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.
(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.)
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.
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.
Bellenois creona – The African White
The children’s ward – the burden of malaria ever present
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.
Nick with Agnes outside her operating theatre
The hills beginning to rise
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.
The Virunga volcano range comes into view
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.
Taking a break from chopping wood
Returning from antenatal clinic
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.
Taking a morning shower in Kisizi falls
Nick doing some first class birding
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.
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.
Hillsides covered in tea
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.
Looking over the lake to the mountains of the DR Congo
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.
Bringing in the night’s catch of talapia
Recent floods around the copper mines of Kalimbe
Arriving in Rwasende
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.
The lush surroundings of Fort Portal
Talking about pulse oximetry. As usual.
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.
The hot springs of Semliki
A spectacular sunrise over the Rwenzoris, alone in the national park
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.
Here are a few inferior photos of butterflies, just a handful of the incredible array of species we came across:
Bicyclus safitza – male
Charaxes varanes – the mimic of an autumnal leaf