Safely ensconced in the BOMA. For all that I have not been suffering any privation for the last four weeks, it is nice to be in a place with a nice hot shower and internet; the fact that it is close to the airport for my ride home tomorrow is no small thing, either…
Wasn’t sure I was going to make it to Entebbe today. My ride was supposed to arrive this morning at 10, by 10:30, still no cars. For whatever reason, there was a miscommunication and the driver did not know that the booking was confirmed. They were nice enough to send out the next person ASAP, and we got to leave at 11:30.
Many more police by the side of the roads today; I think since we were in a passenger car instead of a van we were preferentially waved over, since it happened several times on the way to Entebbe and hadn’t happened at all going to Mbarara. I think it must be the driver that looks shady, surely they don’t suspect little old me of anything untoward? I was very happy that I had a smart driver when the first two cops asked him to pop the trunk so they could look. He got out and went back to talk with them, apparently telling them that we were late in getting to the airport and that he was unable to open my luggage. They were requesting to search my luggage, not sure if that’s just a prelude. They then asked if he could have me open the luggage, to which he smartly replied that he would be happy to do so if the captain of the police force requested it. Since I’m not sure that they were actually supposed to be stopping and searching people, they quickly allowed us to be on our way.
It’s surprising how quickly you can get used to things. I remember on the way out to Mbarara that everything looked so different from what I’m used to seeing driving down the roads back home; on the way back, it was just more of the same old thing. It’s interesting that different regions of the country have different specialties and different emphases- soon after passing a papyrus swamp, the sides of the road were filled with people selling papyrus weavings. We passed through a watery area, and had people waving to get our attention trying to sell tilapia (a very tasty fish- common here). We had to detour through Kampala itself, since the road we were going to take to get to Entebbe by going around Kampala is not one you want to travel on without a four wheel drive after it rains. We passed through an impressive squall on the way to Kampala, inky black clouds and thick drops of rain.
It was nice that it was just the driver Herbert and myself; I got to pick his brain about life in Uganda and its recent history. Until now I have been hesitant to ask about the difficult years under Amin and what effect that had on the country, since I‘ve been unwilling to dredge up possibly painful memories. Luckily, he provided the segue into the conversation, and didn‘t seem to mind discussing politics and culture in Uganda. I also learned that he can apparently tell an Ankole from a Bugandan quite easily, and took delight in trying to explain the subtle differences to a clueless Mzungo.
I also got to learn how much a cow costs in Uganda, and how much a hectare (no clue how big that is) of land costs- apparently Herbert has quite the operation going, with 4 cows and 16 hectares, much of which is planted in a banana plantation. Food is certainly not the problem for his wife and 5 children, since they have so much planted land; paying for school is the issue. From what I understand primary school is covered, but the government run schools are seen as far inferior to private schools for which people have to pay. You can “freehold” here in Uganda, which means that, at least for now, after you pay for the land, surveyor, title, etc you own it free and clear without having to pay taxes yearly, which I find incredible. Not sure how that will fare after the future elections. The elections aren’t scheduled until 2011, and people are already talking about it quite a bit- should be interesting.
I will miss the food here- had a great dinner of tilapia fillet and chips (French fries), with the fish freshly pulled from Lake Victoria. Looking forward to sleeping tonight without being awoken by either the Imam or the trucks bouncing across speed bumps. Not looking forward to waiting until my flight leaves at 11:00 PM tomorrow night, the nine hour flight, 6 hour layover in Amsterdam, another 10 hour flight, nine hour layover in Minneapolis, and then only a short 4 hour flight into Portland. Hoping to catch something on standby….
Monday, November 2, 2009
Saturday, October 31, 2009
Sleepless
I get a little cranky when I don’t get enough sleep. I am very cranky today. For the last several days there has been an evangelical meeting/ concert/ lecture series happening in the park down from the guest house. As I was sitting around last night reading, it was remarkable that I could actually hear the preacher talking on the loudspeaker from so far away. At first it was interesting, hearing the praise songs and the rhythmic rise and fall of the preacher’s voice. Unfortunately, it went on and on. Eventually the one preacher must have tired, since they brought another out to substitute. They would alternate between singing, preaching and at times rhythmically chanting-- I swear at one time he was just yelling monosyllabically at the crowd and they repeatedly called back and forth. This went on until 6:00 this morning….
Must not be neighborhood ordinances here, since I am sure I’m not the only one that was kept awake. For whatever reason they finally quieted down for a break around the time the Muslim call to prayer was announced at 6:00. I only thought about using my earplugs at 6:00 and while it didn’t eliminate the racket, it did lessen the intensity. I assume they stopped soon after 6, but was too tired to notice and slept until about 8:00.
Must not be neighborhood ordinances here, since I am sure I’m not the only one that was kept awake. For whatever reason they finally quieted down for a break around the time the Muslim call to prayer was announced at 6:00. I only thought about using my earplugs at 6:00 and while it didn’t eliminate the racket, it did lessen the intensity. I assume they stopped soon after 6, but was too tired to notice and slept until about 8:00.
Monday, October 26, 2009
Traveling in Uganda
Went to Lake Bunyonyi this weekend, a valley lake situated at 1600m above sea level in southern Uganda, close to Rwanda. The full crew from the guest house went, 7 people in all. Since there were so many, we hired a car instead of all trying to fit into a mutatu (minibus). Of course, there are several things to remember when traveling in Uganda:
1) Travel Time- Unlike the United States, where travel time is most directly proportional to distance, here the most important factor to how long it takes to get to your destination are the condition of the roads.
There were several stretches of road that were quite smooth, but once again large potholes are more the norm. At least much of the way there had the pretense of being paved. On several portions of highway outside of Mbarara they were working on patching the holes, having thoughtfully outlined in white dashes of paint the obstacles to avoid if you wanted to keep your engine block intact. Unfortunately this left little of the road surface unmarked with little white dashes and squares. They used tree branches and rocks as road cones to keep people from driving on the freshly patched asphalt, which was very effective. To control the drivers’ speed, they build monstrous speed bumps every 10 feet throughout the entire portions where fresh gravel had been laid, forcing the driver to weave on and off the shoulder to avoid them. Most other cars were doing the same thing, and we ended up weaving on and off the shoulder on both the right and left sides of the road; I think at one time we were passed on the left hand side by a car coming the other way (not unusual in America, but here they drive on the opposite sides of the road, so it meant that both cars were operating on the wrong side of the road).
After Kabale we turned off onto a dirt road to head up the mountain toward Lake Bunyonyi. When you are scrambling up dirt mountain roads, having to head to the shoulder to avoid oncoming buses hurtling down the mountain, it can take quite a bit longer than it seems like it should based on the distance on the map. The distance on the map from Mbarara to Bunyonyi was less than that from Mbarara to Queen Elizabeth, but it took us 5 hours just on the way there, whereas it took only 2 and a half to get to Queen Elizabeth. Of course there were several delays along the way, as I will explain later. Once again, they were working on the road leading up the mountain, having thoughtfully placed piles of dirt every 5 feet to be used in construction. The fact that this narrowed the already precipitously small road down to ½ lane just meant you had to be more creative when passing. Several times our driver pulled over to the valley-side shoulder to allow larger trucks to pass us coming down the mountain. The only gauge for deference of direction appeared to be the size of the vehicle, with pedestrians and bodas coming out on the losing end. I was able to look out the window and clearly see just how steep the mountainside was down to the valley floor, since I saw no shoulder underneath our van. After a while I just closed my eyes and hoped for the best.
2) Hydration- Ensure that your driver or the car has at least 20L of water on hand.
I was lucky enough to score sitting in the front seat of the minivan. What I didn’t know was that the engine lies directly below the passenger side. At least I didn’t know until I was sitting there and I suddenly felt steam rising up from below both sides of the front seat. I looked over to the temperature gauge on the driver’s panel, and noticed it creeping almost up to the top of the thermometer. Putting my hand down beside the seat, the heat washed over my hand like sticking it near a broiling oven. We were climbing altitude to get to the level of Lake Bunyonyi, and I had been wondering why the driver wasn’t going above 20km per hour. As I looked over, I found out; whenever he tried to push it harder, the temperature gauge would shoot up again. About halfway up the first pass, he stopped the van.
We had organized the driver through Praise, a Ugandan who works with one of the volunteers at the guest house. She was nice enough to coordinate finding a competent driver and transportation. However, the driver did not speak English (I assume he spoke Ankole), so we relied upon Praise to communicate with him. Third hand, he requested that I get out of the car so he could add more radiator fluid. I did, much to the delight of all the pedestrians working their way up the pass; they could all point and call out “Mzungo.” After waiting approximately 20 minutes for the radiator to cool down enough to remove the cap, he poured in all the water that was in the back. Unfortunately, this did not sufficiently fill the coolant tank, and he ran off into the woods. I hoped he was going to come back, since I couldn’t understand what he was saying before he left and he had taken the keys. He eventually returned with two full jerry cans full of water, refilled the radiator, and disappeared again to top up the cans. We then resumed travel. We were still restricted to going 20-30 kilometers per hour, and it felt like we were inching our way up the pass. When we reached the top the driver put the car in neutral and proceeded to careen down the winding mountain road at the closest approximation he could make to terminal velocity, urgently beeping at the unlucky pedestrians and bike riders daring enough to get anywhere near our van.
That was not the only pass, unfortunately, and we had to repeat the water ritual at least once on the way there, and twice on the way back. I’m not sure if there was a leak in the radiator or if the water just boiled off too quickly. After several hours of sitting in the steam bath of the front seat, I felt a bit parboiled. On the way back from Bunyonyi during one of these delays, at least it had started raining buckets so I was able to cool off. I think one of the other riders in the van snapped a picture of me standing out in the rain during our stop- I can’t have looked too excited.
3) Spare Tire- Need to have at least one, preferably two.
I think our driver had an urgent appointment to get back to on Sunday. While going to Bunyonyi we had to inch our way up the pass, only to gain speed on the opposite side. Most of the travel was uphill. On the way back this was reversed, and we spent much more time using gravity to help us cool off the radiator. Once again I shut my eyes and tried not to look at the curves we were navigating, tires screeching on a road freshly covered with the daily rain. I guess he was inspired by the speeds he was able to reach going down the mountain passes, because when we got to the slalom course of potholes on the highway from Kabale to Mbarara he didn’t feel like slowing down, and we were jolted from side to side as he constantly sought the best or least dangerous path through the course of potholes. At times there was no optimal path available, and he would go flying over the pothole, hoping that our escape velocity would carry us over the gap. This worked for a while, at least until we got a flat tire. I forgot to mention that I think our driver was Christian, which doesn’t matter except that he had a liking for old time gospel music and had a tape in the tape deck with no more than three songs on a side. This tape was played at loud volume, repeating over and over in a loop. During one of our stops while the driver got out, I surreptitiously tried to reduce the volume on the tape deck, but it was stuck at 11. I still have one of the songs stuck in my head.
I would have thought we put on quite a show, rocketing back and forth between potholes screaming by pedestrians on the side of the road, gospel music blaring from the open windows with Mzungos staring out, wide-eyed. At least, it would have been a show if every other mutatu had not been doing the same thing…
For all my complaining, we reached Bunyonyi in acceptable condition. Our only concern is that we had planned to stay at Bushara Island out in the middle of Lake Bunyonyi, and the boat going there only operated from “dawn until dusk.” As we were inching up the mountainside, I watched the sun setting lower and lower and pondered the exact definition of ‘dusk.’ Whatever requirements they used, the boat was still there when we arrived, and we were able to shuttle ourselves out into the lake.
Lake Bunyonyi is not a national park, and is surrounded on all sides by settled farmland, with little native forest left. The lake itself is the result of a naturally dammed up valley, so it is very deep and closely follows the course of the land, undulating in and out of narrow bays with numerous small islands. The steep hillsides surrounding the lake have been terraced over the centuries, giving a distinctive appearance. Since the lake is so deep without an appreciable shoreline and lies at such a high altitude, there are no hippos, crocodiles or reported cases of schistosomiasis, making it an ideal swimming location as long as you can stand the chill.
We had decided to stay on Bushara Island since it was highly recommended by the other volunteers, and got out of the motorboat to trek up to the top of the island on 3 or 4 switchbacks. Luckily one of the guides carried John’s (Cameron’s dad) pack for him, since at 79 years of age after a cardiac bypass I don’t think he relishes a steep trek up a forested mountainside with a heavily-laden pack. Bushara Island Camp was incredible- there was a large lounge/ restaurant situated at the apex of the island, with the island itself forming a shallow curve to the north and east. Several cottages dotted the north and south side of the island, with a collection of roofed tents scattered along the spine of the island to the north. The eastern curve of the island was largely taken up by a newly built, solar-powered office and conference center as well as staff quarters. For the first night there was a large German group of travelers that had just finished seeing the gorillas in Bwindi, so all the tents were taken and we all piled into a cottage.
Bushara Island Camp is organized around the community and sustainability- the island supports some 44 employees both on the island and in the surrounding communities, providing food for the guests staying there. Within the lodge itself there is a display of handicrafts, with local women placing items on consignment at extremely reasonable prices. The Camp organizes various community activities such as scholarships for community children, an orphanage fund, HIV counseling and testing, and a yearly pig raffle, where people can sign up to win a pair of piglets with the understanding that they have to donate some of the offspring back to the community. The goal is to provide jobs with a good income and help bring up the communities surrounding the lake.
It may sound like I’m advertising for Bushara Island Camp but there is a reason- I think that if you do happen to visit Uganda, you would be very well served by relaxing for a day or two on Bushara. There is no electricity, so the lounge at night is lit by candles, lanterns, and firelight. There are several swimming docks, many different available hikes and canoe trips, and even a small sailboat. Cameron was brave enough to take the sailboat for a skim around the lake. I deferred, since my only knowledge of ship-lore is being able to talk like a pirate when I’m inebriated; I don’t think telling people to walk the plank would quite get me back to the island if I was stuck out in the middle of the lake. I’m sure I could have jibbed the mainsail or something, but oh well.
Bunyonyi is known as the lake of the little birds, and on Bushara it was clear why. In the morning and at dusk the air was filled with birdcalls of dizzying variety, in fact making it a little difficult to sleep in. Several of them sounded computer generated, so alien and tonally pure were the calls. The north side of the island, being the shadier side, also supports a healthy population of gnats and small bugs, on which I assume the birds subsist. The south side, where our tents were located the second night, is much clearer with panoramic views of the lake and islands, including a view of ‘punishment island.’
Among the uses of the various islands dotting Bunyonyi lake in the past have included a leper colony, church, and the appropriately-named punishment island, where by lore women that were pregnant and unmarried would be exiled to suffer an untimely death unless a man daring enough (and poor enough that he could not afford a bride price) would come over in a canoe and take her away. Not an equitable system, but long-gone now.
I went out for a morning walk the day after we arrived to explore the island for a while, and ended up sitting on one of the benches on the dock overlooking the lake. Since it was still early, the lake was still quite smooth, at least until the rain started. Soon after that, I was drenched and ran for the shelter of the cottage. After drying off and putting on my rain jacket that I should have taken with me in the first place, I headed up to the lounge for an exhausting morning of reading, drinking coffee and listening to the birds and the rain.
I have spent a lot of time in my journal writing about my weekend excursions, but there is a reason. The weeks spent in the hospital are difficult. It’s good to look forward to and plan the weekend excursions, since that prepares me for another week on the wards. I have to give a lot of credit to the PGY’s and doctors that live here for learning to cope. I think the most frustrating thing is feeling helpless when patients come in so desperately ill, knowing that there are resources that could help them if they were only available. Combined with a dearth of diagnostic tests this makes for an endless source of frustration. “Mrs so and so is a 38 year old NYY (HIV+) patient on septrin prophylaxis with evening fevers, a month of severe weight loss and pallor.” The usual course of treatment is to try and get sputum for a TB test, see if they can afford or are stable enough to go into town for a chest xray, and transfuse them. Most people are extremely anemic, so that even if you don’t have a blood count the PGY’s can reliably assume that their palmar pallor portends a significant anemia. If they have a lobar consolidation they will often be started on penicillin with or without chloramphenicol. On certain days the hospital also has ceftriaxone. If they do not get better after several days and the sputum comes back negative for TB, they are often started on tuberculosis therapy regardless given the prevalence. Of course there are many variations on this theme, but you get the idea. The other typical presenting complaints include ‘body swelling’ and abdominal pain. Pretty much every differential begins with TB, since it can mimic or produce symptoms anywhere….
1) Travel Time- Unlike the United States, where travel time is most directly proportional to distance, here the most important factor to how long it takes to get to your destination are the condition of the roads.
There were several stretches of road that were quite smooth, but once again large potholes are more the norm. At least much of the way there had the pretense of being paved. On several portions of highway outside of Mbarara they were working on patching the holes, having thoughtfully outlined in white dashes of paint the obstacles to avoid if you wanted to keep your engine block intact. Unfortunately this left little of the road surface unmarked with little white dashes and squares. They used tree branches and rocks as road cones to keep people from driving on the freshly patched asphalt, which was very effective. To control the drivers’ speed, they build monstrous speed bumps every 10 feet throughout the entire portions where fresh gravel had been laid, forcing the driver to weave on and off the shoulder to avoid them. Most other cars were doing the same thing, and we ended up weaving on and off the shoulder on both the right and left sides of the road; I think at one time we were passed on the left hand side by a car coming the other way (not unusual in America, but here they drive on the opposite sides of the road, so it meant that both cars were operating on the wrong side of the road).
After Kabale we turned off onto a dirt road to head up the mountain toward Lake Bunyonyi. When you are scrambling up dirt mountain roads, having to head to the shoulder to avoid oncoming buses hurtling down the mountain, it can take quite a bit longer than it seems like it should based on the distance on the map. The distance on the map from Mbarara to Bunyonyi was less than that from Mbarara to Queen Elizabeth, but it took us 5 hours just on the way there, whereas it took only 2 and a half to get to Queen Elizabeth. Of course there were several delays along the way, as I will explain later. Once again, they were working on the road leading up the mountain, having thoughtfully placed piles of dirt every 5 feet to be used in construction. The fact that this narrowed the already precipitously small road down to ½ lane just meant you had to be more creative when passing. Several times our driver pulled over to the valley-side shoulder to allow larger trucks to pass us coming down the mountain. The only gauge for deference of direction appeared to be the size of the vehicle, with pedestrians and bodas coming out on the losing end. I was able to look out the window and clearly see just how steep the mountainside was down to the valley floor, since I saw no shoulder underneath our van. After a while I just closed my eyes and hoped for the best.
2) Hydration- Ensure that your driver or the car has at least 20L of water on hand.
I was lucky enough to score sitting in the front seat of the minivan. What I didn’t know was that the engine lies directly below the passenger side. At least I didn’t know until I was sitting there and I suddenly felt steam rising up from below both sides of the front seat. I looked over to the temperature gauge on the driver’s panel, and noticed it creeping almost up to the top of the thermometer. Putting my hand down beside the seat, the heat washed over my hand like sticking it near a broiling oven. We were climbing altitude to get to the level of Lake Bunyonyi, and I had been wondering why the driver wasn’t going above 20km per hour. As I looked over, I found out; whenever he tried to push it harder, the temperature gauge would shoot up again. About halfway up the first pass, he stopped the van.
We had organized the driver through Praise, a Ugandan who works with one of the volunteers at the guest house. She was nice enough to coordinate finding a competent driver and transportation. However, the driver did not speak English (I assume he spoke Ankole), so we relied upon Praise to communicate with him. Third hand, he requested that I get out of the car so he could add more radiator fluid. I did, much to the delight of all the pedestrians working their way up the pass; they could all point and call out “Mzungo.” After waiting approximately 20 minutes for the radiator to cool down enough to remove the cap, he poured in all the water that was in the back. Unfortunately, this did not sufficiently fill the coolant tank, and he ran off into the woods. I hoped he was going to come back, since I couldn’t understand what he was saying before he left and he had taken the keys. He eventually returned with two full jerry cans full of water, refilled the radiator, and disappeared again to top up the cans. We then resumed travel. We were still restricted to going 20-30 kilometers per hour, and it felt like we were inching our way up the pass. When we reached the top the driver put the car in neutral and proceeded to careen down the winding mountain road at the closest approximation he could make to terminal velocity, urgently beeping at the unlucky pedestrians and bike riders daring enough to get anywhere near our van.
That was not the only pass, unfortunately, and we had to repeat the water ritual at least once on the way there, and twice on the way back. I’m not sure if there was a leak in the radiator or if the water just boiled off too quickly. After several hours of sitting in the steam bath of the front seat, I felt a bit parboiled. On the way back from Bunyonyi during one of these delays, at least it had started raining buckets so I was able to cool off. I think one of the other riders in the van snapped a picture of me standing out in the rain during our stop- I can’t have looked too excited.
3) Spare Tire- Need to have at least one, preferably two.
I think our driver had an urgent appointment to get back to on Sunday. While going to Bunyonyi we had to inch our way up the pass, only to gain speed on the opposite side. Most of the travel was uphill. On the way back this was reversed, and we spent much more time using gravity to help us cool off the radiator. Once again I shut my eyes and tried not to look at the curves we were navigating, tires screeching on a road freshly covered with the daily rain. I guess he was inspired by the speeds he was able to reach going down the mountain passes, because when we got to the slalom course of potholes on the highway from Kabale to Mbarara he didn’t feel like slowing down, and we were jolted from side to side as he constantly sought the best or least dangerous path through the course of potholes. At times there was no optimal path available, and he would go flying over the pothole, hoping that our escape velocity would carry us over the gap. This worked for a while, at least until we got a flat tire. I forgot to mention that I think our driver was Christian, which doesn’t matter except that he had a liking for old time gospel music and had a tape in the tape deck with no more than three songs on a side. This tape was played at loud volume, repeating over and over in a loop. During one of our stops while the driver got out, I surreptitiously tried to reduce the volume on the tape deck, but it was stuck at 11. I still have one of the songs stuck in my head.
I would have thought we put on quite a show, rocketing back and forth between potholes screaming by pedestrians on the side of the road, gospel music blaring from the open windows with Mzungos staring out, wide-eyed. At least, it would have been a show if every other mutatu had not been doing the same thing…
For all my complaining, we reached Bunyonyi in acceptable condition. Our only concern is that we had planned to stay at Bushara Island out in the middle of Lake Bunyonyi, and the boat going there only operated from “dawn until dusk.” As we were inching up the mountainside, I watched the sun setting lower and lower and pondered the exact definition of ‘dusk.’ Whatever requirements they used, the boat was still there when we arrived, and we were able to shuttle ourselves out into the lake.
Lake Bunyonyi is not a national park, and is surrounded on all sides by settled farmland, with little native forest left. The lake itself is the result of a naturally dammed up valley, so it is very deep and closely follows the course of the land, undulating in and out of narrow bays with numerous small islands. The steep hillsides surrounding the lake have been terraced over the centuries, giving a distinctive appearance. Since the lake is so deep without an appreciable shoreline and lies at such a high altitude, there are no hippos, crocodiles or reported cases of schistosomiasis, making it an ideal swimming location as long as you can stand the chill.
We had decided to stay on Bushara Island since it was highly recommended by the other volunteers, and got out of the motorboat to trek up to the top of the island on 3 or 4 switchbacks. Luckily one of the guides carried John’s (Cameron’s dad) pack for him, since at 79 years of age after a cardiac bypass I don’t think he relishes a steep trek up a forested mountainside with a heavily-laden pack. Bushara Island Camp was incredible- there was a large lounge/ restaurant situated at the apex of the island, with the island itself forming a shallow curve to the north and east. Several cottages dotted the north and south side of the island, with a collection of roofed tents scattered along the spine of the island to the north. The eastern curve of the island was largely taken up by a newly built, solar-powered office and conference center as well as staff quarters. For the first night there was a large German group of travelers that had just finished seeing the gorillas in Bwindi, so all the tents were taken and we all piled into a cottage.
Bushara Island Camp is organized around the community and sustainability- the island supports some 44 employees both on the island and in the surrounding communities, providing food for the guests staying there. Within the lodge itself there is a display of handicrafts, with local women placing items on consignment at extremely reasonable prices. The Camp organizes various community activities such as scholarships for community children, an orphanage fund, HIV counseling and testing, and a yearly pig raffle, where people can sign up to win a pair of piglets with the understanding that they have to donate some of the offspring back to the community. The goal is to provide jobs with a good income and help bring up the communities surrounding the lake.
It may sound like I’m advertising for Bushara Island Camp but there is a reason- I think that if you do happen to visit Uganda, you would be very well served by relaxing for a day or two on Bushara. There is no electricity, so the lounge at night is lit by candles, lanterns, and firelight. There are several swimming docks, many different available hikes and canoe trips, and even a small sailboat. Cameron was brave enough to take the sailboat for a skim around the lake. I deferred, since my only knowledge of ship-lore is being able to talk like a pirate when I’m inebriated; I don’t think telling people to walk the plank would quite get me back to the island if I was stuck out in the middle of the lake. I’m sure I could have jibbed the mainsail or something, but oh well.
Bunyonyi is known as the lake of the little birds, and on Bushara it was clear why. In the morning and at dusk the air was filled with birdcalls of dizzying variety, in fact making it a little difficult to sleep in. Several of them sounded computer generated, so alien and tonally pure were the calls. The north side of the island, being the shadier side, also supports a healthy population of gnats and small bugs, on which I assume the birds subsist. The south side, where our tents were located the second night, is much clearer with panoramic views of the lake and islands, including a view of ‘punishment island.’
Among the uses of the various islands dotting Bunyonyi lake in the past have included a leper colony, church, and the appropriately-named punishment island, where by lore women that were pregnant and unmarried would be exiled to suffer an untimely death unless a man daring enough (and poor enough that he could not afford a bride price) would come over in a canoe and take her away. Not an equitable system, but long-gone now.
I went out for a morning walk the day after we arrived to explore the island for a while, and ended up sitting on one of the benches on the dock overlooking the lake. Since it was still early, the lake was still quite smooth, at least until the rain started. Soon after that, I was drenched and ran for the shelter of the cottage. After drying off and putting on my rain jacket that I should have taken with me in the first place, I headed up to the lounge for an exhausting morning of reading, drinking coffee and listening to the birds and the rain.
I have spent a lot of time in my journal writing about my weekend excursions, but there is a reason. The weeks spent in the hospital are difficult. It’s good to look forward to and plan the weekend excursions, since that prepares me for another week on the wards. I have to give a lot of credit to the PGY’s and doctors that live here for learning to cope. I think the most frustrating thing is feeling helpless when patients come in so desperately ill, knowing that there are resources that could help them if they were only available. Combined with a dearth of diagnostic tests this makes for an endless source of frustration. “Mrs so and so is a 38 year old NYY (HIV+) patient on septrin prophylaxis with evening fevers, a month of severe weight loss and pallor.” The usual course of treatment is to try and get sputum for a TB test, see if they can afford or are stable enough to go into town for a chest xray, and transfuse them. Most people are extremely anemic, so that even if you don’t have a blood count the PGY’s can reliably assume that their palmar pallor portends a significant anemia. If they have a lobar consolidation they will often be started on penicillin with or without chloramphenicol. On certain days the hospital also has ceftriaxone. If they do not get better after several days and the sputum comes back negative for TB, they are often started on tuberculosis therapy regardless given the prevalence. Of course there are many variations on this theme, but you get the idea. The other typical presenting complaints include ‘body swelling’ and abdominal pain. Pretty much every differential begins with TB, since it can mimic or produce symptoms anywhere….
Tuesday, October 20, 2009
Whole Lotta Shaking Going On
Went to Lake Mburo this weekend with Cameron Cover, the other physician here from Providence, and his father John. Combining Lake Mburo with Queen Elizabeth National Park means that you see more of a variety of animals, since there they have zebra and several varieties of antelope not found in QENP. They also have impala, for which the capital here, Kampala, is named. On the drive into the park we were fortunate enough to see an enormous herd of Eland, the largest variety of antelope. We had to stop for several minutes and allow the herd to pass in front of us, leaping across the road.
We also saw quite a few Topi, Bushbuck and Impala, several other varieties of antelope. We stayed in the Arcadia Cottages above the lake itself, and I got an entire cottage to myself. The cottage itself was framed on the outside in concrete, with painted burlap and wood trim on the inside. Add in a separate bathroom and it was a welcome luxury compared to some of the places I’ve been staying. Walked out my front door to sit on the veranda and startled a vervet monkey that had come to investigate the noise of my unpacking and rustling about the cottage. The mud surrounding the cottage was filled with tracks of every shape and size, from pronged antelope tracks to the three clubbed fingers of hippopotamus.
Took a boat tour that afternoon around the lake. I am still not used to being such an oddity here (sarcastic comments aside). John, Cameron and I headed down to the lake shore to take the boat launch around the lake, and there were a group of primary school students from a town nearby on a field trip to the lake. While we were settling ourselves on a lakeside bench to await the boat, all 60 of them lined up in rows next to us, giggling and pointing at the Mzungos. John was very friendly and went over to them and started having pictures taken of him and the students- they loved to have their picture taken and then see themselves on the small camera screen. He took down the address of the school in order to send the copies of the pictures to them after we get back.
Lake Mburo houses large varieties of bids, groups of hippos and several crocodiles. Unfortunately we only were able to see the adult crocodiles as their heads stuck out of the water, since they rarely went out on land. We did see several baby crocodiles on the bank, ranging from 6 inches to 2 feet in length. While we were out in the middle of the lake the rain started, cascading down in sheets of water. I felt bad for the people up front, since they took the brunt of it- sitting in the middle we were protected by people in front and back of us and the roof overhead. I wasn’t quite sure that the outboard motor would make it back to the dock- on the way back it sputtered in gasps and starts but luckily kept going until we made it to shore.
The rain continued overnight, drumming on the corrugated tin roof loudly enough to wake me up several times. The cottages themselves had no electricity or lighting; we were provided with lanterns to use if needed during the night. Combined with my headlamp and flashlight, it made for quite a cheery setting. When it gets dark out in the African savannah, it gets VERY dark…
I woke up one time at night at about 3:00 with the bed shaking and thumping; having been used to nightly visitations by hippos I assumed that one had decided to rub against the outside of the cottage vigorously. This wasn’t too concerning to me since the cottage was framed in concrete and it would have taken a bull elephant (I think) to do any damage. This happened one additional time, but in my sleep addled brain I didn’t think too much of it. The next morning John and Cameron asked me if I felt the earthquake, to which I sleepily replied “wha?” I guess in retrospect I shouldn’t expect a hippo to be able to shake the entire cottage, but there was apparently a small earthquake that night- not surprising since both the East and West Rift Valleys frame Uganda on either side. No harm, no foul. It was a very minor earthquake, and no damage was done. From talking with the staff at the lodge, they have one or two each year.
We also saw quite a few Topi, Bushbuck and Impala, several other varieties of antelope. We stayed in the Arcadia Cottages above the lake itself, and I got an entire cottage to myself. The cottage itself was framed on the outside in concrete, with painted burlap and wood trim on the inside. Add in a separate bathroom and it was a welcome luxury compared to some of the places I’ve been staying. Walked out my front door to sit on the veranda and startled a vervet monkey that had come to investigate the noise of my unpacking and rustling about the cottage. The mud surrounding the cottage was filled with tracks of every shape and size, from pronged antelope tracks to the three clubbed fingers of hippopotamus.
Took a boat tour that afternoon around the lake. I am still not used to being such an oddity here (sarcastic comments aside). John, Cameron and I headed down to the lake shore to take the boat launch around the lake, and there were a group of primary school students from a town nearby on a field trip to the lake. While we were settling ourselves on a lakeside bench to await the boat, all 60 of them lined up in rows next to us, giggling and pointing at the Mzungos. John was very friendly and went over to them and started having pictures taken of him and the students- they loved to have their picture taken and then see themselves on the small camera screen. He took down the address of the school in order to send the copies of the pictures to them after we get back.
Lake Mburo houses large varieties of bids, groups of hippos and several crocodiles. Unfortunately we only were able to see the adult crocodiles as their heads stuck out of the water, since they rarely went out on land. We did see several baby crocodiles on the bank, ranging from 6 inches to 2 feet in length. While we were out in the middle of the lake the rain started, cascading down in sheets of water. I felt bad for the people up front, since they took the brunt of it- sitting in the middle we were protected by people in front and back of us and the roof overhead. I wasn’t quite sure that the outboard motor would make it back to the dock- on the way back it sputtered in gasps and starts but luckily kept going until we made it to shore.
The rain continued overnight, drumming on the corrugated tin roof loudly enough to wake me up several times. The cottages themselves had no electricity or lighting; we were provided with lanterns to use if needed during the night. Combined with my headlamp and flashlight, it made for quite a cheery setting. When it gets dark out in the African savannah, it gets VERY dark…
I woke up one time at night at about 3:00 with the bed shaking and thumping; having been used to nightly visitations by hippos I assumed that one had decided to rub against the outside of the cottage vigorously. This wasn’t too concerning to me since the cottage was framed in concrete and it would have taken a bull elephant (I think) to do any damage. This happened one additional time, but in my sleep addled brain I didn’t think too much of it. The next morning John and Cameron asked me if I felt the earthquake, to which I sleepily replied “wha?” I guess in retrospect I shouldn’t expect a hippo to be able to shake the entire cottage, but there was apparently a small earthquake that night- not surprising since both the East and West Rift Valleys frame Uganda on either side. No harm, no foul. It was a very minor earthquake, and no damage was done. From talking with the staff at the lodge, they have one or two each year.
Friday, October 16, 2009
HIPAA and You
I went through the ward census the other day writing down information to present. I was anticipating doing case vignettes to give people a sense of what kind of patients I am seeing everyday. However, on reflection, I don’t think that it is fair to post peoples information up for grabs on the internet. I could change the age and sex of the patients, but I think that part of the learning and novelty of the cases here is that people are so young when they present. Also, since I am based on the female side of the ward, it would be a bit transparent to change the sex of the patient. I am starting to think of 65 as old aged. I have heard that the average life expectancy here is 45, which is not surprising given the infant mortality rate and the lack of elderly people that I have been seeing. Eddie, a British registrar volunteer, has a background in geriatrics and hopes to work on outlining an educational curriculum for the PGY’s about geriatrics, but I think he’ll have to adjust his usual age range down, since we have patients who present with end of life issues in their 50’s- 60’s. We still get our share of the 80 year little old ladies that keep falling, but much less frequently than in the states. Admissions for placement are unheard of, since there are no real other options than at home with family.
I have already seen two cases of Stevens Johnson Syndrome, a condition usually caused by medications that causes your skin to ulcerate and fall off; if severe enough, it progresses to Toxic Epidermal Necrolysis. NYY (or HIV+) patients are 40x more likely to get this syndrome. In the states, if they are severe enough or enough of the body is involved, these people would be sent to a burn ward. Even if they weren’t, you would take extreme caution to place them in a safe, sterile environment, since with so much skin loss, they are exceptionally prone to infection and dehydration. Unfortunately here we don’t have those resources; they are kept on the same wards with everyone else, with the septic pneumonia patients, malaria patients, and the lady with that nasty productive cough that makes you very concerned for tuberculosis and wish they would put more masks on people who come in hacking up blood.
Another common chief complaint is ‘body swelling.’ This could mean edema, weight gain, or anasarca depending on who is presenting. Underlying causes, as near as I have come to figuring out, can include heart failure, malnutrition, cirrhosis, or extreme kidney failure. The kidney failure patients are the hardest- we have several that are in their 20’s and are looking like end-stage renal disease, which is unfortunate in that there are no facilities for dialysis outside Kampala, and limited access there. One of the final year PGY’s, John, is interested in nephrology and hopes to expand their ability to care for patients that are end-stage, but it likely won’t come soon enough for the 20 something with diabetes that I am seeing with oliguria (decreased urination) and edema. It could still be schistosomiasis, a form of parasite, so hopefully we’ll actually be able to get some tests to try and figure it out. For body imaging we have an ultrasound available, unless they can pay for an ambulance over to Kampala 5 hours away and afford a CT scan. In the time I have been here I have only seen one CT scan done for a mediastinal mass. Unfortunately that patient could not afford to have a biopsy, so we still don’t know what kind of mass it is. An abdominal ultrasound is quite helpful when you are looking for abdominal lymph nodes, important here because extra-pulmonary tuberculosis is in the differential for most presenting complaints. It seems to be the favorite medical student differential diagnosis, since it can present as just about anything: anemia- could be TB, abdominal pain- could be TB, cough- could be TB, meningitis- could be TB…..Added to this that the diagnostic accuracy of the ZN stain or sputum samples is not great, and we end up treating many people for TB that never have had confirmation of infection, just a sufficiently concerning clinical picture.
Other complaints include palpitations- common since most people here are anemic to one degree or another and I have become blasé about seeing people with hemoglobins of 5 (less than about 13 is abnormal). The residents here are able to tell if people are anemic just by looking at their conjunctiva and comparing their palm color to the patient’s, which doesn’t work as well when you are Caucasian looking at an African’s skin tone… Of course, when the hemoglobin is less than 4 it is pretty clear to look at them and see that they are anemic. We still struggle to make sure patients actually have a blood count drawn before they are transfused, which I would estimate only occurs 70% of the time. Many times, I come in the next morning to see blood hanging and ask the intern what the hemoglobin was, only to be told that the family could not afford the diagnostic tests. In the states, whenever you see someone with iron deficiency anemia you usually make sure that they have had a colonoscopy to look for colonic malignancy- here you deworm them with mebendazole, since hookworm is so commonly the cause for iron deficiency anemia. Of course, we don’t confirm that a low MCV indicates iron deficiency, since we cannot send for iron or ferritin levels easily, but unless they have another clear clinical reason for it you assume that they may have hookworm infection.
Many people also present with fevers of one sort or another; evening fevers, daytime fevers or combinations of both. The differential changes slightly if they have recurrent fevers at one particular time of day. The correlation between fever curve and diagnosis is not exact, to be sure, but there are certain things in the history that make you more suspicious- evening fevers for malaria if the infection is established and the parasites release from the red blood cells in sync, evening fevers for lymphoma, multiple daily fevers for the endocarditis patients, and daily escalating fevers for typhoid (typically described as also having a pulse/ temperature disassociation, with high fevers but a relatively normal pulse). Of course, often we only have suspicion to go on, since many of the tests are not reliably sensitive or specific. Many people have low positive titers for brucellosis, 1+ smears for malaria and oocysts in their stool, but may not have active infections causing their current presentation. Added to the fact that many conformational tests are not available or not affordable for patients makes the practice of medicine here quite challenging.
I have already seen two cases of Stevens Johnson Syndrome, a condition usually caused by medications that causes your skin to ulcerate and fall off; if severe enough, it progresses to Toxic Epidermal Necrolysis. NYY (or HIV+) patients are 40x more likely to get this syndrome. In the states, if they are severe enough or enough of the body is involved, these people would be sent to a burn ward. Even if they weren’t, you would take extreme caution to place them in a safe, sterile environment, since with so much skin loss, they are exceptionally prone to infection and dehydration. Unfortunately here we don’t have those resources; they are kept on the same wards with everyone else, with the septic pneumonia patients, malaria patients, and the lady with that nasty productive cough that makes you very concerned for tuberculosis and wish they would put more masks on people who come in hacking up blood.
Another common chief complaint is ‘body swelling.’ This could mean edema, weight gain, or anasarca depending on who is presenting. Underlying causes, as near as I have come to figuring out, can include heart failure, malnutrition, cirrhosis, or extreme kidney failure. The kidney failure patients are the hardest- we have several that are in their 20’s and are looking like end-stage renal disease, which is unfortunate in that there are no facilities for dialysis outside Kampala, and limited access there. One of the final year PGY’s, John, is interested in nephrology and hopes to expand their ability to care for patients that are end-stage, but it likely won’t come soon enough for the 20 something with diabetes that I am seeing with oliguria (decreased urination) and edema. It could still be schistosomiasis, a form of parasite, so hopefully we’ll actually be able to get some tests to try and figure it out. For body imaging we have an ultrasound available, unless they can pay for an ambulance over to Kampala 5 hours away and afford a CT scan. In the time I have been here I have only seen one CT scan done for a mediastinal mass. Unfortunately that patient could not afford to have a biopsy, so we still don’t know what kind of mass it is. An abdominal ultrasound is quite helpful when you are looking for abdominal lymph nodes, important here because extra-pulmonary tuberculosis is in the differential for most presenting complaints. It seems to be the favorite medical student differential diagnosis, since it can present as just about anything: anemia- could be TB, abdominal pain- could be TB, cough- could be TB, meningitis- could be TB…..Added to this that the diagnostic accuracy of the ZN stain or sputum samples is not great, and we end up treating many people for TB that never have had confirmation of infection, just a sufficiently concerning clinical picture.
Other complaints include palpitations- common since most people here are anemic to one degree or another and I have become blasé about seeing people with hemoglobins of 5 (less than about 13 is abnormal). The residents here are able to tell if people are anemic just by looking at their conjunctiva and comparing their palm color to the patient’s, which doesn’t work as well when you are Caucasian looking at an African’s skin tone… Of course, when the hemoglobin is less than 4 it is pretty clear to look at them and see that they are anemic. We still struggle to make sure patients actually have a blood count drawn before they are transfused, which I would estimate only occurs 70% of the time. Many times, I come in the next morning to see blood hanging and ask the intern what the hemoglobin was, only to be told that the family could not afford the diagnostic tests. In the states, whenever you see someone with iron deficiency anemia you usually make sure that they have had a colonoscopy to look for colonic malignancy- here you deworm them with mebendazole, since hookworm is so commonly the cause for iron deficiency anemia. Of course, we don’t confirm that a low MCV indicates iron deficiency, since we cannot send for iron or ferritin levels easily, but unless they have another clear clinical reason for it you assume that they may have hookworm infection.
Many people also present with fevers of one sort or another; evening fevers, daytime fevers or combinations of both. The differential changes slightly if they have recurrent fevers at one particular time of day. The correlation between fever curve and diagnosis is not exact, to be sure, but there are certain things in the history that make you more suspicious- evening fevers for malaria if the infection is established and the parasites release from the red blood cells in sync, evening fevers for lymphoma, multiple daily fevers for the endocarditis patients, and daily escalating fevers for typhoid (typically described as also having a pulse/ temperature disassociation, with high fevers but a relatively normal pulse). Of course, often we only have suspicion to go on, since many of the tests are not reliably sensitive or specific. Many people have low positive titers for brucellosis, 1+ smears for malaria and oocysts in their stool, but may not have active infections causing their current presentation. Added to the fact that many conformational tests are not available or not affordable for patients makes the practice of medicine here quite challenging.
Thursday, October 15, 2009
Wasn't Aware that I Needed to Know Chinese
One of the things that I like about being here is that you get to use all of your skills. When working on the wards, you have to think creatively to try and figure out a way that you can come to the diagnosis with the limited resources and investigations that you have at hand. Computer skills apparently also come in handy.
The University at Mbarara is actively trying to increase the scope of its practice and its ability to care for patients, as evidenced by the efforts that they take to bring doctors from all over to come and help with teaching. As part of his rotation here the British cardiologist Angus is trying to set up an exercise treadmill machine that patients will be able to run on and determine if they have underlying heart disease. The machine measures their heart’s electrical activity while people are stressed by running on a treadmill. He was able to have a machine and computer shipped here from China for exclusive use by the cardiology department (one local physician with an interest in cardiology). Unfortunately, the treadmill arrived in a large packing crate with Chinese only instructions. From what Angus was saying, it was a little like putting something together from Ikea, but with the instructions in an entirely different language, it was a bit more challenging.
They were able to get the treadmill up and running, and got the computer set up to install the programs. Unfortunately, when the computer started up, all of the menus and dialog boxes were, you guessed it, written in Chinese. Angus asked me to have a look at it, hoping that I could change the menu options around. I was able to change the keyboard settings to type in English, I was able to change the currency and date formats for some programs to English, but apparently to change the menu and dialog boxes to English you need a special “multilingual user interface pack.” I searched on my netbook for ways to fix this, and it helpfully suggested in the help section contacting my nearest Microsoft office location….. Might not work when that could be on another continent.
The computer also needed an extra card installed to accept the serial connections from the EKG machine and the monitor. Having built my own computer at home, I figured this would be a simple task- open up the side, pop in the card, done. However, the Chinese apparently do not use phillips head screwdrivers to assemble their cases, they use torq heads. For those that don’t know, a torq head is a 6 headed star bit, similar to (once again) the hex wrenches used to put together furniture from Ikea. Since I only had a phillips head, I had to improvise a little, using one of my keys to wedge inside the screws and haltingly unfasten the case. 30 minutes later, I had the cover off and was able to pop in the card. Of course, I couldn’t find a driver for it, since all the options were in Chinese, so back to square one.
I was able to find a visiting IT professor from England who has a copy of windows xp, and this afternoon after rounds and teaching the goal is to wipe the computer completely and reinstall a copy of windows that we can actually read. One of the last things I expected to be doing while I was here was trying to fix a computer.
The University at Mbarara is actively trying to increase the scope of its practice and its ability to care for patients, as evidenced by the efforts that they take to bring doctors from all over to come and help with teaching. As part of his rotation here the British cardiologist Angus is trying to set up an exercise treadmill machine that patients will be able to run on and determine if they have underlying heart disease. The machine measures their heart’s electrical activity while people are stressed by running on a treadmill. He was able to have a machine and computer shipped here from China for exclusive use by the cardiology department (one local physician with an interest in cardiology). Unfortunately, the treadmill arrived in a large packing crate with Chinese only instructions. From what Angus was saying, it was a little like putting something together from Ikea, but with the instructions in an entirely different language, it was a bit more challenging.
They were able to get the treadmill up and running, and got the computer set up to install the programs. Unfortunately, when the computer started up, all of the menus and dialog boxes were, you guessed it, written in Chinese. Angus asked me to have a look at it, hoping that I could change the menu options around. I was able to change the keyboard settings to type in English, I was able to change the currency and date formats for some programs to English, but apparently to change the menu and dialog boxes to English you need a special “multilingual user interface pack.” I searched on my netbook for ways to fix this, and it helpfully suggested in the help section contacting my nearest Microsoft office location….. Might not work when that could be on another continent.
The computer also needed an extra card installed to accept the serial connections from the EKG machine and the monitor. Having built my own computer at home, I figured this would be a simple task- open up the side, pop in the card, done. However, the Chinese apparently do not use phillips head screwdrivers to assemble their cases, they use torq heads. For those that don’t know, a torq head is a 6 headed star bit, similar to (once again) the hex wrenches used to put together furniture from Ikea. Since I only had a phillips head, I had to improvise a little, using one of my keys to wedge inside the screws and haltingly unfasten the case. 30 minutes later, I had the cover off and was able to pop in the card. Of course, I couldn’t find a driver for it, since all the options were in Chinese, so back to square one.
I was able to find a visiting IT professor from England who has a copy of windows xp, and this afternoon after rounds and teaching the goal is to wipe the computer completely and reinstall a copy of windows that we can actually read. One of the last things I expected to be doing while I was here was trying to fix a computer.
Wednesday, October 14, 2009
Dying on Rounds
It’s frustrating to have a patient die while under your care and know that there was more you could do.
We had a 27 year old female come in the day before for hypertension with a history of chronic kidney disease. There was no known cause of either her hypertension or her chronic kidney disease, and no way of knowing if one led to the other based on the tests we had available. For whatever reason, even though she had been admitted there had been no baseline labs drawn (you can get a creatinine level, an indication of kidney function, for free) since admission. Unfortunately, since Monday night at 6:00 PM she stopped making urine, a bad sign that the kidneys are failing. Also unfortunately, despite an attempted trial of lasix, a medication used to make the kidneys produce more urine, she was still anuric (without urine output), and no one acted on this until this morning. When I arrived for early morning rounds yesterday, I went over to talk with the medical student caring for her and noticed that while her eyes were open, she was clearly not awake and not interactive, breathing in large gusts of air and occasionally twitching her arms and legs. Her facial muscles were also fasciculating, clenching and unclenching spasmodically. Her eyes were open and dry, occasionally rolling back into her head. She was not responding to me, even with the painful stimulation of pressing her fingernails. When listening to her heart I now clearly heard a pericardial rub, a sound of friction between the two layers of tissue surrounding the heart. These findings, in combination with her known kidney disease made concerned that her renal failure had worsened. Since there is no way to scan her bladder to see if she is indeed making any urine, we decided to place a catheter and drain her bladder. There was only a minimal amount of urine after we placed the catheter. She had no intravenous access, and when I checked her blood pressure it was in the 90’s systolic- very low. I called over the other residents on the team and we started working on her, attempting to place intravenous access and getting medications like insulin, dextrose and calcium drawn up. The calcium gluconate in the drug closet had expired in December 2007, so I wasn’t sure if it would do more harm than good by administering it. We had no access to an EKG machine to check to see whether her kidney failure had caused her potassium levels in her blood to build to dangerous levels, but her heart rate was quite slow at 50 beats per minute. Despite our efforts, her breathing and heartbeat swiftly ceased. The family and the attendants were by her side for the entire time, and were surprisingly accepting when we discussed with them how sick she was.
One of the things that I like about being a doctor is seeing when something is going wrong and knowing and being able to intervene. It’s frustrating to know that in the US we would have done things very differently, and she might have survived. Now, whether that survival is to a life of dialysis isn’t clear. Furthermore, long term hem dialysis is difficult in Uganda, and there are no options in Mbarara yet. I enjoy the role of being the one that knows what to do when patients are getting ill. I forget sometimes that my other role is to be there for and with the patient and family, even and especially if there isn’t much we can do medically. All too important here, where patients are all quite ill and it’s not always clear what illness they have.
We had a 27 year old female come in the day before for hypertension with a history of chronic kidney disease. There was no known cause of either her hypertension or her chronic kidney disease, and no way of knowing if one led to the other based on the tests we had available. For whatever reason, even though she had been admitted there had been no baseline labs drawn (you can get a creatinine level, an indication of kidney function, for free) since admission. Unfortunately, since Monday night at 6:00 PM she stopped making urine, a bad sign that the kidneys are failing. Also unfortunately, despite an attempted trial of lasix, a medication used to make the kidneys produce more urine, she was still anuric (without urine output), and no one acted on this until this morning. When I arrived for early morning rounds yesterday, I went over to talk with the medical student caring for her and noticed that while her eyes were open, she was clearly not awake and not interactive, breathing in large gusts of air and occasionally twitching her arms and legs. Her facial muscles were also fasciculating, clenching and unclenching spasmodically. Her eyes were open and dry, occasionally rolling back into her head. She was not responding to me, even with the painful stimulation of pressing her fingernails. When listening to her heart I now clearly heard a pericardial rub, a sound of friction between the two layers of tissue surrounding the heart. These findings, in combination with her known kidney disease made concerned that her renal failure had worsened. Since there is no way to scan her bladder to see if she is indeed making any urine, we decided to place a catheter and drain her bladder. There was only a minimal amount of urine after we placed the catheter. She had no intravenous access, and when I checked her blood pressure it was in the 90’s systolic- very low. I called over the other residents on the team and we started working on her, attempting to place intravenous access and getting medications like insulin, dextrose and calcium drawn up. The calcium gluconate in the drug closet had expired in December 2007, so I wasn’t sure if it would do more harm than good by administering it. We had no access to an EKG machine to check to see whether her kidney failure had caused her potassium levels in her blood to build to dangerous levels, but her heart rate was quite slow at 50 beats per minute. Despite our efforts, her breathing and heartbeat swiftly ceased. The family and the attendants were by her side for the entire time, and were surprisingly accepting when we discussed with them how sick she was.
One of the things that I like about being a doctor is seeing when something is going wrong and knowing and being able to intervene. It’s frustrating to know that in the US we would have done things very differently, and she might have survived. Now, whether that survival is to a life of dialysis isn’t clear. Furthermore, long term hem dialysis is difficult in Uganda, and there are no options in Mbarara yet. I enjoy the role of being the one that knows what to do when patients are getting ill. I forget sometimes that my other role is to be there for and with the patient and family, even and especially if there isn’t much we can do medically. All too important here, where patients are all quite ill and it’s not always clear what illness they have.
Tuesday, October 13, 2009
The Work of the Day
My day here in Uganda usually starts around 6, when I am woken up by the call to prayer from across the street. I usually lie in bed for 10-15 minutes bitterly cursing before I get up and try to write a journal entry, shower and make breakfast. I’m usually the first one up in the guest house, with the others not getting up until 7, so I try not to bang the pots and pans too loudly.
At 8, Angus and the medical students staying in the guest house leave for lecture- since Angus is only here for 2 weeks he has been doing most of the didactic lectures for the residents at 8 and 3. Usually Cameron and I around that time are looking up cases on the wards or preparing things for teaching. We head across the road at nine dressed in full slacks, button up shirt, tie and white coat in the full African sun, provided it’s not raining buckets, in which case we run.
Post-take rounds start around 9. There is a strong connection here at Mbarara with the Bristol medical school in England for some reason, with alternating rounds of specialists coming out frequently to teach and help on the wards. Also, Dr Wilson is British and is responsible for much of the program. Post-take rounds, which is a British term, are somewhat like our night float accept, except that we all go around in a group, usually the attending, me and the interns, and see all the patients admitted overnight. While one intern is presenting the case in front of the team and the patient, one of the others repeats the examination. After the presenting intern is finished, the examining intern steps up and either confirms or corrects portions of the physical exam. We discuss management and try to make a few teaching points about each case, then move on. The post-take number is variable, from 2 to 5.
After post-take rounds are ward rounds. We have all been divided into ‘firms,’ the equivalent of our ward teams. A firm consists of two PGY’s, an intern and 4-5 medical students. Each firm is responsible for one side of the ward, and the census is entirely made up of patients based on their location; either male or female side of the hospital, and either towards the road (road side) or river (river side). I am currently on the female river side firm.
Ward rounds usually last 1-2 hours, where we go from patient to patient depending on acuity. On Monday, Wednesday and Thursday we have an attending present, but on the other days it’s just the residents and students, which is quite different from the states in that there is no staffing on that day.
We have new medical students that started yesterday, third years. This means that this rotation is only their second clinical rotation, having done pediatrics as their first. Subsequently, they have a lot to learn. Their book knowledge is excellent- when asked about antimicrobial locations of action, they were able to pull out the ribosomal subunit that is acted upon by chloramphenicol without breaking a sweat. I was glad that they didn’t ask me the question, since I would not have remembered. They were also able to rattle off the 5 different organisms to which people without spleens are susceptible. However, their fund of clinical knowledge is, as you would expect, pretty poor. They were unable to take a blood pressure on one patient, and did not know the basic scheme for physical examination. I had been hoping to discuss various articles that I brought with me about heart failure, heart attacks and high blood pressure, but I think that the first week or two will be just focused on teaching basic physical examination skills and presentation skills. I had my first scheduled teaching session yesterday- I had only told the students on my firm about it, but when I got in the room there were 12-14 medical students piled around. It was a little daunting, and more than a little cumbersome, to walk them all around the wards to demonstrate the neurologic exam.
One of our first patients on posttake that morning was an 80ish year old woman (no one knows how old she really is, which is not uncommon) with progressive right sided weakness over the past 2 weeks and a syncopal event where she passed out. Her only real known medical history was hypertension, and when we saw her she was largely non-verbal, unable to adequately communicate, and entirely not moving her right side both on upper arms and lower legs. She was able to move her left side, but wasn’t able to reliably follow commands. Luckily we have Dr Wilson as a resource, since he was doing posttake rounds that morning. Dr Wilson worked for many years in London as the head of neurology and was quickly able to walk us through the Ugandan differential for her presentation. The current working diagnosis is a possible subdural hematoma versus space occupying lesion, both of which are largely not able to be confirmed because they would require a CT scan, not available here in Mbarara. There was talk about sending her to Kampala for consideration of a CT scan, but it isn’t clear that that the family could afford the scan itself even if we were able to transport her to Kampala. Furthermore, it’s not clear whether any treatment beyond that which we are doing could be offered- neurosurgery to drain a blood collection would not be available, and any treatment of a space occupying lesion such as a tumor would not be available. If she had an abscess, or focus of infection causing it we could treat with antibiotics, but she had no other clinical signs of infection. After discussing her case, the most that we could offer her was IV steroids in an effort to reduce any brain swelling she may be experiencing. Regardless of the reason for her illness, her prognosis is quite poor- there are limited to no nursing facilities or programs for physical rehabilitation here, and it is likely that despite her family’s attempted care she will progress to develop complications like bed sores or aspiration pneumonia. We will try to prevent this by talking with the family about her care, but we’ll see. The family or other attendants here are crucial, since they feed the patient, care for them and administer their medications many times- without attendants many patients do not do as well.
Back to the schedule of the day- after ward rounds, we usually head down to the canteen for lunch, a plate full of rice with a side of protein such as fish or chicken, a quarter of an avocado and g-nut sauce, something like a peanut sauce. This mounding plate of food, along with a coke, only runs about 5000 shillings, or $2.50. Usually we discuss the various cases we’ve been seeing in the morning on our different firms, or debate the relative merits of the British versus American medical education system, or medical systems in general (final result, neither are perfect). After lunch, I usually run into town to get errands done, which takes about 45 minutes. Then I come back to the guest house to prepare lecture materials for the students, and head over to the hospital to lecture at about 3 until 4:30. Walking over in the afternoon with slacks, button shirt, tie and white coat is quite a bit more uncomfortable than the morning, unless it has already rained and cooled things down.
Posttake rounds are at 5 PM, with the interns presenting the patients that they have admitted throughout the day. In the early evening, I head back to the guest house and get some reading done. Dinner is alternately eating out or having one of us in the guest house prepare something, taking turns so as not to get too bored with the selection. Then, it’s more reading and preparing at night until I turn in at 10 or so.
At 8, Angus and the medical students staying in the guest house leave for lecture- since Angus is only here for 2 weeks he has been doing most of the didactic lectures for the residents at 8 and 3. Usually Cameron and I around that time are looking up cases on the wards or preparing things for teaching. We head across the road at nine dressed in full slacks, button up shirt, tie and white coat in the full African sun, provided it’s not raining buckets, in which case we run.
Post-take rounds start around 9. There is a strong connection here at Mbarara with the Bristol medical school in England for some reason, with alternating rounds of specialists coming out frequently to teach and help on the wards. Also, Dr Wilson is British and is responsible for much of the program. Post-take rounds, which is a British term, are somewhat like our night float accept, except that we all go around in a group, usually the attending, me and the interns, and see all the patients admitted overnight. While one intern is presenting the case in front of the team and the patient, one of the others repeats the examination. After the presenting intern is finished, the examining intern steps up and either confirms or corrects portions of the physical exam. We discuss management and try to make a few teaching points about each case, then move on. The post-take number is variable, from 2 to 5.
After post-take rounds are ward rounds. We have all been divided into ‘firms,’ the equivalent of our ward teams. A firm consists of two PGY’s, an intern and 4-5 medical students. Each firm is responsible for one side of the ward, and the census is entirely made up of patients based on their location; either male or female side of the hospital, and either towards the road (road side) or river (river side). I am currently on the female river side firm.
Ward rounds usually last 1-2 hours, where we go from patient to patient depending on acuity. On Monday, Wednesday and Thursday we have an attending present, but on the other days it’s just the residents and students, which is quite different from the states in that there is no staffing on that day.
We have new medical students that started yesterday, third years. This means that this rotation is only their second clinical rotation, having done pediatrics as their first. Subsequently, they have a lot to learn. Their book knowledge is excellent- when asked about antimicrobial locations of action, they were able to pull out the ribosomal subunit that is acted upon by chloramphenicol without breaking a sweat. I was glad that they didn’t ask me the question, since I would not have remembered. They were also able to rattle off the 5 different organisms to which people without spleens are susceptible. However, their fund of clinical knowledge is, as you would expect, pretty poor. They were unable to take a blood pressure on one patient, and did not know the basic scheme for physical examination. I had been hoping to discuss various articles that I brought with me about heart failure, heart attacks and high blood pressure, but I think that the first week or two will be just focused on teaching basic physical examination skills and presentation skills. I had my first scheduled teaching session yesterday- I had only told the students on my firm about it, but when I got in the room there were 12-14 medical students piled around. It was a little daunting, and more than a little cumbersome, to walk them all around the wards to demonstrate the neurologic exam.
One of our first patients on posttake that morning was an 80ish year old woman (no one knows how old she really is, which is not uncommon) with progressive right sided weakness over the past 2 weeks and a syncopal event where she passed out. Her only real known medical history was hypertension, and when we saw her she was largely non-verbal, unable to adequately communicate, and entirely not moving her right side both on upper arms and lower legs. She was able to move her left side, but wasn’t able to reliably follow commands. Luckily we have Dr Wilson as a resource, since he was doing posttake rounds that morning. Dr Wilson worked for many years in London as the head of neurology and was quickly able to walk us through the Ugandan differential for her presentation. The current working diagnosis is a possible subdural hematoma versus space occupying lesion, both of which are largely not able to be confirmed because they would require a CT scan, not available here in Mbarara. There was talk about sending her to Kampala for consideration of a CT scan, but it isn’t clear that that the family could afford the scan itself even if we were able to transport her to Kampala. Furthermore, it’s not clear whether any treatment beyond that which we are doing could be offered- neurosurgery to drain a blood collection would not be available, and any treatment of a space occupying lesion such as a tumor would not be available. If she had an abscess, or focus of infection causing it we could treat with antibiotics, but she had no other clinical signs of infection. After discussing her case, the most that we could offer her was IV steroids in an effort to reduce any brain swelling she may be experiencing. Regardless of the reason for her illness, her prognosis is quite poor- there are limited to no nursing facilities or programs for physical rehabilitation here, and it is likely that despite her family’s attempted care she will progress to develop complications like bed sores or aspiration pneumonia. We will try to prevent this by talking with the family about her care, but we’ll see. The family or other attendants here are crucial, since they feed the patient, care for them and administer their medications many times- without attendants many patients do not do as well.
Back to the schedule of the day- after ward rounds, we usually head down to the canteen for lunch, a plate full of rice with a side of protein such as fish or chicken, a quarter of an avocado and g-nut sauce, something like a peanut sauce. This mounding plate of food, along with a coke, only runs about 5000 shillings, or $2.50. Usually we discuss the various cases we’ve been seeing in the morning on our different firms, or debate the relative merits of the British versus American medical education system, or medical systems in general (final result, neither are perfect). After lunch, I usually run into town to get errands done, which takes about 45 minutes. Then I come back to the guest house to prepare lecture materials for the students, and head over to the hospital to lecture at about 3 until 4:30. Walking over in the afternoon with slacks, button shirt, tie and white coat is quite a bit more uncomfortable than the morning, unless it has already rained and cooled things down.
Posttake rounds are at 5 PM, with the interns presenting the patients that they have admitted throughout the day. In the early evening, I head back to the guest house and get some reading done. Dinner is alternately eating out or having one of us in the guest house prepare something, taking turns so as not to get too bored with the selection. Then, it’s more reading and preparing at night until I turn in at 10 or so.
Monday, October 12, 2009
Held Hostage by Hippos
This weekend was the first time that we were able to get out of Mbarara to take a side trip, so we headed out to Queen Elizabeth National Park, a 1900 square kilometer park located in the western rift valley, sandwiched between the Rwenzori mountains and the eastern escarpment.
Instead of popping for the 300$/ night safari lodge (which was admittedly very nice, with a veranda extending out from the bar overlooking the park) we stayed at the hostel down the road, which was the best of both worlds. We could stay in the much cheaper (21$ per person with double rooms) location and still head down the road to the lodge if and when we wanted to sit and enjoy the view.
The hostel itself had a great cantina that served food as well for approx 5000 shillings (2.50$). Most of the rooms were set in a line parallel to the road, set back about 50 meters with a grassy sward between the rooms and the road. About 6 rooms were set in a line opening onto the yard, with bathrooms and showers in the middle. We had the end unit. It was a bit disturbing when we were putting our stuff in the room and heard all the scrabbling noises overhead, but as long as whatever it was stayed up there and out of the room, no problem. When we pulled up to the hostel, there was a resident family of warthogs wandering around the grounds, often going to wallow in the muddy ditch to the north side of the yard.
First day consisted of a game drive through the park, saw tons of waterbuck, birds, elephants, even a hippo out of water, which is unusual. As soon as we came in range of the elephants, the driver stopped the engine, since I guess they are more likely to charge if the engine is running, or maybe they just get disturbed and move away faster. Anyways, we were watching the elephants from the top of the van and another car comes careening down the road towards us (keep in mind it is a single track with ditches, mud and embankments to either side). Unable to pass, they parked themselves in front of us and started flashing their lights and trying to edge pass. They realized this was futile just as the elephant troop was crossing the road in front of us, and tried to reverse, almost into the troop! Our driver had to motion outside of the window urgently for them to stop the engine, but they didn’t listen. Luckily instead of angering the elephants into charging, it just caused them to move more quickly across the road. As soon as they were gone we, who were in a four wheel drive, pulled up and off to the side, allowing them to pass. I don’t think I would have the guts to take a little 2 wheel drive car onto a safari trek, since many of the roads are pretty bad after it rains, but oh well.
The next morning, I woke up as usual way too early. I heard a snuffling snorting sound behind the wall of the hostel room, with on occasional thumping against the wall. This had been going on for at least 30 minutes, and I had chalked it up to a warthog having an early morning meal. I went outside to head to the shower and peeked my head around the corner to see the warthog, only to find that it was actually a hippo, contentedly munching on the grass. I quickly ducked back around the corner and snuck past the other way to the shower. When I got done and headed back to the room, I could hear the snorting much more clearly, since his head was just around the corner from the room. I wasted no time in getting back into the room, and continued to hear the thumping of his tail slapping the side of the room. I will admit I did a stupid tourist thing and stuck my camera around the corner to try and get a picture (only got the red eye reflecting the flash). Angus, the other volunteer working here, brought up a very valid point later when he asked me if I thought that the wooden door of the hostel would actually stop an angry hippo. Probably not, but I was counting on it’s underdeveloped frontal lobe.
More game drives that day, with tons of antelope, several lions, a hyena, and many more water buck. Took a boat channel drive in the afternoon to see hippos in the water, crocodiles, water buffalo and tons of birds. Luckily Angus, the british cardiologist traveling with us, had a SLR camera and was able to take close up photos of many of the birds, much better than with my little canon digital. Definitely need to bring a better camera with a telescopic lens next time. After dinner at the cantina we headed down to the lodge for drinks on the balcony overlooking the valley, and were able to watch the lightning from a thunderstorm over the Rwenzori mountains to the northwest. Not a bad way to spend the evening.
Chimpanzee tracking the next morning down in the gorge. Luckily we happened upon them only about 15 minutes of walking around, and spent the next two hours circling through the brush trying to get ahead of the traveling troop. We were able to see quite a few in the trees, including the alpha male, but were unable to catch any on the ground.
Finally got back to Mbarara, hot and dusty, hoping for a nice shower. Unfortunately, we found out that the power had been out all weekend. The demand is high here in Uganda, and the supply is often lacking, since they only have (I think) two hydroelectric dams supplying the country. During certain periods, the power is deliberately shut off to one area to allow adequate power for another community, rotating around through the month. We did not know this, of course, and arrived to find that our icebox had completely melted and left a large puddle beneath the refrigerator. Luckily there was not really anything in there, so nothing was wasted except for an old avocado.
Hoofed it into town to restock, only to be caught out when the rain started. I am quite happy that I came during the rainy season; the savannah was green and lush and the temperature has been much more moderate than I expected. The rain, when it comes, only lasts for an hour or so and then stops. Overall, it has been great. However, it does rain profusely for that hour, and I was caught out in it without my rain jacket. Spent the time under an awning outside the bank getting to know a couple of local fellows that were also caught out. It was interesting to hear them talking about the US and Europe; many of them had no desire to travel to the US, but thought that it would be great to travel to Germany or France. I was also asked about the quality of steaks in Texas, since that is apparently what they are known for here. One of the guys worked for the power company and was able to explain the absence of power, which was nice.
By the time I got back to the guest house, the power was back on and we were able to whip up some rice and beans, followed by a much anticipated hot shower by me. I crashed into bed that night- we had been up late each evening and getting up extremely early to go on drives and travel to the chimpanzee gorge. I am looking forward to work today as a break.
Instead of popping for the 300$/ night safari lodge (which was admittedly very nice, with a veranda extending out from the bar overlooking the park) we stayed at the hostel down the road, which was the best of both worlds. We could stay in the much cheaper (21$ per person with double rooms) location and still head down the road to the lodge if and when we wanted to sit and enjoy the view.
The hostel itself had a great cantina that served food as well for approx 5000 shillings (2.50$). Most of the rooms were set in a line parallel to the road, set back about 50 meters with a grassy sward between the rooms and the road. About 6 rooms were set in a line opening onto the yard, with bathrooms and showers in the middle. We had the end unit. It was a bit disturbing when we were putting our stuff in the room and heard all the scrabbling noises overhead, but as long as whatever it was stayed up there and out of the room, no problem. When we pulled up to the hostel, there was a resident family of warthogs wandering around the grounds, often going to wallow in the muddy ditch to the north side of the yard.
First day consisted of a game drive through the park, saw tons of waterbuck, birds, elephants, even a hippo out of water, which is unusual. As soon as we came in range of the elephants, the driver stopped the engine, since I guess they are more likely to charge if the engine is running, or maybe they just get disturbed and move away faster. Anyways, we were watching the elephants from the top of the van and another car comes careening down the road towards us (keep in mind it is a single track with ditches, mud and embankments to either side). Unable to pass, they parked themselves in front of us and started flashing their lights and trying to edge pass. They realized this was futile just as the elephant troop was crossing the road in front of us, and tried to reverse, almost into the troop! Our driver had to motion outside of the window urgently for them to stop the engine, but they didn’t listen. Luckily instead of angering the elephants into charging, it just caused them to move more quickly across the road. As soon as they were gone we, who were in a four wheel drive, pulled up and off to the side, allowing them to pass. I don’t think I would have the guts to take a little 2 wheel drive car onto a safari trek, since many of the roads are pretty bad after it rains, but oh well.
The next morning, I woke up as usual way too early. I heard a snuffling snorting sound behind the wall of the hostel room, with on occasional thumping against the wall. This had been going on for at least 30 minutes, and I had chalked it up to a warthog having an early morning meal. I went outside to head to the shower and peeked my head around the corner to see the warthog, only to find that it was actually a hippo, contentedly munching on the grass. I quickly ducked back around the corner and snuck past the other way to the shower. When I got done and headed back to the room, I could hear the snorting much more clearly, since his head was just around the corner from the room. I wasted no time in getting back into the room, and continued to hear the thumping of his tail slapping the side of the room. I will admit I did a stupid tourist thing and stuck my camera around the corner to try and get a picture (only got the red eye reflecting the flash). Angus, the other volunteer working here, brought up a very valid point later when he asked me if I thought that the wooden door of the hostel would actually stop an angry hippo. Probably not, but I was counting on it’s underdeveloped frontal lobe.
More game drives that day, with tons of antelope, several lions, a hyena, and many more water buck. Took a boat channel drive in the afternoon to see hippos in the water, crocodiles, water buffalo and tons of birds. Luckily Angus, the british cardiologist traveling with us, had a SLR camera and was able to take close up photos of many of the birds, much better than with my little canon digital. Definitely need to bring a better camera with a telescopic lens next time. After dinner at the cantina we headed down to the lodge for drinks on the balcony overlooking the valley, and were able to watch the lightning from a thunderstorm over the Rwenzori mountains to the northwest. Not a bad way to spend the evening.
Chimpanzee tracking the next morning down in the gorge. Luckily we happened upon them only about 15 minutes of walking around, and spent the next two hours circling through the brush trying to get ahead of the traveling troop. We were able to see quite a few in the trees, including the alpha male, but were unable to catch any on the ground.
Finally got back to Mbarara, hot and dusty, hoping for a nice shower. Unfortunately, we found out that the power had been out all weekend. The demand is high here in Uganda, and the supply is often lacking, since they only have (I think) two hydroelectric dams supplying the country. During certain periods, the power is deliberately shut off to one area to allow adequate power for another community, rotating around through the month. We did not know this, of course, and arrived to find that our icebox had completely melted and left a large puddle beneath the refrigerator. Luckily there was not really anything in there, so nothing was wasted except for an old avocado.
Hoofed it into town to restock, only to be caught out when the rain started. I am quite happy that I came during the rainy season; the savannah was green and lush and the temperature has been much more moderate than I expected. The rain, when it comes, only lasts for an hour or so and then stops. Overall, it has been great. However, it does rain profusely for that hour, and I was caught out in it without my rain jacket. Spent the time under an awning outside the bank getting to know a couple of local fellows that were also caught out. It was interesting to hear them talking about the US and Europe; many of them had no desire to travel to the US, but thought that it would be great to travel to Germany or France. I was also asked about the quality of steaks in Texas, since that is apparently what they are known for here. One of the guys worked for the power company and was able to explain the absence of power, which was nice.
By the time I got back to the guest house, the power was back on and we were able to whip up some rice and beans, followed by a much anticipated hot shower by me. I crashed into bed that night- we had been up late each evening and getting up extremely early to go on drives and travel to the chimpanzee gorge. I am looking forward to work today as a break.
Friday, October 9, 2009
Waiting on the World Wide Web
I should be happy that there is even internet available at all, and to some extent I am. However, when you are used to broadband connection speeds, waiting on what I only assume is dial up is excruciating. From the time I loaded up Firefox in the library until the time I was able to log in and see my hotmail account: 30 minutes. I ended up playing solitaire while waiting….. There was also about a 3-5 minute wait after I clicked on an email before it came up. When you get 30-40 junk mails daily, it took a while. The university here has a well visited library, full of students at all hours. Looking around I see students reading from textbooks in laboratory science, computer programming, and pharmacy. I have seen several students working on presentations for natural resource conservation, so hopefully that is also an active area for study.
After two hours in the computer lab and getting frustrated enough to throw a brick through the computer screen, I headed up to sit on one of the buildings on campus. There is a wireless network that was located somewhere on campus. After several days of asking around, I was able to track down the administrator of the network in the computer science building who was very kind and gave me the network key. As long as I was within about 5 feet of the building, I was able to receive bandwidth at something approaching real-time. Unfortunately it only lasted for 5 minutes, but it was enough to upload some blog entries.
No ward rounds today- Ugandan independence day. Instead me and a group of volunteers and students are heading to Queen Elizabeth National Park to go on some game expeditions and a boat launch. Then, if there are still permits available, chimpanzee tracking on Sunday. I would like to go see the gorillas down south in Bwindi, since that is one of the things that Uganda is known for; the ability to hike in and observe at close range a troop of mountain gorillas. Permits are a hot commodity, since they often book out months in advance and the park administrators are very careful not to let too many people in or get to close to the gorillas. Unfortunately, it’s at least $500 USD, which is a little spendy for this trip. Maybe next time. Plus, there’s enough to see in the other parts of Southern Uganda that I could spend a year here and still not see everything.
Looking over my map of Uganda today, preparing the route for the weekend. I was a little shocked when I looked to the north of Uganda and saw a warning on the area surrounding lake Albert “Caution Roads in This Area May be Mined.” Years of rebellion and reprisals by and against the Lords Republican Army, or LRA has left northern Uganda a bit unsettled…. Luckily the park is nowhere near this area. Of course, there is a red label over the very southern part (to which we will not be going) of QENP stating “Travel Warning in this Region Due to Civil Unrest in Rwanda and Congo.” This map is also several years old, so who knows how accurate it is. According to locals, there hasn’t been any significant refugee influx since January, when apparently 30,000 refugees crossed the hippo infested river to reach Uganda from the Congo and Rwanda. No word on if any fell victim to wildlife.
After two hours in the computer lab and getting frustrated enough to throw a brick through the computer screen, I headed up to sit on one of the buildings on campus. There is a wireless network that was located somewhere on campus. After several days of asking around, I was able to track down the administrator of the network in the computer science building who was very kind and gave me the network key. As long as I was within about 5 feet of the building, I was able to receive bandwidth at something approaching real-time. Unfortunately it only lasted for 5 minutes, but it was enough to upload some blog entries.
No ward rounds today- Ugandan independence day. Instead me and a group of volunteers and students are heading to Queen Elizabeth National Park to go on some game expeditions and a boat launch. Then, if there are still permits available, chimpanzee tracking on Sunday. I would like to go see the gorillas down south in Bwindi, since that is one of the things that Uganda is known for; the ability to hike in and observe at close range a troop of mountain gorillas. Permits are a hot commodity, since they often book out months in advance and the park administrators are very careful not to let too many people in or get to close to the gorillas. Unfortunately, it’s at least $500 USD, which is a little spendy for this trip. Maybe next time. Plus, there’s enough to see in the other parts of Southern Uganda that I could spend a year here and still not see everything.
Looking over my map of Uganda today, preparing the route for the weekend. I was a little shocked when I looked to the north of Uganda and saw a warning on the area surrounding lake Albert “Caution Roads in This Area May be Mined.” Years of rebellion and reprisals by and against the Lords Republican Army, or LRA has left northern Uganda a bit unsettled…. Luckily the park is nowhere near this area. Of course, there is a red label over the very southern part (to which we will not be going) of QENP stating “Travel Warning in this Region Due to Civil Unrest in Rwanda and Congo.” This map is also several years old, so who knows how accurate it is. According to locals, there hasn’t been any significant refugee influx since January, when apparently 30,000 refugees crossed the hippo infested river to reach Uganda from the Congo and Rwanda. No word on if any fell victim to wildlife.
Thursday, October 8, 2009
Uganda Time
When I go out to eat, I get impatient if I have to wait more than 15-20 minutes for my food to arrive after ordering. Suffice it to say being here is teaching me whole new levels of patience. On the whole, Ugandan food is quite good and very inexpensive (10000 Ushs for 1 meal = $5.00), consisting of a small amount of protein, either fish, chicken or goat, combined with a large amount of starch, either rice or matoke. There are plenty of restaurants in Mbarara to try, including a great Indian restaurant downtown. After placing your order however, you get to wait……
An hour and a half later, at least in one instance, your food may arrive. This is of course assuming that they have what you ordered. If they do not, you may sit there for quite some time wondering hungrily when your food will come, when you finally reach the breaking point and flag down a waiter to ask, he tells you they did not have what you ordered. Apparently they don’t want to inconvenience you by telling you this; they would rather have you sit and enjoy your conversation, all the while your stomach is growing more and more angry.
This has been a great opportunity for socializing, but I have learned to eat a small snack prior to going out to eat. Dining out is a protracted affair, taking some time to walk into town while dodging boda bodas. The drivers have a limited sense of traffic safety laws, and a flagrant disregard for integrity of life or limb. Walking into town at night can be a harrowing experience. There are very few streetlights in Mbarara, and the ambient light of town is not sufficient to light your path, so it gets very dark at night. You often can’t see the bodas barreling down the road, since some of them do not ride with their lights on. Also, they may or may not have their motors on when coasting down a hill. And I have been told that some drivers are not exactly what I would call sober… All this means that you could be blithely walking down a hill into town only to have a silent but deadly boda careening down behind you, and you may not know until you hear the shrill beep of the horn, causing you to jump instinctively across the ditch at the side of the road to the shoulder of the road. Add to this potholes that are (I am not exaggerating) two feet in each dimension, which are also very difficult to see at night, and you have the makings of an interesting night.
At least I got the phone problem fixed…
An hour and a half later, at least in one instance, your food may arrive. This is of course assuming that they have what you ordered. If they do not, you may sit there for quite some time wondering hungrily when your food will come, when you finally reach the breaking point and flag down a waiter to ask, he tells you they did not have what you ordered. Apparently they don’t want to inconvenience you by telling you this; they would rather have you sit and enjoy your conversation, all the while your stomach is growing more and more angry.
This has been a great opportunity for socializing, but I have learned to eat a small snack prior to going out to eat. Dining out is a protracted affair, taking some time to walk into town while dodging boda bodas. The drivers have a limited sense of traffic safety laws, and a flagrant disregard for integrity of life or limb. Walking into town at night can be a harrowing experience. There are very few streetlights in Mbarara, and the ambient light of town is not sufficient to light your path, so it gets very dark at night. You often can’t see the bodas barreling down the road, since some of them do not ride with their lights on. Also, they may or may not have their motors on when coasting down a hill. And I have been told that some drivers are not exactly what I would call sober… All this means that you could be blithely walking down a hill into town only to have a silent but deadly boda careening down behind you, and you may not know until you hear the shrill beep of the horn, causing you to jump instinctively across the ditch at the side of the road to the shoulder of the road. Add to this potholes that are (I am not exaggerating) two feet in each dimension, which are also very difficult to see at night, and you have the makings of an interesting night.
At least I got the phone problem fixed…
Wednesday, October 7, 2009
A New Level of Illness
After a while in the US you get used to the variety of conditions that you see in the hospital. Many people present with typical symptom sets, such as a gastrointestinal bleed, pneumonia or septic shock. Of course most of the time it is not quite so simple, but you have a variety of tests and procedures that you can do to try and figure out what is going on. Not so in Mbarara.
People present very sick. I can think of one man in particular, lying on the floor on a foam pad since there were no beds available. The medical ward consists of two separate wings, male and female, separated by a triage area, something like an emergency room where patients are stabilized and the initial history, physical and examination are performed. Each wing has approximately 18 beds, lined 9 to a side along a long corridor. I first saw this patient during post-take rounds in the morning, where the interns present the patients that have arrived overnight. Immediately after looking at him, my first thought was ‘this man is going to die.’ He was, as the interns put it here ‘wasted.’ This is a slight understatement for the cachectic man that was lying on the floor without the strength to move over on his side. He presented with several months of nausea and vomiting, subsequently unable to take food or any of his medications. He was NYY which here is code for HIV positive (y/n). They do not use the actual term HIV or AIDS since there is a stigma attached to it. In an open ward where patients are required to disrobe in front of the entire ward for the doctors to examine them, in full view of other patients and attendants, it seems like a small item of privacy to try and protect. Since he had been unable to eat for the past several months, combined with his HIV that was ravaging his body, he had severe temporal wasting, a condition where the muscles and fat at the side of your skull atrophy, which brings the zygomatic arch into sharp relief, giving the patient a cadaverous look. He also had an abdomen that was caved in, showing his ribs in sharp detail. Coming from a place where obesity is endemic, and most patients that you see have a comfortable amount of padding around their midsection, it is a very sharp distinction.
People present in late stages of their illness, or with severe ramifications of their disease. Most of the people are quite poor even by Ugandan standards, unable to afford medications or many lab tests. Diagnosis in the United States usually involves running a battery of tests to try and determine the source of infection, how the various organs are functioning, or looking for evidence of infection or anemia. The tests they have here, by necessity, are extremely limited. All tests require the patient or their family to pay out of pocket, meaning that while you may suggest one day that the patient has a chest xray or a complete blood count, you may very well come back the next and see that this has not been done. You can get a chest xray if the patient is well enough to be taken into town. Complete blood counts are also available, as are thin and thick smears where the blood is spread out on a slide, important given the prevalence of malaria. HIV tests and CD4 counts are also readily available; important since such a large percentage of the population seen is NYY. Coming from a location where the first thing you do after seeing a patient is shoot off a variety of tests it is a dramatic change.
Patients will often present with characteristic symptom sets, either weakness, fevers or abdominal pain. Given that tuberculosis, HIV and a wide variety of tropical diseases are so rampant, there is a whole different differential diagnosis than that present in the United States, and your hands are often tied in that the tests that you would need to confirm the diagnosis are either not available or too expensive for the patients. I have to give credit to the doctors working in the hospital, though- while there are fewer lab tests available, the ones that are available are certainly high yield, and they have gone through great efforts to make available the necessary tests to evaluate the conditions that they see commonly. When so many patients present with malaria or HIV, it is a little more important to be able to check their HIV status and white blood cell (CD4) count than it is to look for celiac disease. The doctors here, both the interns and the post graduates (PGY’s, or what we would call residents) are very knowledgeable about the things that they see, many conditions I have only read about in textbooks, such as brucellosis or an actual case of tetanus. The first few days have been a learning experience…
People present very sick. I can think of one man in particular, lying on the floor on a foam pad since there were no beds available. The medical ward consists of two separate wings, male and female, separated by a triage area, something like an emergency room where patients are stabilized and the initial history, physical and examination are performed. Each wing has approximately 18 beds, lined 9 to a side along a long corridor. I first saw this patient during post-take rounds in the morning, where the interns present the patients that have arrived overnight. Immediately after looking at him, my first thought was ‘this man is going to die.’ He was, as the interns put it here ‘wasted.’ This is a slight understatement for the cachectic man that was lying on the floor without the strength to move over on his side. He presented with several months of nausea and vomiting, subsequently unable to take food or any of his medications. He was NYY which here is code for HIV positive (y/n). They do not use the actual term HIV or AIDS since there is a stigma attached to it. In an open ward where patients are required to disrobe in front of the entire ward for the doctors to examine them, in full view of other patients and attendants, it seems like a small item of privacy to try and protect. Since he had been unable to eat for the past several months, combined with his HIV that was ravaging his body, he had severe temporal wasting, a condition where the muscles and fat at the side of your skull atrophy, which brings the zygomatic arch into sharp relief, giving the patient a cadaverous look. He also had an abdomen that was caved in, showing his ribs in sharp detail. Coming from a place where obesity is endemic, and most patients that you see have a comfortable amount of padding around their midsection, it is a very sharp distinction.
People present in late stages of their illness, or with severe ramifications of their disease. Most of the people are quite poor even by Ugandan standards, unable to afford medications or many lab tests. Diagnosis in the United States usually involves running a battery of tests to try and determine the source of infection, how the various organs are functioning, or looking for evidence of infection or anemia. The tests they have here, by necessity, are extremely limited. All tests require the patient or their family to pay out of pocket, meaning that while you may suggest one day that the patient has a chest xray or a complete blood count, you may very well come back the next and see that this has not been done. You can get a chest xray if the patient is well enough to be taken into town. Complete blood counts are also available, as are thin and thick smears where the blood is spread out on a slide, important given the prevalence of malaria. HIV tests and CD4 counts are also readily available; important since such a large percentage of the population seen is NYY. Coming from a location where the first thing you do after seeing a patient is shoot off a variety of tests it is a dramatic change.
Patients will often present with characteristic symptom sets, either weakness, fevers or abdominal pain. Given that tuberculosis, HIV and a wide variety of tropical diseases are so rampant, there is a whole different differential diagnosis than that present in the United States, and your hands are often tied in that the tests that you would need to confirm the diagnosis are either not available or too expensive for the patients. I have to give credit to the doctors working in the hospital, though- while there are fewer lab tests available, the ones that are available are certainly high yield, and they have gone through great efforts to make available the necessary tests to evaluate the conditions that they see commonly. When so many patients present with malaria or HIV, it is a little more important to be able to check their HIV status and white blood cell (CD4) count than it is to look for celiac disease. The doctors here, both the interns and the post graduates (PGY’s, or what we would call residents) are very knowledgeable about the things that they see, many conditions I have only read about in textbooks, such as brucellosis or an actual case of tetanus. The first few days have been a learning experience…
Tuesday, October 6, 2009
Calls in Mbarara
Woke up this morning to two things that were particularly effective as an alarm clock. The first was the broadcast call to prayer from several mosques in town. Promptly at 6:00 AM, they turn on their speakers and blast out the call. It’s really not that bad; quite musical really. Just not something I would usually choose to have waking me up.
The guest house where I am staying has it’s back to the main road in town, High Street. In an effort to reduce speeding, several groups of 3 or 4 speed bumps are located interspersed along the road in multiple areas. I don’t know what kind of trucks they use in Uganda to transport goods, but they sound enormous when its an empty truck rattling over speed bumps at 6:00 in the morning. This must happen all night, but I’m usually so tired that I don’t notice.
I’ve still been waking up at 5 or 6, which is extremely unusual for me since I am a night owl. I think I am adjusted to the time difference, since I am now going to bed around 9 or 10 and waking up early. Still not used to either thinking about the time difference or considering it- I find myself wanting to call people only to find out it’s 4 in the morning there.
Olga, the resident who last did a rotation here, was nice enough to let me borrow her cell phone that she purchased while she was here. They come pretty cheaply, and you can use a pay-as-you-go program that allows you to “top up” your minutes. Shops for this are everywhere, including wooden crates set up on the side of the road with minute prices listed. The phone has worked great for calling within Uganda, I am able to talk with other volunteers and hotels in and around the country. Unfortunately, for whatever reason, I was unable to talk to people in the states. I was able to connect and hear them just fine, but they could not hear me. For two days I tried to figure this out by calling several people I knew, only to hear “hello, hello” for a while and have them hang up. I promise everyone, I was not trying to be rude, I was replying on the other end!
First shift at the hospital today. Thankfully it’s located behind right behind the guest house across High street. Campus here is as confusing as any campus in the states; I had to ask several people for assistance with directions. Luckily, the people here are insanely nice and courteous, and one gentleman led me right to the library. It does feel odd to be the only muzungo (white person) when I am walking around. You feel everyone turn to look and stare at you, even if it is only for a minute. There is nothing hostile in the stares, I just think that actually seeing a white person is an unusual enough event to warrant observation.
Went to the open-air market today. I wish I could take all the vegetables here home with me; there is no pineapple that I have ever tasted that tastes like the ones here! The open air-market is a square filled with rows of wooden displays, covered with corrugated roofs. Piled high on each of the displays is an enormous selection of fresh vegetables, pineapple, avocados larger than my two hands together, ginger, tomatoes, peppers, beans, watermelon, and of course, several varieties of bananas, along with many other vegetables and fruits. Everyone seems to have much the same produce, which helps when you are trying to bargain. It’s funny- I would walk up to someone and ask the price for produce, and I could see them doing a quick calculation in their head after they saw I was a muzungo. This would be followed by the price of the item, say a pineapple, delivered with a small smile; “for you, 2000 shillings.” Of course, I have been told that the real price is around 1000 shillings. The difference is actually pretty small- 1$ American versus 50 cents, which is not a significant amount when you consider that this is the money these people subsist on. Nevertheless, I felt compelled to at least let them know that I was aware of the actual price of things, and wanted to be treated as fairly as everyone else. I have found that after walking around and comparing prices, along with comparing notes with the other western volunteers, I can figure out what the price should be and bargain accordingly. Yesterday was the first time that was successful- I would reply (politely) “how about 1000,” to which he or she would counter, etc. Ended up getting these enormous avacados for 300 shillings each, which is a ridiculously low price. I wish that I had someplace like this within walking distance back in the states; makes for an interesting afternoon.
While exploring the alleys of Mbarara I also stumbled on the apparent garment district. I have been wondering where everyone gets their clothes. To a westerner, the people in Uganda are always impeccably well dressed, with tailored shirts and trousers when they are not wearing a suit. The women are dressed either in business dress or in traditional dresses. No one is seen outside in anything less than the best. I felt like a genuine schlub for walking around in shorts. There is only one person I saw who was not clean and tailored, and that was a construction worker working on a shop. I have been wondering, though, where they get their clothes, since I had not seen any garment shops. I turned down an alley from High Street, trying to cut over to the market, and was suddenly in a collection of alley surrounded on all sides with clothing shops, complete with people sitting outside pressing and cutting cloth for clothes. I think they were quite surprised to see a muzungo strolling through there.
I’ll write more on the hospital and patients here shortly- I’m still processing an entirely new and shocking experience.
The guest house where I am staying has it’s back to the main road in town, High Street. In an effort to reduce speeding, several groups of 3 or 4 speed bumps are located interspersed along the road in multiple areas. I don’t know what kind of trucks they use in Uganda to transport goods, but they sound enormous when its an empty truck rattling over speed bumps at 6:00 in the morning. This must happen all night, but I’m usually so tired that I don’t notice.
I’ve still been waking up at 5 or 6, which is extremely unusual for me since I am a night owl. I think I am adjusted to the time difference, since I am now going to bed around 9 or 10 and waking up early. Still not used to either thinking about the time difference or considering it- I find myself wanting to call people only to find out it’s 4 in the morning there.
Olga, the resident who last did a rotation here, was nice enough to let me borrow her cell phone that she purchased while she was here. They come pretty cheaply, and you can use a pay-as-you-go program that allows you to “top up” your minutes. Shops for this are everywhere, including wooden crates set up on the side of the road with minute prices listed. The phone has worked great for calling within Uganda, I am able to talk with other volunteers and hotels in and around the country. Unfortunately, for whatever reason, I was unable to talk to people in the states. I was able to connect and hear them just fine, but they could not hear me. For two days I tried to figure this out by calling several people I knew, only to hear “hello, hello” for a while and have them hang up. I promise everyone, I was not trying to be rude, I was replying on the other end!
First shift at the hospital today. Thankfully it’s located behind right behind the guest house across High street. Campus here is as confusing as any campus in the states; I had to ask several people for assistance with directions. Luckily, the people here are insanely nice and courteous, and one gentleman led me right to the library. It does feel odd to be the only muzungo (white person) when I am walking around. You feel everyone turn to look and stare at you, even if it is only for a minute. There is nothing hostile in the stares, I just think that actually seeing a white person is an unusual enough event to warrant observation.
Went to the open-air market today. I wish I could take all the vegetables here home with me; there is no pineapple that I have ever tasted that tastes like the ones here! The open air-market is a square filled with rows of wooden displays, covered with corrugated roofs. Piled high on each of the displays is an enormous selection of fresh vegetables, pineapple, avocados larger than my two hands together, ginger, tomatoes, peppers, beans, watermelon, and of course, several varieties of bananas, along with many other vegetables and fruits. Everyone seems to have much the same produce, which helps when you are trying to bargain. It’s funny- I would walk up to someone and ask the price for produce, and I could see them doing a quick calculation in their head after they saw I was a muzungo. This would be followed by the price of the item, say a pineapple, delivered with a small smile; “for you, 2000 shillings.” Of course, I have been told that the real price is around 1000 shillings. The difference is actually pretty small- 1$ American versus 50 cents, which is not a significant amount when you consider that this is the money these people subsist on. Nevertheless, I felt compelled to at least let them know that I was aware of the actual price of things, and wanted to be treated as fairly as everyone else. I have found that after walking around and comparing prices, along with comparing notes with the other western volunteers, I can figure out what the price should be and bargain accordingly. Yesterday was the first time that was successful- I would reply (politely) “how about 1000,” to which he or she would counter, etc. Ended up getting these enormous avacados for 300 shillings each, which is a ridiculously low price. I wish that I had someplace like this within walking distance back in the states; makes for an interesting afternoon.
While exploring the alleys of Mbarara I also stumbled on the apparent garment district. I have been wondering where everyone gets their clothes. To a westerner, the people in Uganda are always impeccably well dressed, with tailored shirts and trousers when they are not wearing a suit. The women are dressed either in business dress or in traditional dresses. No one is seen outside in anything less than the best. I felt like a genuine schlub for walking around in shorts. There is only one person I saw who was not clean and tailored, and that was a construction worker working on a shop. I have been wondering, though, where they get their clothes, since I had not seen any garment shops. I turned down an alley from High Street, trying to cut over to the market, and was suddenly in a collection of alley surrounded on all sides with clothing shops, complete with people sitting outside pressing and cutting cloth for clothes. I think they were quite surprised to see a muzungo strolling through there.
I’ll write more on the hospital and patients here shortly- I’m still processing an entirely new and shocking experience.
Monday, October 5, 2009
Kampala and the Road to Mbarara
10/5/09
Definitely some things I’ve never seen before….
Started out yesterday morning at the BOMA, a hotel in Entebbe. On the grounds itself there must have been 20 different species of birds that I had never seen. Driver came during breakfast of course (not his fault, we knew he would be arriving from 8:30-9ish. Luggage stowed in the back of his truck (with passenger seat attached), while I got to spend the next 5 hours in the back seat with my knees up to my chest. Better than many of the mutatus (minibuses) that I have seen, but not the most comfortable ride.
Driving through Entebbe and Kampala was an experience. Mobile is a big thing here in Uganda, as evidenced by the repeating iteration of buildings painted as billboards. The building is still used, although by building I mean a 9 x 5 brick structure horizontally oriented to the road with two metal doors on the front and a corrugated roof. The buildings themselves are often painted a characteristic color, with ads above the front doors or along the sides of the buildings. Alternating between a bright pink for Zain, white/red for Wydin, yellow for MTN; by the time I got to Mbarara I felt like I had been through South Dakota’s Wall Drug alley. It took until Mbarara for me to figure out what they company of Zain actually did; they had signs everywhere, including billboards and mileposts that proudly displayed their corporate logo, but I had no idea what they actually sold. I guess Nike might seem the same to an outsider, since many of their ads aren’t very particular about what the company actually sells.
The sides of the roads were packed with people. I never realized how much life in the US is spent indoors, or how little we actually see people. Most of us carry out our lives in a building, either with work, living or entertainment. Does not seem to be the case in Uganda. I saw more people out and about on that drive than I have ever seen in Portland. People were standing in masses at the sides of roads, either working on broken down mutatus, sitting on their boda-bodas (motorcycles), or sitting on the stoop of their buildings. It seemed like quite a few people were just sitting staring off into the middle distance. I don’t mean this as any discredit to the Ugandan people; they appear very industrious, but I have been told that for young people, finding jobs is a real problem. Many of the young men on bodas were grouped in clusters, of course.
Driving in Uganda is an active experience. Kampala has traffic the way it should be, as long as you don’t worry about pesky things like speed limits, traffic lanes or safety. Add to it that the city is inundated with mutatus, white minibuses with a horizontal white and blue checkered band along the middle parallel to the ground. I never understood how the buses knew when and were to stop, but they appeared to swerve both into and out of traffic in random intervals. Their were alternately 2 to 5 lanes of traffic. Bodas and bicycles commonly got swept to the sides, with a driver imperiously pounding on his horn to say “if you don’t move, you will be run over.” Broken down bodas and crashed mutatus on the side of the road attest to this mad max philosophy. From time to time from the road I could see down the dirt roads further into town. I caught glimpses of what I would only call a slum, with pucked and cratered dirt roads with a central ravine and flanking wooden shacks.
After a while I felt that I should put together Kampala bingo, since there were so many things that came up again and again:Shop selling bed frames, with the bed frames prominently displayed on the ground between the shop and the road
Shop selling chairs, once again with merchandise wedged in the 6 feet of space between the stoop of the building and the every shifting lanes of traffic on the road
Broken down mutatu
Shop selling metal doors
Shop selling metal window grates
Man urinating on side of the road
Three (or more) people stacked on a boda, women riding sidesaddle
The following would only count in multiples
Mutatus (could make the number as high as you like and it would still fill in minutes.
5 (or more) young men on bodas in a group sitting and staring
Bundles of motoke (a type of banana)
People carrying a yellow plastic canister- in appearance, much like a jerry-can for gasoline, but they are all a stereotypical yellow color. I saw women, men and children carrying up to three of these; not sure what they were carrying whether it was water, oil or gasoline. If they had a bicycle, it could be loaded up with many more, with the bike itself mainly used to transport goods, and only rarely ridden.
Our driver took a ‘short cut’ to avoid the traffic in Kampala itself. Not sure if it worked; we definitely did not get stuck in traffic, but were barreling down dirt roads, up hills and down around corners at a concerning pace given how close people were to the road.
On the way we got to talk with our driver, Daniel, about his family and life in Uganda. We asked him why Mbarara had been growing so much, since it is one of the fastest growing cities in Uganda. He replied that many of the people of Mbarara, culturally distinct and separate from those people in the capitol, used to come to Kampala to do manual labor, digging, planting and building. According to him, a while ago they got it into their heads that maybe they should work for themselves, and started building up their own city, working and expanding their existing subsistence farms and supplementing with crops such as tea and coffee.
Finally got to the road outside of Kampala, only 200+ km to go to Mbarara.
I drove the Alcan, I winded my way up logging roads in the mountains of Montana looking for old mine tailings, I’ve driven my car through the tidal pools of denali flats with the water coming up through the floorboards; but I have never been on any road like that from Kampala to Mbarara. They are doing quite a bit of construction, and on the refinished parts our driver was able to punch it up to 120km/hr. Unfortunately, the maximum length of these repaved sections appeared to be one mile long, since he would then have to rapidly decelerate in order to clamber down from the sections of paved road. Add to this craters waiting to swallow your car- I could call them potholes, but that would be a discredit to potholes everywhere. There are potholes, and then there are holes in the road that if you hit them you will lose a bumper, muffler or perhaps your engine block. There were many of these, and at times it felt like we were riding speed racers on Endor (I know, geeky star wars reference, but whatever) or slaloming back and forth between potholes, all the while alternating gunning the engine to 120km/hr or slowing down to a snail’s pace.This went on for more than four hours….
Our driver was wonderful, and navigated this obstacle course without scaring the four mzungus (white people- but I’m not sure how it’s spelled) wedged inside the truck cab. He didn’t pass around blind corners and respectfully honked his horn when passing people to let them know he was going around. Of course, there are no single or double lines to tell you if and when it is ‘safe’ to pass. Not really necessary, since you can pass someone on the right with traffic barreling down to you from the other direction and they will scream by you on the right. It does not make for a comfortable trip when you’re passing a car and can see a huge cargo truck just down the road heading towards you.
As we got further out from Kampala I liked the countryside more and more. The shacks on the side of the road got more well maintained, the broken down lots full of plastic bags and trash were replaced with banana fields, and there appeared to be many more people industriously working on something, whether it was in the fields, working on a drum or basket, or selling motoke or other vegetables on a plank by the side of the road. There doesn’t seem to be a lot of native forest left in this part of Uganda; mostly rolling hills with field after field of banana trees.
Finally after an interminable trek we arrived in Mbarara and were settled into the guest house at the university, thankfully there were enough rooms available that we could stay right near the hospital instead of having to walk in from the hotel.
Definitely some things I’ve never seen before….
Started out yesterday morning at the BOMA, a hotel in Entebbe. On the grounds itself there must have been 20 different species of birds that I had never seen. Driver came during breakfast of course (not his fault, we knew he would be arriving from 8:30-9ish. Luggage stowed in the back of his truck (with passenger seat attached), while I got to spend the next 5 hours in the back seat with my knees up to my chest. Better than many of the mutatus (minibuses) that I have seen, but not the most comfortable ride.
Driving through Entebbe and Kampala was an experience. Mobile is a big thing here in Uganda, as evidenced by the repeating iteration of buildings painted as billboards. The building is still used, although by building I mean a 9 x 5 brick structure horizontally oriented to the road with two metal doors on the front and a corrugated roof. The buildings themselves are often painted a characteristic color, with ads above the front doors or along the sides of the buildings. Alternating between a bright pink for Zain, white/red for Wydin, yellow for MTN; by the time I got to Mbarara I felt like I had been through South Dakota’s Wall Drug alley. It took until Mbarara for me to figure out what they company of Zain actually did; they had signs everywhere, including billboards and mileposts that proudly displayed their corporate logo, but I had no idea what they actually sold. I guess Nike might seem the same to an outsider, since many of their ads aren’t very particular about what the company actually sells.
The sides of the roads were packed with people. I never realized how much life in the US is spent indoors, or how little we actually see people. Most of us carry out our lives in a building, either with work, living or entertainment. Does not seem to be the case in Uganda. I saw more people out and about on that drive than I have ever seen in Portland. People were standing in masses at the sides of roads, either working on broken down mutatus, sitting on their boda-bodas (motorcycles), or sitting on the stoop of their buildings. It seemed like quite a few people were just sitting staring off into the middle distance. I don’t mean this as any discredit to the Ugandan people; they appear very industrious, but I have been told that for young people, finding jobs is a real problem. Many of the young men on bodas were grouped in clusters, of course.
Driving in Uganda is an active experience. Kampala has traffic the way it should be, as long as you don’t worry about pesky things like speed limits, traffic lanes or safety. Add to it that the city is inundated with mutatus, white minibuses with a horizontal white and blue checkered band along the middle parallel to the ground. I never understood how the buses knew when and were to stop, but they appeared to swerve both into and out of traffic in random intervals. Their were alternately 2 to 5 lanes of traffic. Bodas and bicycles commonly got swept to the sides, with a driver imperiously pounding on his horn to say “if you don’t move, you will be run over.” Broken down bodas and crashed mutatus on the side of the road attest to this mad max philosophy. From time to time from the road I could see down the dirt roads further into town. I caught glimpses of what I would only call a slum, with pucked and cratered dirt roads with a central ravine and flanking wooden shacks.
After a while I felt that I should put together Kampala bingo, since there were so many things that came up again and again:Shop selling bed frames, with the bed frames prominently displayed on the ground between the shop and the road
Shop selling chairs, once again with merchandise wedged in the 6 feet of space between the stoop of the building and the every shifting lanes of traffic on the road
Broken down mutatu
Shop selling metal doors
Shop selling metal window grates
Man urinating on side of the road
Three (or more) people stacked on a boda, women riding sidesaddle
The following would only count in multiples
Mutatus (could make the number as high as you like and it would still fill in minutes.
5 (or more) young men on bodas in a group sitting and staring
Bundles of motoke (a type of banana)
People carrying a yellow plastic canister- in appearance, much like a jerry-can for gasoline, but they are all a stereotypical yellow color. I saw women, men and children carrying up to three of these; not sure what they were carrying whether it was water, oil or gasoline. If they had a bicycle, it could be loaded up with many more, with the bike itself mainly used to transport goods, and only rarely ridden.
Our driver took a ‘short cut’ to avoid the traffic in Kampala itself. Not sure if it worked; we definitely did not get stuck in traffic, but were barreling down dirt roads, up hills and down around corners at a concerning pace given how close people were to the road.
On the way we got to talk with our driver, Daniel, about his family and life in Uganda. We asked him why Mbarara had been growing so much, since it is one of the fastest growing cities in Uganda. He replied that many of the people of Mbarara, culturally distinct and separate from those people in the capitol, used to come to Kampala to do manual labor, digging, planting and building. According to him, a while ago they got it into their heads that maybe they should work for themselves, and started building up their own city, working and expanding their existing subsistence farms and supplementing with crops such as tea and coffee.
Finally got to the road outside of Kampala, only 200+ km to go to Mbarara.
I drove the Alcan, I winded my way up logging roads in the mountains of Montana looking for old mine tailings, I’ve driven my car through the tidal pools of denali flats with the water coming up through the floorboards; but I have never been on any road like that from Kampala to Mbarara. They are doing quite a bit of construction, and on the refinished parts our driver was able to punch it up to 120km/hr. Unfortunately, the maximum length of these repaved sections appeared to be one mile long, since he would then have to rapidly decelerate in order to clamber down from the sections of paved road. Add to this craters waiting to swallow your car- I could call them potholes, but that would be a discredit to potholes everywhere. There are potholes, and then there are holes in the road that if you hit them you will lose a bumper, muffler or perhaps your engine block. There were many of these, and at times it felt like we were riding speed racers on Endor (I know, geeky star wars reference, but whatever) or slaloming back and forth between potholes, all the while alternating gunning the engine to 120km/hr or slowing down to a snail’s pace.This went on for more than four hours….
Our driver was wonderful, and navigated this obstacle course without scaring the four mzungus (white people- but I’m not sure how it’s spelled) wedged inside the truck cab. He didn’t pass around blind corners and respectfully honked his horn when passing people to let them know he was going around. Of course, there are no single or double lines to tell you if and when it is ‘safe’ to pass. Not really necessary, since you can pass someone on the right with traffic barreling down to you from the other direction and they will scream by you on the right. It does not make for a comfortable trip when you’re passing a car and can see a huge cargo truck just down the road heading towards you.
As we got further out from Kampala I liked the countryside more and more. The shacks on the side of the road got more well maintained, the broken down lots full of plastic bags and trash were replaced with banana fields, and there appeared to be many more people industriously working on something, whether it was in the fields, working on a drum or basket, or selling motoke or other vegetables on a plank by the side of the road. There doesn’t seem to be a lot of native forest left in this part of Uganda; mostly rolling hills with field after field of banana trees.
Finally after an interminable trek we arrived in Mbarara and were settled into the guest house at the university, thankfully there were enough rooms available that we could stay right near the hospital instead of having to walk in from the hotel.
Morning in Entebbe
Landed in Entebbe last night. Usually when I travel, I can find parallels between my destination and some place that is familiar to me; this was much more difficult when I landed here. Maybe it was the fact that I hadn’t slept in 24 hours, plus landing at night in a strange country, but it all felt alien. The smell is the first thing that hit me; rich, verdant. Uganda is apparently highly agriculturally based, and based on how it smells, it shows. It was not unpleasant; if anything it reminded me of a warmer, more humid Iowa. I assume some of the farmers burn off their fields, since there was a hint of smoke in the air.
Got out and got through customs quickly; apparently we could have bypassed a significant line if I had known that that line was to purchase visas, which we all already had. Of course, nothing was signed to indicate this, but oh well. Had the common feeling of panic until I saw my luggage come off the rack, of course it was one of the last out of the plane….
Glad we had a driver waiting at the airport to take us to the hotel- the lobby was filled with 20 or so young men looking for taxi fares. Nothing aggressive, with a polite no they were quick to turn away, but we had to wade through a couple rows of them when leaving the airport.
Apparently I thought I was going to drive the shuttle bus, since I tried to get in the right front side; for future reference they do indeed use the other side of the car and road when driving. Not much to say about Entebbe at night, aside from the sharply lit government buildings up on the hill. We had landed in a flat valley surrounded as far as I could tell with low hills.
Struck me that I was in an entirely different country when we arrived to the hotel, the BOMA in Entebbe. The driver pulled up to the wooden gate set into a surrounding fence, only to have the gate opened by a young security officer packing a rifle. I don’t know if I was more reassured that they were prepared for any trouble, or concerned that they thought they needed it. There has been some riots several weeks ago in Kampala; to my limited understanding something involving the monarchy of one of the main clans and restriction of travel of their leader. According to our driver, of course, they were small and not an issue, which does fit with everything I saw when looking through local news over the last several weeks.
The hotel itself is wonderful; of course after traveling for 2 days and lack of sleep, any place horizontal and soft probably sounded wonderful. Main lodge was done up almost lodge style, with open dark beams overhead and intervening stucco. Had a separate room set back through the lodge, passing through to the back of the lot and into a separate building housing Cameron and John’s room and my own. Bed was an enormous four posted construction draped with mosquito netting; reassuring, since I can’t seem to find the ones I packed…. And, best of all, plenty of hot water!
Promptly collapsed in bed, only to wake up 4 hours later. My body, despite being exhausted, apparently still wanted to function on Portland Time. It would almost be easier if it was a straight 12 hour time difference, since I could easily say four o’clock is too darn early to wake up, but having to do the math when I’m half asleep doesn’t work too well.
Today we get to travel more; 5 hours drive to Mbarara. Good thing I’m here for several weeks, since I would not want to make the trek from Portland anytime soon.
Got out and got through customs quickly; apparently we could have bypassed a significant line if I had known that that line was to purchase visas, which we all already had. Of course, nothing was signed to indicate this, but oh well. Had the common feeling of panic until I saw my luggage come off the rack, of course it was one of the last out of the plane….
Glad we had a driver waiting at the airport to take us to the hotel- the lobby was filled with 20 or so young men looking for taxi fares. Nothing aggressive, with a polite no they were quick to turn away, but we had to wade through a couple rows of them when leaving the airport.
Apparently I thought I was going to drive the shuttle bus, since I tried to get in the right front side; for future reference they do indeed use the other side of the car and road when driving. Not much to say about Entebbe at night, aside from the sharply lit government buildings up on the hill. We had landed in a flat valley surrounded as far as I could tell with low hills.
Struck me that I was in an entirely different country when we arrived to the hotel, the BOMA in Entebbe. The driver pulled up to the wooden gate set into a surrounding fence, only to have the gate opened by a young security officer packing a rifle. I don’t know if I was more reassured that they were prepared for any trouble, or concerned that they thought they needed it. There has been some riots several weeks ago in Kampala; to my limited understanding something involving the monarchy of one of the main clans and restriction of travel of their leader. According to our driver, of course, they were small and not an issue, which does fit with everything I saw when looking through local news over the last several weeks.
The hotel itself is wonderful; of course after traveling for 2 days and lack of sleep, any place horizontal and soft probably sounded wonderful. Main lodge was done up almost lodge style, with open dark beams overhead and intervening stucco. Had a separate room set back through the lodge, passing through to the back of the lot and into a separate building housing Cameron and John’s room and my own. Bed was an enormous four posted construction draped with mosquito netting; reassuring, since I can’t seem to find the ones I packed…. And, best of all, plenty of hot water!
Promptly collapsed in bed, only to wake up 4 hours later. My body, despite being exhausted, apparently still wanted to function on Portland Time. It would almost be easier if it was a straight 12 hour time difference, since I could easily say four o’clock is too darn early to wake up, but having to do the math when I’m half asleep doesn’t work too well.
Today we get to travel more; 5 hours drive to Mbarara. Good thing I’m here for several weeks, since I would not want to make the trek from Portland anytime soon.
Amsterdam
Finally on my way; 2 sunrises in one day. Sitting in Amsterdam, feels like 11PM, actually 8AM tomorrow. I emailed my wife to tell her what the future looks like…. Shiny.
One more hour until I board for Entebbe. I’ve already thought of 5 things that I should have brought, and five things I probably did not need. We’ll see.
You’ve gotta love an airport that has recliners, a meditation room, and a balcony full of massage chairs.
10 hour flight to get here, though. Does not make for a convenient travel hub. Had my last Big Mac for sometime, thankfully. Just thought it would be nice to have one last taste of Americana before heading out. Unfortunately, they taste the same here as they do in the states.
I’m glad that I’m traveling in the internet age; I’ve already emailed Laura and updated my face book page while sitting in a café in Amsterdam. Not something I could do during my last trip to Ireland. Of course, we’ll see how much I’m able to use the internet in Mbarara.
Well, battery is charged to 96% (I’m stationed at an internet café, hooked into a free american style power source. Hee hee. Batteries charged for another round. Next stop, Entebbe….
One more hour until I board for Entebbe. I’ve already thought of 5 things that I should have brought, and five things I probably did not need. We’ll see.
You’ve gotta love an airport that has recliners, a meditation room, and a balcony full of massage chairs.
10 hour flight to get here, though. Does not make for a convenient travel hub. Had my last Big Mac for sometime, thankfully. Just thought it would be nice to have one last taste of Americana before heading out. Unfortunately, they taste the same here as they do in the states.
I’m glad that I’m traveling in the internet age; I’ve already emailed Laura and updated my face book page while sitting in a café in Amsterdam. Not something I could do during my last trip to Ireland. Of course, we’ll see how much I’m able to use the internet in Mbarara.
Well, battery is charged to 96% (I’m stationed at an internet café, hooked into a free american style power source. Hee hee. Batteries charged for another round. Next stop, Entebbe….
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