Ward Round

We arrive on the ward and there is anxiety in the air. The nurse calls me over, she looks quite flustered. There is a young woman, second trimester, gasping. She still has a pulse but clearly about to go into cardiac arrest. She needs to be ventilated so I ask for the usual bag-mask-valve combo we use to ventilate in the first instance. The nurse is frantically looking through a cardboard box and not winning so I go and help; a tangle of old tubes and oxygen masks, covered in dust, but not the one we need, and it’s not a great surprise. Back at the bedside, things have deteriorated and I ask the woman’s sister to step aside. I ask for a bag of fluids to get things going, but there is no stock. We have a look through the notes, not much is known yet, maybe meningitis, maybe malaria, maybe a blood clot to the lungs. No investigations back yet, the lab is not working and blood gets sent across town for analysis. Her breathing is worse, I consider mouth to mouth, but that’s for the movies, and this woman’s fate is sealed. The pulse weakens and stops. Another doctor has come and tries some chest compressions, and I ask him to stop. A moment for collection and the ward team start preparing the body. A bandage used to strap the mouth closed, the body covered in a sheet, and a cardboard tag with her details tied around her left big toe. Another maternal death, unknown cause. I offer my condolences to the sister who seems remarkably calm. She must be shocked. The death of her sibling won’t sink in until later. The patient in the adjacent bed looks terrified; they’re only a metre apart and there are no curtains. On with the ward round.

A few moments to settle the nerves of said terrified adjacent patient. She cries whilst I hold her hand, worried she’s in the same boat. Fortunately, she’s on a different journey. She suffered with severe pre-eclampsia, the high blood pressure disorder in pregnancy. Her baby was born early and died the previous day. She has three, but wants two more. Fluid has built up in all the wrong parts of her body from the inflammation of pre-eclampsia, but most importantly for her in the lungs. I can hear the two puddles of water in the base of her chest. The SHO (obstetrics and gynaecology trainee) has arrived now and says they have asked the cardiothoracic surgeons for an opinion. It’s a blessing that they won’t come anyway, the last thing she needs is a knife. Her body should pass the water naturally over the next few days. I counsel her that she may need blood pressure medication when she goes home, and her next pregnancy will be very high risk. She will need careful antenatal surveillance in case this happens again, a service she unfortunately will not get. She’s going to get stepped down to the general post-natal ward now, a room with 40 mothers and crying newborn babies, and she will feel her loss.

I notice the catheter bag of a lady in the corner is a brownish red and suggest we see her next. She’s not looking well. She presented yesterday from another health centre after a prolonged obstructed labour at term, her first pregnancy. The baby had already died, and the operation notes suggest a very difficult Caesarean section. She is now semi-conscious and breathing very quickly, heart rate too fast, oxygen sats low, blood pressure holding. She’s either bleeding, or there is infection. No investigations, the family can’t afford the blood tests. She’s on some nasal prongs with a futile amount of oxygen trickling through. We get her on a more appropriate mask, and get another cannula in her arm. She needs some fluids, then I realise we have none. The woman’s mother is buzzing around, so the nurse writes ‘normal saline’ on a scrappy piece of paper and sends her to the strip of private pharmacies that line the hospital fence. ‘Free healthcare for all women and children!’ the government announced some years ago… I ask if we can check her blood sugar, but there is no glucometer available. I have my own machine, and one last testing strip. It’s low at 2.1, we give her a push of IV glucose. I’m half hoping it really picks her up; she stirs a little, but not much more.

We need to see what’s happening down below, why there is blood in the urine. The specialist gynaecology consultant has arrived now, thank goodness, he knows exactly what to do. But it’s bad news for the woman; the wall between the vagina and the bladder has been completely destroyed, a large fistula. The end of the catheter has prolapsed into vagina, and is draining a mixture of urine and blood and infection. We clean the area and there is clearly rotting flesh. The woman is in septic shock. With some basic plumbing we manage to get the catheter to stay up in the bladder. Back to treating the whole patient. The woman’s mother has returned with the fluids and we are into the second bag. We get some stronger antibiotics into her. More cleaning down below. Then the gurgling that I recognise, some fluid in the chest, we need to slow down the fluids. Everyone is working well as a team, despite the difficulty of the case and the conditions. The oxygen levels have come up, the pulse reduced a little. It’s the basics of medical resuscitation, it’s exhilarating and shocking all at the same time. Then things change, the pulse suddenly races to 210 beats per minute, far too high, a sprint that the heart muscle will struggle to keep up with. The adrenaline from the pain of the internal examination has probably shocked the heart into a short circuit. We continue the resuscitation, I’m hoping the rate will revert spontaneously, but it’s not budging and the oxygen level is dipping a bit. It would really help to know what rhythm she is in, but there is no ECG machine in the hospital. I start weighing up the options – difficult without knowing the rhythm. Some beta blocker? Some amiodarone? Would it be safe without monitoring? First do no harm. No chance of a defibrillating shock if she crashes, no defibrillator! Her salts could be abnormal causing the rhythm, but no way of knowing as the lab is not working. Probably wise to give some potassium and magnesium in case, low potassium will kill quicker than high potassium. We manage to get an anaesthetist from downstairs. She agrees, chance of harm if we start giving other cardiac drugs blindly, let’s give her some time. On with the ward round. Another woman has had a stroke from the high pressure of pre-eclampsia, another is swollen with fluid as her kidneys have completely stopped working. She needs dialysis which the family can’t afford, and she too will die.

I drive out of the hospital with that familiar feeling, a bit disconnected, a little overwhelmed, but knowing it will pass soon. Everyone getting on with life as usual out here. Those women are out of sight and out of mind. Maybe it would be different if we were at the heart of a humanitarian crisis, but this is a capital city in 2018. 2018! Do you remember how futuristic 2018 sounded? Hover boards? A meal in a pill? In 2018 a pregnant woman teetering on that fine line between life and death can’t get a bag of fluids and a basic blood test, whilst all the world carries on. One assumes that the health system they are working in is on an upward trajectory but a longitudinal view over some years makes me wonder otherwise. The funding and systems in place are deficient, creating a demoralising environment for the doctors and nurses that work tirelessly to make things better, indeed they are the strongest cog in the wheel. Families are not shocked, because this stagnation is an accepted part of life. The problems are systematic, and they come from the top. Whilst I stand by the philosophy of singing the good news stories, sometimes one feels the need to lay out the truth of what is really happening on the ground. It can’t be right. What on earth are you meant to do about it? Who does one shout at when we all know that method doesn’t work? Surely it’s wrong that we let pregnant women die of preventable causes well into the 21st century. Frustration and anger, probably not constructive, but important emotions, to write down and perhaps to share.

The woman in the photo is a generic image pulled from the internet.

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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

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.

diabetes projections

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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The tightrope of pregnancy in Uganda

Pregnancy is an uncomplicated business (in the medical sense at least..) for most women, most of the time. But when things go wrong, the situation can rapidly deteriorate putting both the mother and baby’s lives at risk; babies get stuck, mothers bleed both prior and after delivery, and many suffer a serious disorder of blood pressure called pre-eclampsia which can lead to fits and strokes. The avoidance of such grave consequences requires a tight system of antenatal surveillance and rapid sequence of action when complications arise. Whilst the health system in Uganda has the potential to supply each of the component parts of this system, they are weakly tied together, and elements of the chain may break due to basic inadequacies in infrastructure such as electricity and surgical supplies.

Each year we teach a two week of module of maternal, neonatal and child health which forms part of the East African Diploma in tropical medicine and hygiene (DTM&H). Seventy-two post-graduate doctors from both East Africa and around the world pass through and will expect an introduction to the practicalities of clinical medicine and research in sub-Saharan Africa. Each afternoon we take groups to meet women and hear stories which exemplify both the public health and obstetric challenges a woman may meet along the tortuous journey of pregnancy in Uganda. We make an effort to celebrate good maternal and neonatal care, as well as pick up on shortfalls. The cross-cutting themes include the impact of gender inequalities, educational background, and socio-economic components of care-seeking behaviour. Here are some of their stories. Names have been changed.

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A group of students on the 2017 course

Respectful care

Robhina is a 26-year-old lady, with a good educational background. Her first baby was born by Caesarean section due to obstructed labour; the baby’s head was simply too big for the mother’s pelvis, a common problem worldwide but even more prevalent where woman’s growth is stunted due to malnutrition in childhood. A vaginal birth is possible after Caesarean section, but must be done in a very supportive environment, and probably avoided in the context of pelvic insufficiency. Robhina laboured at home for a considerable time before going to a health centre IV, which should be able to provide blood products and a Caesarean section if needed. She continued to labour there overnight in considerable pain before it was clear she would need an operation. Unfortunately no doctor was there to do the operation and was transferred an hour across town to our facility which was overflowing. She was received in a very poor state and in agony. After another hour she was in theatre; her uterus had ruptured along the previous Caesarean scar and the baby was found floating free in the abdomen and already dead. She got the blood transfusion she needed and the surgeons managed to repair the uterus and avoid a hysterectomy (removal of the uterus). The team did a great job saving the woman’s life, but it was too little too late for the baby. We see around 4 of these ‘fresh’ stillbirths every day. Rhobina told her story totally matter of fact; she clearly had no idea that this was an avoidable outcome. So common are such stories amongst women that they are normalised. I asked her why she hadn’t come to the hospital sooner to deliver. It came down to the way she had been treated previously; talked down to, no privacy, scorned for complaining. Why not have a go at home with loved ones around? Explanations like these remind us that the respectful care of women is an integral part of future health system reform.

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Hearing personal stories provides context and a deeper level of learning (East African DTM&H 2016)

A new wave of medical disorders in pregnancy

Urban Africa is not only about empty plates. There is a rapidly expanding middle class with a taste for refined sugar, and a culture which associates large abdominal girth with higher social class. As a result we are beginning to see a rise in cases of diabetes in pregnancy. Doreen is 31 and has just had her third child. The first was delivered normally and weighed a decent 4.2kg. The second was even bigger at 4.8kg and needed to be delivered by Caesarean due to obstructed labour. Big babies are the hallmark of untreated diabetes in pregnancy; the high sugar level means the baby lays down more fat around the shoulders and abdomen raising the likelihood of complications at delivery. They also get so used to the high sugar and produce so much insulin that when they are born into the world their sugar level plummets which can kill. There is no screening for diabetes in pregnancy in Uganda. We do not yet even know which screening test would be best, or even what we would do if it was picked up as management is not straightforward and beyond the present antenatal system. As I spoke to Doreen the story of diabetes in her case was clear. This recent baby needed a Caesarean as there was not enough fluid around the baby (diabetes causes both too much or too little fluid). Her baby was wrapped up in sheets beside her and I see a tiny area of the sheet flickering over and over again in a repetitive way. I ask to see her 2-day old baby and sure enough the tiny girl was having a seizure, repetitively jerking her left arm up in the air. Doreen has no idea, and no doctor has been around that day. One junior doctor usually has to cast an eye over around 80 women and their new babies in the course of a morning. Few get a thorough check, and besides Doreen has no diagnosis. We take her baby to the special care unit for anti-convulsants; perhaps a low sugar level soon after birth could explain the fits, or infection, or low oxygen levels, we don’t know. Fortunately both are discharged a few days later, but the impact of the seizures and damage to the brain may not be realised until months later.

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The Maternal HDU (High Dependency Unit) during clinical rounds with Dr Anita Makins

Living with fistula

Ruth is 43 and has travelled from a very rural farming community. She has a coy smile and has the air of a once confident person who has suffered too much hardship in her life. She came to the hospital after hearing a radio advertisement. She had been leaking urine for twenty years having developed a vesico-vaginal fistula (abnormal connection between the bladder and vagina) after the birth of her third child. She laboured at home for three days before giving birth to a baby who had already died; she had been unable to afford the transport to get to the nearest hospital 7 miles away, a mere £3. The pressure of the baby’s head, stuck in the pelvis, caused damage to the tissues leading to abnormal tract formation. It’s a condition very rarely seen in the West, but still common in areas without accessible and affordable health services. Since that time she withdrew from village life, and farmed alone, hiding her shame from the community. Fortunately a supportive husband stayed with her, though many are not so lucky. Ruth has had decades to contemplate her fate, has come to terms with her condition, and is now happy that something may finally be done about it – surgical repair. Opposite Ruth sits another girl, with the same condition, but at the start of her story. She is very small, and looks incredibly shy. She is only 16 years old, but as I gain her confidence she tells me her story. Her first statement says so much; her family was not able to pay for her to go to school, so she stayed at home and became pregnant, totally matter of fact about the inevitability of such a chain of events. Again she laboured at home and got to the hospital too late. A dead baby was delivered using a suction cup in what sounded like an extremely traumatic series of events. She started leaking urine 6 weeks later, again due to injuries from a prolonged obstructed labour. She looked very vulnerable and alone, in a room full of women with totally avoidable internal injuries, victims of a world that still fails to recognise the equitable status of women in society.

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With Dr Ed MacLaren, my tutoring partner for the module, and one of the HDU nurses

The antenatal visit

Annett is a 24-year-old lady, a bubbly character with a broad smile across her face. She had given birth to a baby boy the week before and is overjoyed. Her first pregnancy had not been so successful; she had suffered high blood pressure which hadn’t been picked up in her antenatal visits. They didn’t have the basic testing strips for analysis of the urine, and blood pressure had not always been measured. She lost her first baby at 34 weeks of pregnancy. The staff encouraged her to get to antenatal visits early in subsequent pregnancies. Annett had the confidence and educational ability to speak up at her antenatal visits and demand the basics were done. She also had some money to get an antenatal scan – less than £10 which is far more than many can afford. As often happens she suffered with high blood pressure again. She came into the hospital at 26 weeks and was managed with medication for another 5 weeks to give her baby the chance to mature. At 31 weeks her condition was so severe that her baby had to be delivered, since the placenta is the cause of the blood pressure disorder. Her baby boy was taken to special care unit. On the first day Annett showed me pictures on her phone, but the next day took me to see him in the neonatal unit. Seventy similar babies were lined up, many with NG tubes in their noses, their mothers expressing milk and pushing it down the tube with a syringe. One doctor has the job of looking after all these delicate beings. Annett tells me all about what she does several times per day for her baby, and in immense detail. This is a mother’s love and casts out the common attitude of ‘just another stillbirth, or just another neonatal death.’ Annett and her baby had received great care, using basic principles of medicine. But she only got there because she had the educational and financial means to transcend the gaps in the chain, a privilege of few. Four young women, one just 19 years old, died of this high blood pressure disorder in our two weeks on the unit this year.

They are morbid stories in themselves, but more frightening is the sheer number of similar stories that are told every day, even in this one hospital. An old friend presented me with an audit of the women’s health service in the same hospital from 50 years ago, 1967-1968. Each maternal death is detailed and the stories are hauntingly similar. However much we try to champion good progress in sub-Saharan Africa, with health statistics improving year on year, it’s hard not to feel like the two worlds in which I spend my time are moving further apart. Whilst total average worldwide wealth improves, the inequities both within and between nations are worsening. It’s easy to be paralysed by the enormity of the problem, but inertia is far from an effective solution. Sharing stories like this will not change the world, but the least one can do is advocate for those without a voice. It may at least help in appreciating the excellent standards that our National Health Service affords our women and mothers.

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The 2017 contingent graduating in the gardens of Mulago Hospital

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Tutor group on the 2017 course

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A group on the 2016 course

World Tour Review – “All pretty much the same”

It’s hard to sum up what has happened over the past four years, so I’m going to keep it confined to a message of thanks and one general observation. I’ll leave the really heavy self-involved stuff for the pub, it’s the usual cliche stuff, just bearable when listeners are drunk, but vomit-inducing when committed to print.

A pair of little bee-eaters in the morning sun during my last birding walk in South Africa

A pair of little bee-eaters in the morning sun during my last birding walk in South Africa

1) Thanks weirdos

The biggest thanks has to go to the fascinating array of people i’ve had the privilege of working with or living alongside during my travels. Despite all of the goodbyes I hope I can remember a part of what each has taught in some small way. There’s one group that i want to give a special show of appreciation, an often overlooked group who commit their lives to the forces of good in the face of adversity. I’m not talking about people like myself and my mates from the uk who come to parts of africa for 5 minutes and write a blog and make a big show about it. I’m talking about the ones who spend decades dedicated to small projects, who prefer not to be named. It’s the nurses that spend year after year changing the nappies of grown men dying from HIV, it’s the doctors and therapists that spend years working in rural hospitals with no schools for their children, it’s the people who run small income generation projects for women abandoned by their roving husbands. They don’t win prizes and you never hear about them in the world of NGO internet multimedia. When you meet them they are usually a little bizarre, often lacking social graces, commonly rather enthusiastic about a particular ideology, males have beards and both sexes exhibit strange choices of footwear. But they are their own people, inspiring in their originality, peculiar in their habits, and free from the intoxicating effects of ego. My biggest thanks is dedicated to them, for teaching us what’s right.

Some of the Manguzi characters

The Manguzi characters – some proper weirdos – goodbye and thank you

2) All pretty much the same

I’m often asked, or told rather, how fascinating I must have found it living with so many different people and cultures along the way. But in fact what stands out is a sense of ubiquity. At the beginning of the trip was the thrill and excitement of getting to know people who looked unfamiliar and talked in foreign tongues. This was accompanied by a lot of photographs and emails home and tales told to friends. Coming back to the UK I felt like modern explorer bringing back slides of bizarre peoples and pathology to delight my colleagues in the motherland (obviously too many colonial references in children’s books.)

But after some time I think I became desensitised to what are perhaps more superficial aspects of different cultures, and I began to see more clearly aspects of myself and my friends and my family in the local people that I met. And the generalisations never held true. For instance one cultural group wasn’t more jovial than another group. Perhaps they would appear more jovial on first impressions by their habits, but within the group there would be happiness and sadness in more or less the same ratio as back at home (please exclude humanatarian disasters from this generalisation). Social structures included the same ratios of cocky and shy people. Cultures weren’t dishonest; there was the same spread of petty thieves and moral guardians. And (almost) whatever the situation, rich or poor, educated or not, people would always dig around and find something to both laugh and cry about. Yes there are groups that are faced with greater hardship than others, but I think we should avoid patronising those who we imagine have only their tears to water their failing crops (I think that’s a line from a Geldof Christmas sing along). In fact it’s the sound of open mouthed laughter that will remind me most of life on this fine continent. Anyway, take away the bells and whistles and we’re all more or less the same really, or at least variations on a theme.

So that’s the most important lesson I learnt; that we’re all more similar than we like to think, the human condition runs true, and as a friend once told our class graduating in Uganda, at the end of the day ‘We are all one’. Is that a bit cheesy? Am I a bit late to the party with the whole anti-racism thing? I know I’m not re-writing the textbooks with this point, but it’s really rather important, and a quick look at the world news suggests not everyone’s getting the hang of it.

'We are All One' Credits: Muse - Abdallah Amir, Drawing - Kidd Keir

‘We are All One’  Muse – Abdallah Amir, Drawing – Keir Philip

3) Goodbye Hello

So I say goodbye, at least for now, as I write this post from deep within the savannah. The sun has just risen over the Lobombo mountains and the valley below me, layered with strata of mist, is coming to life with the sound of bulbuls and the scarlet-chested sunbirds that feed on the flowers of aloe. The impala and inyala look to the light, having survived another night free from persecution. It’s a remarkable sight and a fitting tribute to the cycles of danger and positivity that give this continent an enduring beauty that both tests and rewards those that walk its land.

Final Blogspot - sunrise over the Ubombo mountains

Final Blogspot – sunrise over the Lobombo mountains

It’s not easy leaving a life that has been so full of adventure, but the feeling of excitement for the next chapter in the UK is managing to suppress the mourning. I’ve spoken to many people who have spent many years traveling the world trying to find that something that’s missing. Most conclude by saying that, after all the fuss, it was there at home right under their noses all along. So I suppose that’s the most sensible place to look next. I can’t wait to be with all my old friends and family once again, I’m eternally thankful for their letting me do what I needed to do. Thanks to everyone, thanks to everything, many many thanks indeed. Big love xx

Final sunset n South Africa shared with a family of giraffe

Goodbye African sunsets – This was my final sunset in South Africa, shared with a family of giraffe

Goodbye great weekends on the beach with good friends

Goodbye to great weekends on the beach with good choms

Goodbye to my trusty steed, and thank you for taking us to incredible places

Goodbye to my trusty steed, and thank you for taking us to incredible places

Goodbye to some very dear friends

Thanks for the good times to my very dear friends

Farewell to some very fine views over the savannah

Farewell to some very fine views over the savannah

Goodbye to my great friend and housemate Charlie

Goodbye to a great friend and true gentleman – my housemate Charlie

Goodbye to the desert (for now)

Goodbye to the desert (for now)

The striped kingfisher - photographed here by Charlie in Ndumo park

The striped kingfisher – photographed here by Charlie in Ndumo park

And goodbye of course to the Dark and Stormy experience with these fine barmen

And goodbye of course to the Dark and Stormy experience with these fine barmen

When the Sangoma read my bones…

It’s Christmas time so I’m going to keep it light; a little story about my time with a local traditional healer (not meant to say ‘witch doctor’..) – The Sangoma.

'I'm right!' - 'No, I'm right!' - Differing approaches to healthcare

‘I’m right!’ – ‘No, I’m right!’ – Differing approaches to healthcare

Part of our job here is providing primary health care to the rural clinics out in the bush. A couple of weeks ago a South African doctor Jeanie and myself set off in the buckie into the heart of the savannah to visit Mshudu and ZamaZama clinics. Nothing out of the ordinary, the bulk of our workload focussed on community HIV care. After a long hot day we stopped in a local tavern for a sunset beer. Halfway through my 850ml quart of Castle lager I noticed a man dressed in various robes and animal skins in the homestead next to us and so I enquired. It appeared that this was Gumede, the local Sangoma. Everyday in the hospital I talk to my patients about their relationships with the Sangoma. He has the power to reduce all sorts of symptoms and suffering through his ceremony, but also to persuade our patients to stop taking their HIV drugs or ingest liver/kidney toxic herbs. It’s a strained relationship to say the least. We try our best not to let our patients get trapped in a tug-of-war between us, but to compromise and work with rather than against their cultural beliefs. Anyway I was well up for meeting Gumede, so I asked if he’d have a look at my gammy back.

It's not just in the UK that doctors spend the entire afternoon getting leathered

It’s not just in the UK that doctors spend the entire afternoon getting leathered

We were led around the corner to his hut to meet the man, a stern figure who emanated authority and mystery. Some people just instill the urge to do a little bow when you meet them. This guy was good. He spoke Zulu so another local joined us to translate. We entered the dark and dusty room. Hundreds of jars of various herbs and potions surrounded us and I could feel my liver melting with every breath of their sweet aroma. Grass mats were laid down and we sat cross-legged in front of Gumede. It became apparent that we weren’t just going to talk about my problematic lumber spine. Gumede was bringing down his basket of bones. He was going to read my future and look into my past. Jeanie shuffled back a bit, it looked like I was up first.

The next 10 minutes were dedicated to instilling a particularly intense atmosphere. The incense was lit and the evening sun streamed through the cracks around the door casting long beams through the smoke. Gumede laid out the various bones and shells that made up his crystal ball. He cowered over them, gathering up the pieces in his hands, piling them up and casting them down with a clatter, over and over again as he chanted repetitive Zulu phrases, his companion responding in subdues tones. The last drops of alcohol seaped into my blood and a wave of goosebumps spread from my arms up to my back and into my core. I was primed and it was time to begin.

Modern Family

Modern Family

The bones were piled up and one final cast made across the floor. Gumede used a wooden stick to poke around, recognising patterns made by the fallen pieces. I was asked permission if he could go ahead and read my bones, but it appeared to be a rhetorical question, the ball was already rolling and I couldn’t back out now. He fixed on an area and he told me what he found, through our translator of course..

‘You have a problem with your waist.’

Not completely sure what he was going for here. Was he was focussing on my lower back pain or something a little more private?

‘You cannot ever enjoy sexual intercourse because you have problems with your performance.’

A little surprised with the opening gambit to be honest. And I mean, sure, we all have good days and bad days, who doesn’t? Oh dear, he’s touched a nerve.. Is this guy for real? I could feel Jeanie creasing herself behind me, but not a peep from either of us. The critique of my private life didn’t stop there…

‘You have a problem when you urinate. You feel burning when you pass water.’

So he’s gone down the sexually transmitted infection route. I bet Jeanie was looking forward to putting this on the hospital whatsapp group later. Unbelievable. After initially focussing on my genitals, Gumede thought we should get a little deeper.

‘You have one main problem in your life. You are not able to love other people.’

Woah wow woah, hold on a minute there. Easy tiger. I know I’m self-centered but I can love other people can’t I? Then why am I living in the middle of Africa pushing the people I thought I loved away from me? Why don’t I have a girlfriend when everyone else is getting married? Can I really ever love other people without loving myself first? Ok this was getting a bit much now. Gumede asked if I wanted to say anything. I wanted to take the conversation forward. I thought that any comments on the preceding forecasts would cue a smug ‘Ooh, my lady doth protest too much’ comment from Jeanie later in the car. I asked if there were any more positive aspects of my life we could explore.

‘You have bad luck in your life. But sometimes you can have good luck. But there is a lot of bad luck.’

Ok well I had a go. I asked why I was suffering so, and what I might be able to do about it.

‘You have problems in your life because you do not pay respects to your grandfather. You must make a ceremony to remember him and everything in your life will be ok. Is there anything else you would like to know?’

By this point I was feeling viscerally unwell and thought it best to cut my loses and pass the batten to Jeanie. For some insane reason I thanked Gumede for looking so astutely into my life.

Jeanie was next. Bruised and battered I took myself off to the back of the hut to watch from afar. Jeanie has one of the purest souls of any person I know. Kind and generous, a brilliant boyfriend, pleasing on the eye. She was no doubt going to get a gleaming report which was going to make the car journey back home very awkward. I didn’t want her sympathy. Anyway the ceremony started again and the bones were thrown down.

‘You have a problem with your menstruation. There is a bad spirit in your womb. You may be infertile.’

Yes! In your face Jeanie! Who’s got such a perfect little life now eh? In my mind I gave Gumede a little wink and a thumbs up, I knew I could trust him to be deeply dispiriting and offensive. So much more fun when you’re not in the hot seat.

‘You have a boyfriend. (I wasn’t too impressed as this is information had been divulged earlier when Gumede’s brother had asked if Jeanie would marry him). He appears to be involved in the relationship but in fact he does not love you. He will never love you.’

Ouch! Ok it’s always a bit of fun with the genital-based slurs but that’s a little out of order. Her boyfriend Leon is completely committed to her and drives 6 hours from Durban every other weekend to see her. I guess living a lie takes lot of effort…

‘You will not have luck in your life. Your life will end when you die in a car crash.’

You think it can’t get worse – then he brings out the car crash line. Kick a girl when she’s down. And I have to drive back with her! Shouldn’t have had the beers. Wow this is a lot to take on board. We are completely fixated. We are in a trance. Every comment he makes sets off a chain reaction in our brains of what it all means. He lays a small foundation upon which our minds are free to build around in whatever way is meaningful to us. That’s the way to get someone’s attention; talk about them. She asks what she can do about it.

‘You must buy these medicines from me and wash yourself in them every day. Then none of this bad luck will happen and you will live a good life.’

With an hour car journey ahead of us on bad roads we confer and agree to take the herbs. Some crushed dried leaves are brought out which could easily pass for Sainsbury’s Italian Mixed Herbs and a few spoonfuls are lifted into a plastic bag. It’s time for us to go. We are rather shaken and have a lot to talk about. Neither of us is particularly keen on getting to know Gumede much more. We take a few pictures, give Gumede 100 Rand, and load up. We don’t know whether to laugh or to cry. What we do know is that a particularly long debriefing is in order.

Jeanie does well to cover up her cramping dysmenorrhoea

Jeanie does well to cover up her cramping dysmenorrhoea

POST-MATCH ANALYSIS

It turns out that our visit to Gumede has been one of the most important experiences of my time here. I used to pour scorn on my patients for listening to the Sangoma and not me, but now they have my greatest empathy because the Sangoma is a very powerful man. By creating an eerie atmosphere and addressing the most common human insecurities he can rattle most of his customers. Every woman in rural Africa is worried about infertility and whether their boyfriends love them. All of the guys are concerned with their performance in the bedroom. A huge percentage of the population have STIs, and car crashes are a common cause of death. Life is confusing, and we all relish the opportunity to hear causal relationships that make sense of it all; why has this problem occurred, and what can I do to make it better. The Sangoma can answer those questions, and offer the solution right there and then.

I like to think of myself as a rational human being, and my educational background allows me to produce a reasonable framework of how the Sangoma may operate. But that afternoon he got under my skin. However much Jeanie and I spoke about how it was all a load of rubbish, a part of us still wondered. Even now I can’t bring myself to write ‘Sangoma’ without a capital ‘S’ (just in cases..). Imagine how a local man or woman with no educational background responds, whose upbringing has been centered around the mysticism of Zulu culture. You do what the Sangoma says. He’s more powerful than a white boy banging on about something called a virus that goes in your blood and how if you take a tablet which makes you feel unwell it will go away, but not forever, and you have to take it for the rest of your life and you shouldn’t have sex with all sorts of delicious looking people.

But let’s not patronise the Zulu people. If you think that you are immune from the workings of the Sangoma how wrong you are. Every time we buy magazines with dieting advice, every time we watch an advert that depicts a perfect life that’s better than our own, every time we walk into Holland and Barretts. Every time we do these things we entertain our deepest human insecurities, and someone much cleverer then us profits as a result. The workings of the human body are complex. We are far far off understanding how it all works and that’s the reason the alternative medicine section in Waterstone’s is so much bigger than the science section. We don’t like not knowing, and we like someone giving us a good causal relationship that makes sense of it all. And we’ll pay good money for it too. Do we get value for money? Well yes, that’s how market forces work. I’m not saying it’s wrong, I’m just saying it’s pretty similar to how the Sangoma works. Let’s not get caught up and call it evil just because of all the animal skins.

I don’t think Gumede is a bad man. I don’t think that he goes back around the hut and laughs with his mates about how he’s tricked another customer. I think he has a deep spiritual connection to his work. I think that he truly has a set of rules in his mind that recognises patterns of fallen objects and translates them accordingly. And I think that by trial and error over the years the predictions that elicit a response from customers have survived through natural selection. The power he has over the behaviour of our patients far outweighs my own. There can be no contest. Some Sangomas go through training which verses them in various aspects of Western medicine too, but many do not and that’s where the challenge really lies. Every day I talk to patients who have stopped taking their HIV medicines as a result of advice from the Sangoma. Given a break from the drug their HIV forms resistance patterns that render those medicines useless taking their HIV from being a treatable disease to a palliative case. These are the challenges we face in this environment. Universities and laboratories can spend as much money as they like developing clever drugs, but actually getting it down people’s throats and stemming the HIV epidemic is another matter all together. Something is working as the prevalence of HIV has reduced from 45% of the population a few years ago to 35% of the population now. But with a third of people still infected there’s still along way to go. I imagine that getting the Sangomas on board would far outweigh the benefits of employing us lot.

I seemed to have rambled on a bit but it’s just such an interesting place to work. I am relishing every minute of worrying about challenges like these rather than the bureaucratic challenges of the NHS. It truly is what tropical medicine is all about. Happy Christmas everyone and let the capitalist Sangomas of Christmas infiltrate all our hearts and minds. After all isn’t Christmas about making sense of it all?

ZamaZama clinic

ZamaZama clinic

Landing in KwaZulu Natal

Word on the street is that the blogs are too long. In fact word on the street is that, generally, when I talk or write, I bang on for far too long. That is a lifetime’s worth of advice that I have refused to take any notice of. Here’s to a new start.

I’ve been in South Africa for 6 weeks now, tucked up on the north coast of KwaZulu Natal, the countries most Eastern province. Cue map. I’ll be spending a year working in a very rural hospital which looks after an entirely Zulu population. We have no specialists here. Each of the 12 doctors is a generalist and expected to cover all departments – medicine, surgery, obstetrics, paediatrics, psychiatry etc etc. Everyone knows a bit about everything and gives it their best shot. There are no doubt going to be some sweaty moments..

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The largest burden of disease in this area by far is HIV. The prevalence, so the proportion of people infected with HIV, is the highest in the world at 35% – down from 43% a few years ago. I’ve spent a good deal of time over the last couple of years learning about HIV and treating patients with the disease but only now are the stark realities of the epidemic really becoming apparent. Most of my medical ward are suffering with the complications of HIV and unfortunately our patients often come late and there is sometimes little we can do. I won’t get too dark too early, and I’ll probably leave it there for now. For 5 minutes on the subject with yours truly being a bit melodramatic see a recent video blog I posted a few weeks ago – HIV: are we winning?

https://www.youtube.com/watch?v=jYdgfOkeXuE

It’s been brilliant to spend time working in the other departments as well. My other passion besides tropical medicine is maternal health and I’m spending a lot of time in the obstetrics unit and doing some Caesarians and removal of ectopics in theatre. I must share a truly wonderful moment from Friday morning of my second week here. I was operating on a lady with a large baby who had gone into obstructed labour. The Caesarian is done under spinal block so the mother was awake and conscious. As we proceed she began singing in Zulu, and it must have been a well known song as all of the theatre nurses joined in, rich African voices, off tones and harmonies. All were singing as I cut through the uterus and found the baby. It was no easy job delivering the head and a couple of manoeuvres were required but the baby finally came to a crescendo of voices. I was relieved to say the least as the baby cried. I had goose pimples and thought ‘do you know what, this is f*****g brilliant’. A beautiful experience.

I know it's an indulgent photo and yes that is a shoe cover on my head

I know it’s an indulgent photo and yes that is a shoe cover on my head

My first night shift in the casualty department fell on my first Friday, doing what you can with whatever comes through the door. The fun started as a 20 year old man was dropped of by the police, naked and covered in blood, collapsed on the floor with a bushknife wound to the back of the neck. An artery had been severed and he had clearly lost a lot of blood, freezing cold with a feeble blood pressure requiring may litres of resuscitation fluid. He had a tattoo across his chest with the words ‘Not Guilty’… An hour later he was talking again. A brief history revealed the cause to be an argument over a girl, as standard. Not long after another young lad was carried through the doors with a gunshot to his leg. The wound was not to impressive but the shin had lost all stability. An X-ray revealed the true extent of the damage, both shin bones shattered. A bit of a clean, some strong opiates, a bandage, and a nice referral letter to the referral hospital 3 hours down the coast. The leg would need extensive surgical exploration by the specialists. The story behind it? You’ll never believe it, a tiff over over a fair madame, not far off a femme fatale.

gunshot

It’s not all medicine, we’ve already had a couple of trips to the Indian ocean which is lapping at the sandy beaches just 5km away. The surfboard has had a couple of trips out, but nothing major to report with the winds blowing out the swell, as is typical of the August season, but the snorkelling has been sensational. First trip to Mozambique lined up for next weekend. So there it is, as short and sweet as I can possibly make it. You’ll notice a recurring theme in the ailments I have described, the HIV medicine, the obstetrics, the trauma. It all comes down to one thing. Be kind to us girls, we get over-excited.

Kosi mouth

Kosi mouth

Black Rock

Black Rock

Tembe elephant park

Tembe elephant park

Full moon brai at the mouth

Full moon brai at the mouth

Crossing the channel when the rope has snapped

Crossing the channel when the rope has snapped

Crested guinea fowl

Crested guinea fowl

Lifebox

I first met Nick about a month ago. He’s an anesthetist from the UK working in Hoima in northern Uganda. He has been part of a project that donated some anaesthetic equipment to rural hospitals in Uganda about 3 years ago, and was about to embark on a journey around the south west to follow them up. He needed an assistant and extended the invitation my way. He said it was going to be a great adventure. I trusted him and so with very little information to hand I said yes, a habit that has taken to me to some extraordinary places in my life, both good and bad, but always interesting.

A pulse oximeter measures the heart rate and the amount of oxygen in a person’s blood. It’s a routine piece of equipment used in the west and you’ll know it by the painless finger clip. Rural hospitals in Uganda rarely have this technology where anesthetics and surgery are regularly performed with no monitoring equipment at all. This is a dangerous business with little way of telling if a patient’s condition in deteriorating. The charity with which we are working, called Lifebox, saw this gap and have produced robust and simple to use oximeters – themselves called a Lifebox. They were given out with training to the anaesthetic officers in 80 rural hospitals 3 years ago. Follow up at 6 months suggested that they were being put to good use, but the real test was whether the improvements to patient safety have been sustainable and the project should be extended to other parts of the world. Nick and I were to find out just that; Were the Lifeboxes still working? Were they still being used? Had the project made any difference? Here are the notes from out trip.

Lifebox-LogoIMG_6765

(Anaesthetic officers: Uganda has a population of 35 million but is home to only 30 aneasthetists. The majority of the anaesthesia is provided by the 300 anaesthetic officers who don’t have a medical degree but have attended a 2 year diploma. They would be the source of all the information we needed.)

Day 1

An early start to begin our journey south. 3 hours drive to Masaka to visit our first hospital, the non-governmental catholic-run St Peter’s Kitovu hospital. As we drove through the main gates the difference from a government establishment was palpable – pristine gardens and a sense of order and calm. The anaesthetic officer we are to meet was called Sister Mary Prospero. She appeared in her brilliant blue habit and was all smiles. She took us into the convent quarters where we interviewed her about the use of her 3 Lifeboxes since she received them in 2011. She’s thrilled to tell us all were in working order, used regularly, and made a great difference to the care she could offer her patients. Her equipment was in a similar condition to her veil – immaculate. We were shown around the theatres and admired the old ether drawover machines that they still use, real antiques. I was pleased to see they have a special VVF theatre for fistula camps. I hear that my old friend Andrew Browning will be coming here to operate in August. Great to see that fistula camps are being run in the same way in Uganda as in Sierra Leone. Tea and chapatis were laid on for us and Sister Prospero asked if we would like to stay the night their with them, an offer we couldn’t refuse.

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Nick with Sister Mary Prospero

After a fill of oily pancakes we were back in the car and made our way about half an hour further south to the second site, government run Kalisizo health centre IV, to meet the anaesthetic officer Rosemary. Again we were welcomed with open arms and shown around her theatre. Her original Lifebox was working well and again she had no problems with its use. She had a brand new GE 9100 anaesthetic machine but unfortunately there was one missing filter and her oxygen supply was inadequate. This is often the case with expensive donated equipment. Again a lovely atmosphere in this hospital with birds in the trees and children playing below the great jacarandas. We drove Rosemary home and made our way back to Kitovu. Nick headed down into town to meet another anesthetic officer at Masaka referral hospital and I took a couple of hours to explore the compound. We saw many of Uganda’s great birds on the journey down – the long-crested eagle, great blue turaco, and black and white casqued hornbill. This walk was notable for it’s butterflies who were congregating at the top of a cliff. They must have chosen this spot for the fine sunset over the maize fields to the west and the views down into the lush green valleys to the East. A fine supper with Sister Prospero and an evening visit to the paediatrics wards to blow up some balloons for the kids. We met some wonderful people in Kitovu.

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Bellenois creona – The African White

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The children’s ward – the burden of malaria ever present

Day 2

We started the day with mass in the chapel. Lovely hymns in African voices accompanied not by the organ but by the drum. After breakfast we headed an hour further SW to a small referral hospital called Lyantonde. There we were welcomed by Agnes who has been the only anaesthetic officer on call for the last 20 years. Lyantonde was an example of the most basic anaesthetic set-up we had seen so far. Whilst they do about 40 operations per month she has no anaesthetic machine and sedates all of her patients with a continuous infusion of ketamine. She has no way of protecting the airway with a tube. Again we found one of new 9100 machines but they don’t work without a good supply of oxygen, which was the case again here, and in most facilities we were to visit, a massive oversight. We were shocked in two ways really – that a hospital on a main road can be left with such basic equipment, but also how one woman can do such much with so little. We were charmed by Agnes. She is a great example of human endeavour overcoming the challenges in the resource-poor setting. We were so pleased to see he still has her Lifebox in fine working order, a monitor that she treasures. We were shown around the hospital by one of the four medical officers and even had time to pop into the laboratory, look under the microscope at some malaria parasites, and teach Nick some tropical medicine.

We kept moving and headed another hour south to Mbarara. Great laughs as Nick struggled through another difficult phone conversation, talking very slowly and very loudly, to arrange visits for tomorrow. In Mbarara we met Charles at Ruharo hospital, another church run establishment. Again the difference in organisation is clear. He was very eloquent in describing the benefits he derives from the two Lifeboxes that were still in working order. Like all the other anaesthetic officers he seemed very happy to give up his time and talk to us. It really felt as though they were enjoying someone taking an interest in their work. We headed into town and had a great time catching up with my old friend Dr Amir over a soda. We didn’t stop for too long as we had to head another hour and a half further SW to Itojo hospital, a rather dilapidated district hospital.

As we travel further along this road the hills began to form around us and the landscape was becoming more and more spectacular. We drove down that familiar scene, the red snake of road, lined with children, slicing through the lush green countryside. In Itojo we met Angelo, a great tall man. He took us to the theatre where a man was having his testicle operated on. He was awake with a local anaesthetic and neither he nor the surgeon seemed to mind our invasion. I know I certainly wouldn’t have wanted anything to distract the surgeon… We found the Lifebox, but unfortunately it was no longer working due to a blown plug and battery, probably from a power surge. We asked all of our questions and replaced the device with a brand new one with some training. The anaesthetic officer who was originally trained was off duty so we would drive to her village the next morning. Again the new anaesthetic machine was present, but never been plugged in due to the lack of oxygen. It was dark by the time we finished but we managed to find a place for the night at a nearby community centre, fairly basic but provided chips and beans and a bed. And the Brazil Vs Chile game.

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Nick with Agnes outside her operating theatre

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The hills beginning to rise

Day 3

An early start with a boiled egg and coffee. The AO from Itojo that had originally attended the Mbarara course was off duty and at home so we drove 30km or so off the main road and up into the plantain covered hills to her home in the village. It was well worth the trip and we learnt a lot from her about the challenges she faces in the hospital and in her career. Anaesthetic officers earn a maximum wage of £150 per month. This does not increase with the number of years of experience or the extra hours worked. On top of this the government will not pay for extra training or refresher courses which are about £100 per go. They say they are trained enough, whilst the AOs know they need further skills. There is a severe shortage of anaesthetic providers. Surgeons country wide are available but unable to operate due to the lack of AOs. I have been in the same position waiting for three hours with a woman who had a ruptured uterus by the time we operated. She probably ruptured whilst I was sitting with her like a lemon. Like other AOs she has four children and can’t afford to send them to school. Unless the government gets to grip with the fundamental principle of providing a sensible wage, the shortage will continue.

We then drove a further two hours south to Kabale where landscape changes from rolling pastures to steep terraced cultivated hills. Here we visited two hospitals. The first was the large regional referral hospital where we met Harriet in the well groomed lawns. We are welcomed into the theatres and were amazed to see the first working 9100 continuous flow anaesthetic machine, filled with not just isofluorane but sevofluorane too. We ask the AO how this had come about and she told us it was all down to good communication with their procurement manager. She says the equipment was there if you shout loud enough. Their Lifebox had begun to play up so we replaced some of the parts. They do a huge number of operations there, up to 140 Caesarians per month for instance, so we provided them with another Lifebox pulse oximeter and a paediatric probe. She then took us down to nearby Rugarama mission hospital to meet the AO Alex. They do far fewer operations there and rely on an ether drawover machine. Again there were some issues with the Lifebox so we replaced the necessary parts and did some training on the setup. Like all of the AOs we had met, these two harbour a huge amount of knowledge and take on staggering responsibilities. They clearly understand the benefits of measuring oxygen concentrations in the blood and provided beautiful examples of where the Lifebox had saved lives. After chapati and beans with Harriet we headed further SW. We took the scenic road along the Western edge of Lake Bunyoni and were afforded spectacular views. The children were beside themselves with excitement as we drove past. The winding road then took us over the col and through dense rainforest until the great Virunga volcano range came into view before us. From the top we could see across the borders into Rwanda and the DRC. We truly were in the heart of Africa. The political significance of such an area was brought home as we drove past the large, now redundant, UNHCR refugee camps. We drove down into the small town of Kisoro as the sun set and quickly found a bed for the night.

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Lake Bunyoni

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The Virunga volcano range comes into view

Day 4

A fresh morning in Kisoro. Nick visited two local hospitals during the course of the morning whilst I caught up with some other work. 3 Lifeboxes, 2 working well and another needing replacement. Again Nick found very basic equipment. In Kisoro hospital there was just one classic Ether drawover machine for three busy theatres. There were recurring themes – lack of oxygen supply, and issues surrounding limited career progression as an anaesthetic officer. By midday we were back on the road towards Kabale to meet another AO, winding our way through the green terraced hills, on the tail of a vehicle carrying three men armed with oozis and draped in ammunition. Innocence, the AO, usually works up in the hills but bought his Lifebox down to us. He was most complimentary about the use of the box, but again it needed replacing after three years of daily use. After another lunch of beans we broke off the main road and starting climbing a dusty track high into the Kisezi highlands. The next couple of days we would be out in the sticks. Locals were all smiles and cheering as we drove past and gave them the customary dust storm. Much of the hills are wooded with pine. We were amazed to see the men working in the valleys, 2 to each of the 9 foot saws, cutting straight planks from the round trunks. We were heading towards Kisizi hospital, a well known church of Uganda establishment. We could appreciate the influence of the place as we met women with their babies, on their way back from antenatal clinic, 20km by foot. We met men packing huge bags bulging with fresh tea leaves on our approach through the valleys. Kisizi is a very small and isolated town, dominated by the large hospital, which is renowned for it’s community health insurance scheme, which keeps the local population in fine health at little cost. We were met at the guesthouse by 2 medical students, beaming with the idea of some fresh faces. The isolation had been catching up with them and they were pleased to be taken out for a couple of Nile Specials. I had deserved a beer after a metaphorical undressing by the locals on the football field.

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Taking a break from chopping wood

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Packing tea

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Returning from antenatal clinic

Day 5

After 4 full days we decided to slow down for day 5 as we weren’t able to organise any appointments. We started the day with a walk up to Kisizi falls, 30m high and the pride of the town. The previous night I had committed to taking a swim in the icy waters. There was no way I was going to lose face so I took the plunge and pretended to enjoy it. Nick was very impressed. We then walked up to the top to admire the hydroelectric engineering and put forth various theories based on an elementary knowledge of physics. What seems probable is that the 30m vertical column drives a turbine which then supplies the entire town with electricity, another of the hospital’s famous local initiatives. After our walk we visited Kisizi hospital. Moses, the principle hospital administrator, gave us a warm welcome, and I was shown around by a lady called Confidence and a man called Happy. Whilst I visited the various wards, I left Nick in theatre to talk about his favourite subject – pulse oximetry. All the wards were busy with patients and staff, a working atmosphere that I have not grown to associate with healthcare in Uganda, and quite particular to private and missionary establishments. There was a lot of tricky medicine around. I met a 23 year old girl with HIV and TB going into liver failure as an adverse reaction to her TB medications. Conditions like these are difficult for even very experienced physicians so I had utmost respect for those junior doctors whose care she was under. The theatres had three full lists for the day and we were happy to supply them with another Lifebox in light of their heavy workload. We were most impressed by Kisizi hospital. It was by far the most organised and hardest working hospital that we had found that caters for the general public who have little or no money. We said our goodbyes and were back on the road after lunch, dropping from the cool forest and heading north into the warmer rolling hills of Bushenyi district. We dropped in on one further site, the government run Kitagata hospital. The feel was instantly different as the sleeping guard failed to get his shoes on to open the gate. The theatre staff were just about to do a Caesarian section and the AO we were looking for was not around. We found the Lifebox, replaced the sensor, and made our way. After another 30km we arrived in Ishaka where we stopped for the night. I took a sunset run around the local area, getting lost in the fields of matoke, exciting and scaring the local children in equal measure. After talapia and gin we were ready for bed.

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Taking a morning shower in Kisizi falls

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Nick doing some first class birding

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Day 6

I awoke to see the valley shrouded in mist. By the time we had eaten our bright orange toast and purple sausages the sun had burned it off and we made the 5 minute drive up to KIU hospital (Kampala International University). Here we were meeting two AOs who work either at KIU, in Katagata, and in Bushenyi. The KIU building was by far the most impressive we had seen, almost looking like the outbuildings of a French chateau. This is a private hospital which offers private medical education. A total of 1000 students pay fees of $4,000 per year, making up a hefty income ($4 million per year!), allowing the patient fees to be subsidised. The hospital houses impressive equipment and a large number of specialists. The only thing it was missing was any patients! We visited the ICU where an anaesthesiologist looked after 5 beds with ventilators (that’s more than Mulago…), but no-one using them. We were never to find out why, but apparently the impressive architecture intimidated the locals. We visited the theatres and tracked down the Lifeboxes. One was working well and the other needed replacing. The AOs were happy as always to spend time with us and answer our barrage of questions. One had travelled 5 hours to see us, and was then traveling 5 hours back later in the day.

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We then headed an hour north and stopped for lunch on the escarpment overlooking Queen Elizabeth National park. The view that unfolds is a true spectacle, an expanse of safari savannah, with Lake Edward in the distance, topped off with the 5,000m tall Rwenzori mountains as the backdrop. We even had time to slap on some suncream and have a swim. After lunch we dropped down into the park. We were immediately met with two large African elephants by the roadside and herds of grazing Kob antelope. We cut straight across the park, crossing the Kazinga channel, and then drove NW to a small predominantly muslim town called Bwera, 5km from the border with DR Congo. We were met by the AO John at the hospital perched on top of a hill, again with good views over the park. We looked around the hospital and then were welcomed into theatre. Nick put on his scrubs and joined the team to prepare a lady for Caesarian section whilst I sat with John and got a good idea of his work in the hospital. He had cherished his Lifebox until it had gone missing 6 months ago. The importance of the equipment was all to evident, his face lighting up as I offered him a new pack. This was clearly a hard working hospital, and all the staff we met were very enthusiastic to tell us what they were up to.

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Hillsides covered in tea

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Taking a break overlooking Queen Elizabeth national park

We wished to stay longer but had to find somewhere for the night. We had heard a rumour of a small hotel on the banks of Lake Edward, off the beaten track, and we went for it. After 8km down a dirt track we found Kayanja, a small fishing village which was clearly untouched by tourists at the park. The hippo lodge was quite clearly still under construction but the manager, my Congolese namesake Jacques, assured us that they had officially opened a couple of days before and welcomed us in. The fuss they made confirmed we must be amongst their first guests. The sun was coming down over the mountains of DRC. We made our way straight into the village to meet the locals around the fishing boats. The children were uncharacteristically terrified, and it took a fair while until they plucked up the courage to take a closer look at the funny looking people. Some of the younger ones just burst into tears at first sight. Before we knew it we had an entourage of 15 or so kids who escorted us around. The sunset was magnificent and gave way to a clear starry night over the lake to a chorus of frogs.

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Looking over the lake to the mountains of the DR Congo

Day 7

We woke up to the calm of the lake and took half an hour to visit the boats coming in after a night of talapia fishing. We said our goodbyes to Jacques and headed north to our first stop of the day, a mission hospital called Kagando, tucked up in the foothills of the Rwenzori mountains. Another fine welcome by another Moses, and a good look around the theatres. There seemed to be some good funding from somewhere in the UK, and we even found a ventilator in the paediatric ICU, a piece of equipment not even enjoyed by the national referral hospital. The AOs Richard and Felesta told us great stories of how the Lifebox had changed the way they practice. Richard showed us the precordial stethoscope with the long tube he used to use to constantly listen to the heart of a patient under anaesthetic. He said that thanks to the Lifebox this ungainly piece of equipment now lives in the museum. After our goodbyes we drove another 80km north to another mission hospital called Kalimbe. Again this hospital was tucked into the spectacular setting of the foothills, surrounded by green and lush interlocking spurs with a river running through. We had a really good laugh with the two AOs and the three surgeons there. The atmosphere and team spirit was the most energetic and good humoured we had come across. They were really pleased to have us there and were keen to establish a more permanent link. We gave them a new paediatric probe and joined them in theatre to see it put to good use as they repaired a bowel perforation on a 5 year old caused by typhoid fever. They were most grateful for the equipment. We heard a story of the Lifebox being used to transit a woman with cardiac arrest from Kalimbe to Mbarara, with a good result. We also heard of the recent floods which forced the surgeon to use three broad stitches midway through a laparotomy and swing the patient over his shoulder to take them to safety and complete the operation. TIA. After high spirited goodbyes we drove a little further uphill to see the old copper mines which have fallen into disrepair before moving back to the main road.

After another hour north we drove for half an hour up a dirt road to find Rwasende HC IV. Although only 12km off the main road it felt very rural. The kids in the school went berserk as we drove past and our car was surrounded by their raucous chanting. We finally met Dr Seth, the only doctor working there. He doesn’t have an AO but does the anesthetic himself whilst he operates, perhaps 10 spinals and 4 general anaesthetics with ketamine every month. He was also grateful for the Lifebox which again we found in good working order. By late afternoon we were done and drove another hour north to the pretty town of Fort Portal where we had supper with some colleagues and put up for the night. It had been a great couple of days tracking the Western edge of the majestic Rwenzoris.

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Bringing in the night’s catch of talapia

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Recent floods around the copper mines of Kalimbe

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Arriving in Rwasende

Day 8

The last day of hospital visits. Nick went off to visit Fort Portal regional referral hospital whilst I hung back and got on with my own business. He was pleased to see the Lifebox in good use, and impressed with the team of 5 AOs, many of whom came in on their day off to meet him. We couldn’t believe how generous they were all being with their time, it really made us think they truly value this equipment. After a quick lunch we drove around the northern apex of the Rwenzoris, off the rift, and down into the true lowlands on the Congolese side. The climate was very different, hot and humid, as the expanse of the DRC’s rainforest began. We drove up to Bundobugyo district hospital 5kms from the border on an unannounced visit. We had no number for any AO there, but had information they had received an Lifebox 3 years ago. Despite the lack of warning we were welcomed by the medical superintendent who was the same age as me having graduated in 2010. He is the only doctor there, whilst 10 other posts for doctors remained unfilled. He deals with every speciality, does all the surgery, and even performs the post-mortems. Anyone medical will understand this is an unheard of amount of responsibility. There was no AO there as such, and they had never received an Lifebox, but we found Mary who was an anesthetic assistant and delivers the anaesthesia hospital wide. Although they do around 30 Caesarians per month she is not comfortable with spinal anaesthesia and so gives a general anaesthetic in the form of ketamine or ether to everyone. She is not comfortable with intubation and has not provided such airway support for over 10 years. The other anaesthetic provider has never intubated anyone in her life and never had any formal training. The look on Nick’s face… This really is basic rural medicine. We don’t enquire about their safety record, but we suspect it is probably not as shocking as we would expect. Again with very little at their fingertips these anaesthetic providers are doing amazing work against the odds. They have very rudimentary equipment but know how to work it, and Nick admits probably better than himself. In the corner of their theatre is one of the new $15,000 GE 9100 machines that have been handed around. No one knew how to use it and Nick suggested they continue to avoid its use until they have had proper training. This really was a situation where new technology can be dangerous. Nick arranged for another UK anaesthetist to visit them in September and support them with some more training, as well as a Lifebox.

We 30km back down the road to the park gate of Semliki national park, Uganda’s premiere birding spot. There they have some relatively basic bandas where we settled in for the evening. We were the only ones in the area, our only company the piping hornbills and black and white colobus monkeys swinging through the trees.

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The lush surroundings of Fort Portal

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Talking about pulse oximetry. As usual.

Day 9

We were up before sunrise to take a walk through the park with our guide (called Moses of course). As the light grew the forest came alive. Moses knew all the bird calls and we encountered no less than 5 different species of monkey including the particularly shy De Brazza’s monkey. He led us to the natural hot water springs, where super-heated sulfurous water boils up through the ground depositing minerals as it cools. It was great to interact with the landscape rather than being restricted to tourist walking boards. We cooked eggs in the water for our breakfast and walked perhaps for 4 hours. The sun breaking over the mountains was a real highlight as all the wildlife celebrated the new day. We spent a decent amount of time identifying the huge array of butterflies with the use of a new field guide (thank you Ellie!), you start seeing so much more when you get your eye in. We felt very lucky to take in the experience of Semliki, a park rarely visited.

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The hot springs of Semliki

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A spectacular sunrise over the Rwenzoris, alone in the national park

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After lunch in Fort Portal it was time to catch the bus back to Kampala and say goodbye to Nick. A week ago we hardly knew each other, but through the course of our adventures we had become great friends. I had great admiration in the way that he conducted the study, taking a real interest in the people behind the equipment, and extending genuine offers of support. There is no doubt that we had collected some very powerful data which is down to the organisation and planning that went into this trip. Foreigners don’t always get it right in Africa, but Nick was an example of how to conduct great research in this part of the world. We had learnt a great amount about the state of healthcare in rural SW Uganda, been inspired by the people that work for humanity against all the odds, and taken in a lifetime’s worth of spectacular natural beauty. It had been a truly incredible week in the office, deep in the heart of Africa.

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Here are a few inferior photos of butterflies, just a handful of the incredible array of species we came across:

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Actinote bonasia

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Bellenois raffrayi

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Bicyclus safitza – male

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Charaxes varanes – the mimic of an autumnal leaf

A preventable curse

The next series of bogs will be coming from Uganda. I am currently based at Mulago Hospital which is the national referral hospital in the capital Kampala. During my time here I’ll be running an evaluation of the maternal high dependency unit which was set up 4 years ago by the partnership from Liverpool I’m here with. This was also a chance to brush up on my obstetrics skills (pregnancy and childbirth for the non-medics..) before starting a job in South Africa in August. UK trainees are somewhat sheltered when it comes to obstetrics and this is my chance to avoid getting egg/amniotic fluid on my face.

Helmeted guineafowl in Queen Elizabeth National Park

Helmeted guineafowl in Queen Elizabeth National Park

Childbirth is dangerous because of two major events in human evolution. I know I’ve said it in a previous blog, but I’ll say it again. Feel free to skip a paragraph.. As we evolved to walk on two legs, the female pelvis was rendered less flexible, and as we developed higher social skills larger skulls were required to house increasingly large frontal lobes. The disproportion between the inflexible pelvis and the large head means that a lot more babies get stuck on their way out into the world as you would expect. In light of this, health services in the developed world boast truly excellent obstetric services. The attention to detail on an obstetric ward is second to none, fueled by a fierce (yet performance-enhancing) medico-legal system. Ironically all this is made possible by the large cerebral cortices that make childbirth dangerous in the first place. My sister is having a baby in June and I have complete faith in the system that is caring for her. She already knows about the lie of her baby, where the placenta sits, the genetics of her baby, and when the time comes she will be surrounded by a number of highly trained professionals to see her through the process. The fact that mothers in the UK have time to choose the incense and music for the birthing process suggests that some very able people have got them covered. In this setting a maternal mortality is an anomaly, which warrants years of investigation in the rare instances it does occur.

Having a baby in Uganda however remains a dangerous business. The maternal health statistics here remain some of the worst in the world, marginally better than those I encountered in Sierra Leone. Most women have had little or no antenatal care. Most have not had their blood pressure taken, let alone an ultrasound scan. The last menstrual cycle is usually a guess and so a delivery date is hard to estimate. The population in Uganda remains largely rural so it often takes many hours to reach a healthcare facility. You hear the word ‘emergency’ more often in the world of obstetrics than any other speciality, so a journey of many hours is not just an inconvenience but a threat to life. If the risk of maternal death per pregnancy is multiplied by the fertility rate (i.e. the number of babies the average woman has) we see that a woman has a 1 in 20 chance of dying of pregnancy related problems during the course of her life.

Mulago Hospital is the tertiary referral centre for the whole of Uganda so besides seeing a large number of deliveries each year it also sees the country’s most complex cases. The unit where I am working expects to deliver 33,000 babies in any one year, compared with 8,000/year in Liverpool, one of Europe’s  busiest obstetric unit. The hospital truly is one of the beasts of African healthcare. There are 1,500 beds but probably over 3,000 patients in the hospital, not to mention the family members that are needed to deliver a large proportion of the nursing care. Supplies are critically short and there is often no supply of basic drugs or medical equipment. One nurse can expect to look after 50-80 patients, hence the need for family attendants. The entire hospital has lacked running water for the last few months due to billing issues, and there is no alcohol gel available, so infection is a serious risk. (Since writing this running water has been restored!)

Mulago Hospital

Mulago Hospital

Part of the post-natal ward

Part of the post-natal ward

The maternal pathology that presents at Mulago is nothing short of shocking. It is sometimes very tempting to blame ‘the hospital’ or the people that work within it, but the shocking pathology we see is the result of countrywide failings in health infrastructure which are in turn a result of myriad historical and political events with countless contributors. I am not exaggerating when I say that in one day we see as many of these ‘late’ and unstable conditions that a senior obstetrician in the UK may expect to see in a lifelong career. Probably the most common pathology is eclampsia. Eclampsia is the reason that midwives obsessively record a woman’s blood pressure at every antenatal appointment. As the placenta begins to age in the later stages of pregnancy, parts of the tissue begin to die and release toxins into the maternal blood stream. This is turn aggravates the inside of the mother’s blood vessels causing them to clog up, squeezing the blood volume into tighter vessels, causing the blood pressure to rise. Picked up early this can be managed with simple medications, and delivering the baby (either by inducing labour or by Caesarian section) terminates the problem. Left untreated the condition is life-threatening, both to the mother and the baby. The high pressure can disrupt the blood flow to the baby, starving the baby of oxygen in uterus, leading to a late stillbirth. The pressure will continue to rise until it causes fitting and convulsions for the mother, which has the potential for other complications as well, such as bleeding in the brain or aspiration into the lungs. The condition is completely avoidable with standard antenatal care, a blood pressure cuff, and basic obstetric services, but cases of full blown fitting eclampsia are seen here every day. Unfortunately a ‘crash’ Caesarian section (i.e. on the operating table minutes after arriving in the hospital) for a fitting mother is not always possible as the waiting time for surgery can be 8 hours or more due to the shear volume of patients, but eventually the mothers make their way to HDU for ongoing care, either with or without a baby. On Monday we received a mother from Northern Uganda who began to fit. She couldn’t be operated on for many hours and unfortunately her baby had died before she delivered. 2 days after the operation she stopped passing urine as her kidneys began to fail, and the whites of her eyes have become the deep orange of jaundice, an indication of liver damage. Red blood cells are literally torn by the aggravated lining of the blood vessels and she breathes rapidly with the anaemia. This is the severe end of the eclampsia spectrum, so called HELLP syndrome.

You can’t help feel emotionally involved when talking to the woman’s husband. A few days beforehand he was excited about the delivery of his first baby. His posture is entirely strong as he stands beside her bed. He tells me he can’t even begin to grieve for his baby until he has been there for his wife, who is thrashing around on the bed, her orange eyes wide and mad, disorientated and confused by the toxins flooding her brain. He asks me if his wife is going to survive, with complete bravery, and all I can muster is the non-committal ‘we’re doing everything we can’ line, not very bravely. Fortunately this family can afford the first round of dialysis, about $400. However the story would end there for most other mothers who at times struggle to pay for the bed sheets that they need to bring to the cover the hospital bed.

Another of the big killers here is post-natal bleeding. A huge amount of blood is supplied to the uterus, placenta and baby during pregnancy. After delivery the uterus needs to contract hard to close off all the blood vessels that have been cut. In most cases this happens successfully, but in a few the mechanism fails. This may be because the uterus is tired (it’s a muscle) after a long labour, or because part of the placenta has been torn off and trapped inside, stoping the uterus contracting down. A woman can lose a lot of blood very quickly under these circumstances. Last week we received a mother who had delivered at home and been bleeding ever since. She was still conscious but very confused and her hands and feet were cold as her body shut down the blood supply to non-essential parts of the body. It was thought that some of the placenta had been retained and she was taken to theatre for evacuation. On the ward afterwards she continued to bleed. By this point most of the clotting factors in her blood had been used up, and despite removing the offending article, the bleeding continued. This is called ‘DIC’ and is usually the end process that is very difficult to reverse. We spent hours with her squeezing in many units of blood and clotting factors but she continued to deteriorate. It’s a very distressing condition and blood begins to appear from everywhere, from each cannula/drip site, to the lips and eyes. The volume of blood lost from below makes the scene quite horrifying. Unfortunately the process had tipped over into the irreversible category and she died. This again is a completely preventable condition. Yes placenta is retained at times, in women all over the world. But the fact that this woman had delivered at home and taken many hours to reach the hospital meant that the situation was too dire by the time she reached us. She sadly left behind four children. Looking back to my time in the paediatric clinic in Sierra Leone I always noticed that the very sick children with malnutrition/TB etc were the ones who had lost their mothers for whatever reason. Lack of obstetrics services affects whole communities, not just the mothers.

If there is one thing that I have had to learn to deal with since being here it’s seeing young mothers like this die. Unfortunately this happens on a weekly basis. Having been trained in the UK I was only ever exposed to dealing with the death of older people, usually of the expected conditions of old age. (If a young person did die for any reason, the situation was handled by the most senior members of the team, the junior doctor or medical student being told to butt out.) Talking to families about death is never easy but telling a young husband, or the parents of a mother, is something different altogether. But sometimes you are surprised by the responses you get. After I told the husband about the mother I mention above he raised his hands in the air calmly and said ‘It happens Doctor’ and thanked me for our work. I’ve seen this response more often than I expected. Death here is a very apparent part of life. I don’t know whether the frequency of tragedy desensitises people, or whether there is an acceptance built on both strong traditional spiritual and modern religious beliefs (many Ugandans sign up to both). What I can tell you is that I don’t understand it and probably never will. The general impression I get is that families see these events as inevitable, that God has chosen that fate for them. Whilst this belief gives them solace, something which I would never take away from them, it’s important for us to understand that they are wrong. All of these deaths are preventable with very simple measures. When I started at Mulago hospital I was ready to blame the lack of this and lack of that on all the maternal death we saw. However having spent three months here I realise that lack of hospital care has been very little to do with the deaths that have occurred. All the mothers that have died with us had already passed the point of return before reaching the hospital doors. Obstetrics in the UK is largely about procedural skill and accuracy in the hospital setting, but in Uganda the issue remains one of community public health. Women continue to die of preventable conditions due to a lack of basic education, healthcare workers and healthcare infrastructure.

That feeling of inevitability that families feel must be the saddest thing. It is something that has been ironed out of culture in the UK as the people have realised that tragedy like this is entirely preventable. That is a culture of which we should be proud and a barometer of great successes in healthcare. My sister has now had her baby and it is an absolute pleasure to hear her talking about the process, how the doctors are bugging her, how the midwife is visiting her (yes in her own home! and there is someone called a healthcare worker who visits her in her own home too! just incredible..). The right to be overwhelmed by too much care and pampering during pregnancy and childbirth should not be confined to countries which have had a fortunate modern history. My hat goes off to all the people that are here trying to change that (I don’t count myself as one of them by the way, I’m a medical tourist compared to these martyrs). To find out more about the Liverpool-Mulago Partnership see:

www.liverpoolmulagopartnership.org

My apologies for the lack of birding photos recently. Many thanks to Henry Tufton for the use of his perv lens to capture a few of these critters on my travels:

Uganda's national bird - the grey crested crane - posing for us on a rock

Uganda’s national bird – the grey crested crane – posing for us on a rock

A couple of jacarnas get a bit too close to an African spoonbill

A couple of jacarnas get a bit too close to an African spoonbill

The majestic African fish eagle

The majestic African fish eagle

A pin-tailed wydah in full breeding plumage, caught here in the first light of day

A pin-tailed wydah in full breeding plumage, caught here in the first light of day

The wattled lapwing

The wattled lapwing

 

The children of ABAaNA

The ABAaNA study

One the ABAaNA children with their mum

The blog for the next 3 months or so will be coming from Uganda. I have a few months to play with before starting a job in South Africa in August so I have returned to Kampala to take up a job in obstetrics (that’s everything from pregnancy to childbirth for the non-medics). Not only is it a chance to explore this side of healthcare a bit more before physician training, it’s a chance to build up my surgical skills so I can be of more use in South Africa. Whilst I will be working in the maternal high dependency unit 4 days in a week I will be spending one day per week helping out on a large study looking at the long term childhood outcomes of newborn brain injury in Uganda, and I thought this would be a good place to start the blog.

Mulago Hospital is Uganda’s national referral hospital housing about 3000 patients. Not only does it see about 100 deliveries everyday, but it is the destination for the most complex cases of pregnancy. Whilst many of the babies born here leave the same day, many need to stay in the special care unit whilst they recover from complications that occurred during birth. Unfortunately each day there may be two or three neonatal (newborn) deaths and a few more suffering from seizures due to oxygen starvation during birth. The seizures may indicate brain damage which may later manifest as disability in the form of cerebral palsy. Life in the UK with a disability is tough enough, even with all of the equipment and support groups available, but life in Uganda with a disability is something else.

Whilst child mortality in Africa is reducing at record levels, mortality and morbidity of newborns remains static. There are about 200 million children living with disabilities in the world and 80% of these live in low income countries like Uganda. The overwhelming cause is a lack of basic obstetric services meaning women routinely give birth in the home with no-one to help if things go wrong. Giving birth remains a dangerous business; as we evolved to walk on two legs, what the pelvis gained in strength it lost in flexibility; and as we developed more complex social skills a larger skull was required to accommodate an increasingly large brain. As a result a large number of babies get stuck on the way out into the world. The brain is starved of oxygen, and the subsequent brain damage can  manifest itself as long term disability. The long term outcomes of such damage in Africa are not yet know, and the specific risk factors that lead to damage have not been delineated either. I am pleased to now be part of the largest prospective study ever performed in Africa that is addressing these unknowns, the ABAaNA study (Associations of Birth Asphyxia and infection amongst Newborns in Africa). The results of this study will be used to help target interventions and get newborn health, and the related disability in survivors, onto the healthcare agenda.

About the study

Ellie and Julius with one of our children

Ellie and Julius with one of our children

600 babies were recruited into the study 2 and 1/2 years ago (200 suffered trauma during birth and 400 were normal deliveries.) The children are now toddlers and it’s time to assess how they are developing to determine the longer term outcomes. Conducting this form of assessment on a two year old is no easy task. We will be using the Griffith’s neurodevelopmental test which is a series of games and puzzles that address different developmental modalities – speech and language, movement, practical reasoning, hand-eye co-ordination, and social skills – all easier said than done. When assessing a child of this age it’s on their terms, and the name of the game is improvisation. The operator must be both calm and opportune, skills which a paediatrician develops over a lifelong career. Up to this point my interaction with two year olds has been based on the following formula – get them as excited as you can, as quickly as possible, encourage them to do ridiculous things, and then leave them with somebody else when they become over-excited and begin to cry. I was going to have a lot to learn.

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We would start the proceedings with two weeks of intensive training. To the credit of the study we were to be trained by two of the best; Prof Frances Cowen is Professor of perinatal neurology at Imperial College London and joining her was Miriam Biarge, consultant paediatrician at the same institution. We thank them for giving up their time for free. It was to be a fascinating two weeks and an honour to be taught so closely by world authorities on the subject. Not only did they impart a huge amount of technical knowledge, their instruction in dealing with children of this age was second to none. The way an experienced paediatrician interacts with a child is a beautiful thing. The child appears in charge and the paediatricain must play a series of roles to suit the ever changing situation and sometimes volatile mood of the toddler. Through subtle tricks of body language and voice the paediatrician may lead the child down certain avenues, all the while keeping up the impression that the child has arrived there of their own volition. In this game blatant force is useless, subtle coercion is the order of the day. The learning curve was steep indeed, and often demoralising as another child’s attention was lost and the game was up for another hour. The process can take 5 hours in all accounting for approximately three tantrums, two pairs of wet trousers, a sleep and some lunch. By the end of the two weeks, whilst we were still feeling the pressure, we were ready to go it alone. I saw my first child in clinic yesterday (now a few weeks ago..) and, despite an early trouser wetting incident (on the toddlers part..), all went to plan. Bricks were piled on top of each other, choochoo trains were made to go under bridges, and the horse was correctly identified as a goat. The Griffith’s test was made in the UK so a few aberrations due to cultural reasons are allowed.

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Other than learning about the technicalities of newborn brain damage, and the intricacies of performing neurodevelopmental assessments, working on a study like this can teach you a lot. Following children for this amount of time in an environment like Uganda is an extremely difficult challenge; mothers move away, phone numbers change, and families don’t see the value of bringing a child that seems well. One would expect a large loss to follow up in such a study. The study’s strength in this regard falls to the work of two remarkable ladies, both called Margaret, a senior midwife and a senior paediatric nurse in their earlier careers. Their ongoing relationships with the mothers is what keeps them turning up for evaluation. The Margarets are able to relate to these women in ways that we can never imagine, not just in terms of the language but in terms of what it means to be a mother in a city like Kampala. Working with locals like the two Margarets is the key to conducting successful research in Africa. They may not be giving professorial presentations at international meetings but they remain absolutely integral to the success of the study. These are things that are only learnt with experience in the field.

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Despite the clear value of this study it’s still been difficult for the team to acquire funding. Whilst there is enough money to conduct the research, it hasn’t always been easy to raise additional funds to provide the families with something that will make a real difference to their lives. It only seems right that whilst these families contribute to the global scientific literature we give something back to them to help with the daily struggles that they have. Today we launch a campaign to make some money so that we can offer the families some basic equipment, support and education. For example we are now getting customised chairs built to help the families in the home, and a support group to teach the mothers about cerebral palsy. A child born with disabilities in the UK is eligible for services to the value of many thousands of pounds, and rightly so, but a child born with disabilities in Uganda is often afforded nothing. If you can help us out with a bit of cash to help out the families it would be much appreciated. No gimmicks, no skydives (maybe a triathlon in a crater lake on the border with DRC in a few weeks), just a simple request for help on their behalf. See the JustGiving page for more:

www.justgiving.com/CerebralPalsyUganda

 

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