That Sacred Hour

You’re supposed to lie-in on your birthday, but the woodland kingfisher knew better. It was six o’clock and the first photons of light were breaking through the cloud cover and onto the curtain. The morning call of the woodland kingfisher is ubiquitous in East Africa; a long tone followed by a rapid repetitive chatter. It’s not a relaxing sound. We were on the banks of the river Nile, perhaps 20 miles north of its source at Lake Victoria. We had only few hours the previous evening to explore this paradise, but I knew the trees would be full of birds come the morning. The excitement was too much to bear; I left my sleeping partner beside me and headed outside.

The light was still low, the thick cloud muting the usual rapidity of the sunrise. We had a huge view of the Nile surging past us. I could just see the first teams of great and long-tailed cormorant flying at a clip, close to the river’s surface, keen to get to the best fishing spots from their communal roost. I immediately spotted the vocal woodland kingfisher, a large dumpy kingfisher, but still too dark to see his blue colour. Over the next fifteen minutes this still and empty space would be submerged in multiple layers of bird song, filling every gap of potential pitch and tone. I would start at the water’s edge and work my way inland from there.

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The view from Saranac-on-the-Nile

I stood on an exposed rock, and watched the world come alive. Immediately I saw a short stocky heron fly into a nearby reed-bed, or was it a bittern? I had seen this same bird yesterday but not had the chance to identify properly. With a bit of positioning I could see where he came to rest. Again, too dark to really see the plumage, but I knew where he was, I would come back, he wouldn’t move unless disturbed. Amongst the reeds were several marsh flycatchers, so distinctive in their flight behaviour, launching up for an aerial display, snatching an unsuspecting river fly, and returning back to the same perch. Together they were making a racket. Further along a lanky African open-billed stalk was combing the banks of the river. Even when at rest the long beak sits slightly ajar, so designed to break the shells of the snails and crustaceans that make up its riverside diet.

The light has come up and the river has become a busy motorway. I return to the small heron, and after a bit of angling to get a view through some branches I find him – the striated heron. He is precisely still, hunched forward staring into an eddy of water, on the hunt. He’s got a dark crown, much like the larger grey heron, but the crouching stance and thicker neck distinguish this group from their gangly cousins. The stooped shoulders make this bird so characterful; you can almost imagine them cast as cloaked and wicked minions in a Disney film, like the vultures of the Lion King’s elephant graveyard. Whilst I watch him a quick flash draws my attention to the neighbouring rock. A malachite kingfisher has taken up position, and the light is now sufficient to light up this jewel of a bird, bright orange and azure blue. The fast, flat and direct flight adds to the sense of mineral density, though I suspect he weighs just a few grams.

I look up from the binoculars, return to the rock and take in the scene. The first fishing boat, an old and bashed dug-out canoe, is making its way upstream. One man paddles, whilst the other dives down to pick the nets. The diver stands tall, completely naked, with water running off his beautiful muscular body, shaped by the demands of physical labour. A flock of greater blue-eared starling take off from one of the islands, clearly disturbed by something. Then I see them, eight helmeted guineafowl motoring my way. The lead bird doesn’t see me until twenty meters from the bank. It’s probably my imagination playing games but I can picture the look of surprise on the birds face when an intruder was noticed on his usual landing spot. They settle on the lawn and trot off into the undergrowth. A large bird draws my eye back to the river; a purple heron has found a spot to settle a fish. The feathers of the neck look like ermine, you wouldn’t resist to stroke it. The previous evening we had seen the undulating flight of the palm nut vulture, wide formations of pelican in the evening sun, and even the unmistakable giant kingfisher which really should belong to another species altogether. Every 30 seconds a large splash draws my attention to another part of the water’s surface, and once or twice I manage to see the tail of a large Nile perch that has jumped. The river is swollen with life.

I can’t ignore the commotion behind me and I head to the gardens. The raft of sound is dominated by one distinctive call; a set of four pure piping notes, slightly off a descending minor chromatic scale. The previous afternoon I had assumed the call was from the chin-spot batis, which often reminds us of the nursery rhyme ‘three blind mice.’ But there was an extra note, and I hadn’t found the culprit. I walked slowly and calmly into the copse of trees from where the sound came. As is always the case, you get near, the bird startles, and the sounds stops. Some patience, and the call returns, and returns sooner at this hour as I imagine the birds puffed up in the confidence of morning spirit. Some movement in the trees, and a flash of clean white a black – a small bird, moving like a batis. A few minutes later and I get my first proper view, and so surprised am I to see a bright red wattle above the eye of this bird. I take as many mental notes as I can, and as the bird retreats from view I open the book and flick through the pages. I find him – the brown-chested wattle eye – indeed closely related to the assumed batis. The description of voice reads, ‘A unique syncaphonic sound, usually a series of up to five descending minor key notes. A pair of birds may duet.’ How satisfying.

Some quick snaps and then rustling within a bush; were there ever such tempestuous lovers as sunbirds? Not a surprise with such pompous well-preened males, the females taking the drabber plumage. They commonly embellish gardens all over the continent, but a huge variety of species exist. A male and a female typically move together, constantly squabbling a clicking at one another, chasing and dashing between foliage, before feeding almost serenely like hummingbirds taking nectar from floral cisterns. I had identified the red-chested sunbird the day before, but I spotted another species now with a longer tail. It wasn’t long before the bird revealed himself, and what a display he put on. The feathers of these birds have a metallic shine, and I caught this specimen in the perfect light. The head was a brilliant emerald green, and down the neck shone golden streaks. The moment lasted miliseconds, but what a gem, the bronze sunbird in all its glory. Several other birds flitted between branches, including the dusky-flanked Prinia. This is a small active bird, with an erect tail that flicks up like an antenna, twitching with interest. Very busy indeed. Within the branches I catch a flash of bright chestnut. My binoculars find the bird, an African paradise flycatcher, without the long breeding tale this time. I can’t think of a brown that appears so bright and vivid, yet so soft in its milkiness. The bird doesn’t stay for long, paradise flycatching to do no doubt.

I make my way back round to the river. The action of men in boats now seems to be the main event, and a new chapter of the day has begun. I can sense the house is stirring, and I hear the kettle whistle. I had almost forgotten when and where and why we were here, so absorbed had I been in the nature of things. How lucky I feel to still love a hobby that first captured my interest in childhood, what texture these birds bring to any environment. She comes with coffee and we sit on the veranda, and I recount the stories that were told in that sacred hour.

As if the action were over! The conversation is interrupted by an unmistakable bubbling and fruity call, followed by the harsh reply in duet. It’s not long before we spot the red chest of the black-headed gonolek, and she finds the bird through the binoculars. We will make a birder of her yet! Soon we will be gliding over the surface of the river Nile by boat, taking in the sights from water level. Before we set-off I finally see the bright blue of the woodland kingfisher as he flies away towards his woodland home, and I imagine him say ‘you’re welcome!’ for his morning wake-up call.

Visit Saranac-on-the-Nile: http://www.saranaconthenile.com/

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Morning coffee on the veranda

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I love birdwatching

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A great birthday

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Sweet things – diabetes in pregnancy

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And so another chapter begins! I have written before about the tortuous journey of pregnancy in Uganda; the number of women and their babies that die in this part of the world is still staggering. Of thirty female friends you may have, you could expect at least one to die of pregnancy-related issues, and five of their new-born babies to die in the first days of life. The disasters tend to cluster around the time of delivery – babies getting stuck, bleeding, accelerated high blood pressure – so surely the answer is better surgeons, better labour suites, new instruments. But it seems that each of these seemingly sudden events has a slightly longer story. What if we could predict who would end up in a critical condition, and intervene before things unfold?

Friday morning at The Royal London Hospital in Whitechapel. The waiting room in the antenatal clinic is a cacophony of Bengali chit-chat. We will see about 50 women who have developed diabetes during the course of their pregnancy. There is a natural tendency of the body to become slightly resistant to insulin during the second half of pregnancy; add to this increasing maternal age, obesity, and a South Asian genetic preponderance to diabetes and you have the perfect storm. The evidence is quite clear – uncontrolled diabetes in pregnancy is associated with bad outcomes – babies grow too big and get stuck during labour, the placenta begins to wither early and cause the high blood pressure disorder ‘pre-eclampsia’, and the baby’s blood sugar can rebound and crash in the first 24 hours, causing seizures and death. We therefore offer these women an intensive service of surveillance; blood sugars are checked four times per day, medications and insulin are tweaked, babies are scanned regularly. We know that if we get it right (and don’t ruin the woman’s joy of pregnancy too much…) then their perinatal outcomes are almost as good as their non-diabetic friends. How fortunate to live in a place where such a service may be afforded.

Back in Uganda and the department of obstetrics have noticed an increasing number of large babies, and the usual complications of pre-eclampsia and early neonatal seizures. Do women in Uganda get diabetes in pregnancy too? That’s the question. The evidence is sparse, unreliable, and contradictory to date. One thing is clear – diabetes should no longer be seen as a ‘disease of affluence’. 100 years ago only the rich could enjoy the luxuries of sugar, tobacco, opiates; indeed the tides of world history were governed by their consumption. But today these products are increasingly available and cheap, and are being consumed in greater quantities by impoverished communities. Diabetes and obesity, once the signature of wealth and prosperity, and now diseases of the poor in the UK. In Africa, the cheapest way to take calories are through sugar and other fast carbohydrates, where universal access to coca-cola seems to have been realised more readily than universal access to health. Add to this a theory that malnutrition in childhood and chronic infections may reduce the body’s ability to secrete insulin later in life and suddenly the idea of diabetes in Africa doesn’t seem so far-fetched.

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I’m pleased to have joined a project which has set out to try and answer some of these questions. Is there a large burden of diabetes in pregnancy here? how bad are the outcomes? what’s the most practical way to diagnose the condition? what happens to the babies as they grow? Extracting quality data from a noisy environment is a challenge, but there seems to be a great team dedicated to the work. We have five sites, three here in Kampala, and then two others in Entebbe and Masaka. The initial site visits have shown that the diagnosis of diabetes is rarely made; that’s not to say it’s not a problem, as the disease is often asymptomatic and reveals itself through bad perinatal outcomes that are often put down to another cause. If a baby dies on the first day of life, ‘birth asphyxia’ is considered before diabetes in pregnancy. If a baby gets stuck during labour we say ‘inadequate pelvis’ before we say big baby. The pilot recruitment has finished, and we expect to have all sites up and running in the coming weeks.

The next question is how we treat this condition in an environment where measuring sugar levels at home and complicated insulin regimens are neither practical nor affordable? My job has been to write the treatment protocol for the study, a pragmatic approach to diabetes in pregnancy in the low-resource setting. For now there is a lot of room for individual clinicians to make decisions based on their own experience; facilities are so varied that imposing a universal approach would be futile. But we are laying the groundwork for the creation of national guidance in the future. My own feeling is that a more robust system of antenatal surveillance will be the intervention that makes the difference, not an obsession with precise glucose measurements. It comes back to this recurring theme; many of the bad outcomes women suffer contain a story in the antenatal period. Studies like this will familiarise us to the twists and turns of this story, so we are in a better position to interpret things as they happen, and intervene before things deteriorate. The long-term vision is the ability to identify women at high risk of any metabolic disorder, not just diabetes but hypertension too, and support them in a more streamlined and dedicated service. Most pregnancies are uncomplicated; can we predict which will turn out otherwise, and help them not get lost in the crowd?

And of course, we’ve done a bit of biking…

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Team Ultimate Cycling Uganda

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The view from Rwakobo rock across the acacia savannah

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Fish drying on the lake, SW Uganda

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Hitching a ride across the lake with the bike

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Liam teaches the kids some bike maintenance

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Entebbe’s premier car ferry service

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Finishing the Lake Mburo park race with Steve

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