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….
 
 
 
 

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