing in prevalence in Uganda but virtually nothing is available for family caregivers. No one seems to know how to assist caregivers to understand the disease. I learned a lot and hopefully made some good connections for the future. I'll spend tomorrow night at a retreat center near the airport that is designed to promote reconciliation (remember this country has had a big civil war, a turbulent and violent dictator in Idi Amin, and continues to have problems with corruption). I wanted to visit this center started by a Duke Divinity school professor - and it seemed to be a fitting end for the trip. I'll try to add a couple more photos to this blog when I get home- but thanks for reading Over and Out! Laurel

Days for Girls

One goal of this trip was to partner with a great charity - Days for Girls (Daysforgirls.org) to deliver some health education and re-usable feminine hygiene supplies.  OK, male readers hang in there...

Girls and women in the majority world often stay home from school or work when they are menstruating. They can't afford disposable feminine hygiene products, and often use rags instead.  This great charity has developed a "kit" for girls/women with washable, re-usable products for them to use, which also includes: soap, washcloth, zip lock bags for soiled supplies, new underwear and the washable pads/holders.

I recruited a local woman leader who is in training for public health to work with me on the teaching here at the school.  Winnie (in the white Tshirt) was excited about the program and hopefully will continue to shepherd it along when I go.  The hope is that the sewing students at the vocational school will pick this up as a project to make the kits - even possibly using it as a "micro-business" idea.  Here are a few photos of our presentation... Winnie speaking about the kits - bringing up some volunteers to help her.  We had about 30 girls and some teachers too (hoping they will become trainers too)

Winnie was a natural teacher and she had them laughing with her impersonations and "local" jokes... I on the other hand taught about the female anatomy and the menstrual cycle.  I was at a definite disadvantage as far as entertainment value.

All in all it went really, really well.  It was a great opportunity to watch a talented African woman lead the presentation, and move into topics like staying in school, caring for your own health, controlling your destiny by not getting pregnant (or getting HIV)...  we were able to give each girl a tangible "gift" that is helpful, re-usable and replicable on a local level.  A big win, and hopefully it will continue on in this area.

(later when I get home I'll try to post some video's of the meeting.)

thoughts on poverty

Since I have continued to read and think about poverty while I am here, I thought I would share a bit more.  Development expert Robert Chambers asserts that, "The materially poor are trapped by multiple, interconnected factors - insufficient assets, vulnerability, powerlessness, isolation, and physical weakness - that ensnares them like being caught in a spider's web."  

Steve Corbett adds to this with, "Imagine being caught in such a web.  Every time you try to move, you just get more hung up on another strand.  You think to yourself, Maybe this time will be different, so you try to make a change in your life.  But immediately you find yourself even more entangled than before.  After a while you come to believe that it is better to just lie still.  This is miserable, but any further movement only brings even greater misery.  You hate your situation but you have no choice."

Most of us from the "minority world" do not lead this type of life.  We grow up believing that we have potential, possibilities and options...  work hard and you can do anything.  (which I don't fully believe but it is the "mantra" of our world.)  Nobel Laureate Amartya Sen says it is this lack of freedom to be able to make meaningful choices - to have an ability to affect one's situation - that is the distinguishing feature of poverty."  (from "Development as Freedom)

It is obviously hard to come face to face with such profound poverty, and just carry on with one's life.  I want to be changed by experiences and be a more compassionate person.  More to ponder... and much to be grateful for.

little joys

We sponsor a child here at the school and I was able to take him shopping a couple of days ago for a backpack, shoes, and some clothes.  That is another story... white woman bargaining with local shops for goods.  I imagine I didn't get the best price.  ANYWAY - today I got called up to the office and his mother had brought me a thank you gift of a "popo".  I think it is a breadfruit, but I am not sure and gave it to the cook here to prepare for tomorrow.  I'll tell you about how it is later.  Pretty amazing to get a gift from a desperately poor widow with 5 children, I wanted to hand it back and give her all my cash too.  But I graciously thanked her so as not to embarrass her or myself.

Another little joy was to be invited over to Peter's home to meet his family.  Peter is the Clinical Officer at the clinic.  He is not really a full medical doctor - so I guess he is more like a Physicians Assistant in our system.  He is a lovely guy, with good clinical sense, a great work ethic and a quiet, kind manner.  We got to meet his wife and mother and his child Shadrack.  I asked if the next two kids would be Meshak and Abendigo  (a little old testament joke for those of you paying attention)  Peter said, "God willing!"

These are two photos of he and his wife and son, and then one of us sitting around the tree on their land.  They have mud huts for each family member. (grandma, two sons and their families, one cousin) Imagine keeping your work shirts/pants, shoes all clean and in good condition if you lived in a mud hut without electricity - REALLY!  He took us in his hut to see it, all swept clean.  They roll out a foam mattress on the mud floor to sleep on.  He has a box on one side that he keeps his medical books, certificates and cell phone in.  They have an iron that they fill with hot charcoal to iron his clothes each day before going to work (walking about 3 miles to work).
I have to admit - I am in awe of Peter, and what it must take to get to work each day.  I am going to buy him a bike as I leave, as a thank you present for his gracious hospitality.

PS we brought the sodas  :)

medical work

Ahhhh, where to start?  The place I am visiting has a hospice and infant feeding program sharing the same space.  That may sound odd - and I guess it is, but there is some logic in it.  Most of the kids in the infant feeding program are either orphans (mom's may have died in the hospice) or they have HIV positive moms.  Those little ones need to stay nearby to receive the formula since they cannot breastfeed.  If an HIV positive mom breastfeeds, it significantly raises the chances of transmitting the virus to the child.  So the hospice provides formula which would be way too expensive for the moms to afford.  It actually seems like a wonderful mix - the dying and those who are being given a chance for life.

One of my jobs has been to bring a bit of order to the feeding program - start an enrollment book, describe the criteria for admission and discharg, set up a system for weekly weighing and measuring the infants and thereby provide the correct amount of formula for the particular infant.  I know some of you are laughing right now imagining the geriatrician doing an infant feeding program - well God has a sense of humor, that is for sure.  Here is a picture of student nurse, Prisca, helping me with weighing a child.  He probably is crying because of the scary white lady standing in front of him, I am getting that reaction a lot from the little ones!

I went over to the Catholic hospital this afternoon to get a bit of help on the guidelines and phases of treatment for child malnutrition (you can easily see I am out of my depth).  They have over 60 children in their nutritional feeding program and clearly some of the most severe cases.  This little guy was brought by his mom from the Sudan - I think he is 3 years old.  He is all swollen in his limbs (which makes them look bigger than they actually are) and you can see how wasted and thin he is in the face.

On the hospice side of things, I am trying to help them with the tough concept of curative versus palliative care.  Even I am confused by this in Africa.  An example is a 21 year old woman with AIDS and chronic diarrhea and wasting syndrome.  She is on HIV medications and has had multiple treatments for possible causes of her diarrhea (where is Steve when I need him? Gastroenterology in Africa might even present him some challenges without an endoscope and without tests  :)  Anyway, the government hospital where she got her original diagnosis and HIV medications didn't have any answers for her so she came to our hospice.  The staff nurses really want us to "fix" her, and the first few days, I went through everything they had tried for the last month, including various courses of antibiotics and antifungal medicines, but nothing has worked.  She is losing ground, and probably weighs 50 pounds at most.  I am trying to help them transition to comfort care, but it seems hard for them to accept.  I understand completely, and yet using the valuable resources of IV fluids may not be the wise thing to do, and may just make her death more uncomfortable.  So this is supposed to be my speciality area and I am still humbled.

There are a lot of tangible, small things I have done that hopefully will bear fruit.  These include helping them standardize a pain scale that they use on patients every day, re-organizing their charting so it helps them avoid medication errors and keep a better connection between the disease and which medications are targeting for the disease or the symptom.  (ok, now I know I am boring some of you)

I did the workshop with the nurses today that I told you about earlier.  I started with asking them what their skills and talents were.... at first it was like pulling teeth, but then one said, "I am good at putting in IV lines", and then another said "I am a good at telling credos"  I said what? - what is a credo?  She explained it was a "local story".  It turns out she is a great storyteller and often spends some of her shift telling patients a native story.  What a great talent!  I told her how important it is for people who are sick to have a way to be distracted from their discomfort and illness for a time.  Maybe our hospice units in the US should have a resident story teller!  We moved on to what things might be improved and I think the exercise was a good one - and I learned a lot.  To bring it back to reality though - none of the nurses thought that all of them taking their break at the same time was a problem - arrrrrgh!  Oh well, I'm trying.

I leave you with this image... a great young man I met while here.  I think he has TB of his bones, which has caused his spine to fold over forward.  He also has a shortened right leg that he has to adjust to by walking on his right toe.  Would you believe he tries to run around and play basketball, and even is on a dance team?  Absolutely incredible.  I was able to ask him if he was in pain, and he nodded.  So we talked more about where he hurt and I asked him to try some tylenol three times a day.  (yeah, rocket science)  He tried it and told me he feels better - so I got him a bottle of tylenol and set him up in the new clinic to get refills every month.  Priceless.

village life

As I walked over to the home of a friend today, these kids said, "hi, how are you?"  I said "Fine, how are you?" which provoked a torrent of laughter.  Somehow my appearance in combination with my voice is just too much for them.  I think they have caught on to the sound of the question, Hi how are you?  but they have no idea what it means.  I am glad to provide them some entertainment in an otherwise dreary, hot day.

These kids are from the village and do not go to school.  When you are on the school grounds of the charity I am visiting, there are thousands of kids attending school for free - an awesome sight.  It is hard to imagine that there are any more kids here that aren't in school.  However, the truth is that there are still so many kids without an education, without health care or vaccinations, and basically without  much hope for something better.

Along the way, I also saw this little house with a homemade tin bird house (better termed a bird hotel) on top.  I asked someone what kind of bird lived there, and I was told pigeons, and that they are raised to eat.  Hmmm, I wonder why the pigeons stay in the hotel if they are going to be eaten?

A family visit...  I was able to stop by and visit with John and his wife Grace.  She is holding their youngest child (of 4 children).  Some of you may remember that John is an administrator of the school and he had been kidnapped by the reels to be a soldier when he was in his teens - he is 29 now.  he tried to escape and was beaten and they hacked off his hands, ears, nose, and upper lip with a machete.  They left him for dead, but somehow he survived and was found.  Today, John lives near the school in a mud hut with his family on a small plot of land owned by Andrew Wright, the doctor from Australia I am working with here.  He is allowing John to live on the land as the caretaker.  Below is a photo of Doc Andrew on the piece of land.  He is deciding whether to build a small home on it for when he comes to help with the medical work.Andrew spent 3 months here a few years ago - has come back frequently over the last 10 years and now is planning to come back every 3 -4 months to continue to develop an outpatient clinic on the school grounds.  I 'll tell more about the medical work in a later post...  until then.

reflection

The weekend provides a bit more time for reflection, reading and processing of the time here.  One of the books I am reading is called, "When Helping Hurts, How to Alleviate Poverty Without Hurting the Poor and Yourself"  by Corbett and Fikkert.  I am finding it very helpful and personally challenging.  Near the beginning of the book the authors challenge the reader to consider their motivations for helping the poor.

Here's a quote - "Development practitioner Jayakumar Christian argues that the economically rich often have "god-complexes", a subtle and unconscious sense of superiority in which they believe that they have achieved their wealth through their own efforts and that they have been anointed to decide what is best for low-income people, whom they view as inferior to themselves.


Few of us are conscious of having a god-complex, which is part of the problem. Consider this: why do you want to help the poor?  What truly motivates you?  Do you really love poor people and want to serve them?  Or do you have other motives?  I confess to you that part of what motivates me to help the poor is my felt need to accomplish something worthwhile with my life, to be a person of significance, to feel like I have pursued a noble cause... to be a bit like God.  It makes me feel good to use my training in economics (medicine) to "save" poor people.  And in the process, I sometimes unintentionally reduce poor people to objects that I use to fulfill my own need to accomplish something."


This is certainly causing some self evaluation...  and hopefully a more humble approach to my efforts in improving healthcare here.  It is easy to "teach" and tell people how it should be done, or how we do it in the US, or what the research shows...  and while there is certainly a place for sharing knowledge, the "HOW" it is done is crucial.

After reading later sections of the book, I have re-designed my approach for a meeting with the hospice nurses aides this week.  I was going to teach them about pain assessment, charting tools, etc.  to help them improve the quality of the care that the hospice patients are receiving.  After more reading and reflection today, I am going to start the meeting asking them each what things that they do well as nurses aides/people - what talents do they have?  Then I am going to ask them what they like about the hospice...  then what they don't like or what we could do better.  Would they like to be patients here if they were very ill?  What would they change?  Hopefully, this will prompt them to come up with the gaps  (ie.  not asking about pain everyday)  and maybe a few more things that I have not noticed.

Anyway - it has been a good weekend.  It is Ugandan Independence Day today, so tomorrow is a national holiday.  We will be working in the clinic and hospice anyway, but maybe the work will be light.  Baby David is coming back from the hospital tomorrow, so it will be good to check him out, see his wound, etc.  I saw his adopted "dad" at church today and he reported that David is improving.

I am very much enjoying Andrew Wright, the Australian physician who is leading the efforts here in the clinic development.  I think we complement each other well - he is soft-spoken, thoughtful and has a great sense of humor.  I am the bull in the china shop, often apologizing for being too energetic or opinionated.... oh well, hopefully I am learning.

The rhythm of the day

I thought it might be interesting to hear what events "mark" the day here in Kitgum, Uganda...

At around 4:30 am, the roosters start to crow...  it is dark outside and I check my watch and think, "really, 4:30 am?"  I put the pillow over my head and try to go back to sleep.  Eventually the sunshine breaks in and the noise level continues to rise.  I start to open my eyes when the singing starts.  Kids singing on their way to school, cooks singing as they pump water - the morning is here.

I fill my wash basin with water and go into the outdoor shower/bathroom.  Washing up and washing hair by pouring cups of cool water over my head.  A night shower is even better under the African stars  :)  Bathing twice a day is absolutely necessary because of the heat and dust - I am grimy at the end of the day.

Anyway - I also wash some clothes in the washbasin each morning and hang them out to dry.  Breakfast of porridge or toast. bananas, and tea - and a talk about what is on for the day.  By the time I gather my things to head to the clinic or the hospice, most of the 3,000 kids are in classrooms.  I can hear them repeating the teacher or the occasional giggle as I walk by.  The vocational students (high school age kids in training for building, sewing, secretarial, mechanics, etc.)  are all gathering outside and singing and clapping to start their day as well.  Wow, does that start the day off on the right foot!

We meet back around 1 pm for a lunch - which is usually rice, beans and some meat stew.  We had chicken today at lunch and I crunched down on neck and other unidentified bones  - so one has to be careful!    See Frances, the cook, below plucking our lunch.  May I add that the smell of the burning feathers does not stimulate the appetite in the morning (we were eating breakfast while he was doing this )  However, I really do appreciate all the work that goes into our meals - no refrigeration, no electric stove or oven... it would be hard to cook for a big group in Africa.  We are invited out to a staff's house for dinner tomorrow and they are preparing "game meat" - I think gazelle or antelope is on the menu.

Then back to whatever work I am doing until the end of the day around 5 - then washing up again, a light supper with the group and then usually we have a bit of conversation, or computer time or reading until the satellite modem is shut off.  Some days there are power outages, but so far we have had power most of the time.  Each day so far has had a bit of rain - but the temperature doesn't drop below 70 at night - and gets up to 80 or 85 in the day.  Kitgum has beautiful, vast skies that somehow seem different than home.  Maybe it is the flat landscape or the lack of pollution (although there is plenty of dust).  You'll just have to see it someday - yes, and open invitation to come back with me.

Off to bed - under mosquito netting.  (don't worry Steve - I am also taking my malaria pill)

The journey and the destination

Hello readers! You will have to wait a bit for an explanation of the picture attached...

I know that some of you will be disappointed to hear that my travel to Kitgum, Uganda was not nearly as eventful as the last time. No bus fires, hitch hiking, or traveling with stealthy chickens.

I caught a ride north to Kitgum with a staff member from IGF (Irene Gleeson Foundation), who was transporting a refrigerator and a radio transmitter from Kampala in a truck. (No, I got to ride in the cab, not in the back). One funny sign in a village on the way advertised an office for SLAP - Support Least Advantaged People. I almost asked to stop to take a picture of it, but didn't think quick enough. Is that the worst possible acronym you have ever heard of? I cannot imagine anyone even wanting to go into the office to ask for help :)

The ride was more green and lush than the last visit because of the rains - which also meant some washout areas. However it was only a 7 hour drive - with the last segment from Gulu to Kitgum being similar to riding on the inside of a washing machine for 2 hours. Taking the larger bus may have a distinct advantage on this last section. It seemed surreal to see little children walking along the road with large jerry cans of water on their heads, or women with a child tied to their backs and carrying jerry cans in both hands and on their heads. There is pretty much nothing to complain about when you see that.

At the end of the long day's travel there was a beautiful rainbow that seemed to end at Kitgum - a sign for me. Irene was there to greet me, and I finally met Dr. Andrew - an Australian family doc who has been here several times and is encouraging me to partner with him in the medical work here. He is a very warm, compassionate doctor and I am going to be very lucky to work with him - I have much to learn. There is another Australian couple here visiting as well (I am outnumbered by the Australians - I am the only white person without an accent :) He is a mechanical engineer and she is a retired pharmacist - so we are all gainfully put to work here.

After being awoken by roosters at 5 am (earplugs tonight for sure) - I sat down with Andrew to hear about what he has been doing here for the last couple of days. Then he showed me around the clinic area - which is very simple but impressive. Would you believe he even has an electronic medical record system for the clinic? There is still much to do as far as standards of practice/lab testing/ approaches to common problems like fever/cough etc. We have a lot to learn about a whole array of new diseases in the differential diagnosis of a symptom - in other words typhoid and malaria are not usually in my differential at home!

I then was asked to see an "old" man in the hospice ward. Sure - something I might actually have some experience in... When I got there and heard his story - it turns out he is only 55 but looked 80 - very thin and obviously dying. He had AIDS and TB and the question for me was whether the TB meds were the possible cause of his lack of appetite and obvious decline. I spoke with the wife and son, as well as the medical officer (a young man who is the equivalent of a doctor here - but probably more like a good Physicians Assistant in the US) and we talked about the various options. I thought we should give him some IV fluids in case dehydration was the cause of his decline over the last few days. (He was basically unresponsive at this point). He did not seem to have any physical discomfort - which is good because there is not any morphine or other opioids in stock (Note to self - fix this issue before I leave). I'll check on him tomorrow, but I dont think anything can stop his decline at this point... he is in the right place.

I was pulled away again to examine a little orphan boy (whose name is DAVID! ) who had only weighed 2 pounds when he was born prematurely about 5 months ago - now he is about 8.5 pounds. He was doing well except for an inguinal hernia (note picture above). Some of his intestine had gone through a weakness in his abdominal wall into his little scrotum. So I felt like a monster as he screamed and I tried to gently maneuver (or "reduce) his hernia back into his abdomen. No luck. So I packed him up with his "grandma" caregiver from here and we went to the Catholic hospital. We got prompt help and within 30 minutes we were waiting for the anesthetist. The young African medical officer welcomed me into the operating room where I helped a little bit (if holding a retractor is helping) while he did the operation. Good news was that the bowel was not ischemic and pinked right up when he got it out of the hernia opening. He should make a full recovery. It was a great privilege to be part of helping him avoid an early death - especially since they had worked so hard to save him from his low birth weight and prematurity.

It was a busy first day - I have a lot to learn, and a lot of listening to do so I can hope to be sensitive to the needs here, and not just tell them how we do things in the US. Thanks for reading!