Chimps

Getting up at 5.30 a.m. on Saturday was definitely worth the effort. By 7 a.m. we were deep in the forest witnessing a community of chimps waking up. This was a once in a lifetime experience for us; a special treat from our chimp researching friends, Cathy and Roman, who invited us to spend the day with them at their place of work. We kept up with one family group of chimps for the whole day and observed their daily routine. It was fascinating watching the inter-action between the family and their friends and learning about the different relationships. We had it all - the love story, the jealousy, the frustration, the rejection, the sibling rivalry, the parental angst! It would make a great soap! One of the tasks of the research assistants was to collect a urine sample from a particular female. I was intrigued by how this could be possible and expected to see a technical piece of equipment. It turned out to be a long branch with a plastic bag on the end which was strategically placed under the chimp whenever she was up a tree! They weren’t successful on this occasion but I’m told it’s not always so difficult. It was an amazing experience to be with these wild animals at such close quarters. Sometimes they walked right past us, just a few feet away. A couple of times we had a display of anger from one of the males who came charging past us at speed; it was pretty scary! A lot of the day is spent eating and grooming but when the chimps decided to move on we just had to keep up with them. We stomped through the forest and jungle, fighting with the undergrowth, for eight hours. It was totally exhausting but so exhilarating and worth every ache and pain the next day.

Maggie.

It would be impossible to up-load all 380 photos so here’s a very small sample:






Setting out with the sophisticated 'wee catcher':

Back at base, exhausted:

Highs and lows

By Tuesday it is difficult to remember what happened in the last week. Time is going quickly now as October approaches. We keep thinking of the things we are looking forward to and also thinking about the people and things we will miss about Masindi.
Work has been the usual mix of highs and lows. The grandmother of Vincent the little boy with dislocated knees came to see me this week to show me a picture of him walking normally. She also brought some prize mangoes which were delicious. I also saw Joel a boy with Burkitts lymphoma who has done really well thanks to the Hope Ward, the charity ward at IHK Kampala. He had the biggest tumour I have ever felt but it has disappeared with chemotherapy. Not so lucky are the two patients on the ward with advanced cancer. Their cancers are inoperable and we have not even got simple drugs to relieve their distress. I have failed to get the medical superintendent to order any morphine. There is a great fear of opiates here and little understanding of their role. It has been one of the frustrations working here that I have failed to develop a palliative care service. There is one in Hoima but that is too far away for most patients. Another patient that did not do well is a young women admitted unconscious with gas gangrene of the leg. It was a horrible site and one I will never forget. She would have needed a major amputation to save her life and it was not an option here.
On each ward round there are new things to see and new things to learn. Unfortunately it is rarely that you can do the investigations you would like or give the treatment that is needed. One of the things I have learnt is to be flexible and often the next best thing does still work. The human body has amazing recuperative powers.
Chris
On a more cheerful note I had a great day on Saturday at the Family Spirit School and Orphanage helping some of the older girls with sewing. Naturally there are some children who are coming to the end of their education and the staff are trying to find ways to give them some vocational training in the hope that they can make a living and a new life for themselves. Tailoring is a very popular occupation here. Many people have their clothes and their children’s school uniforms made locally. Just about every street in Masindi has its share of tailors and tailoresses sitting outside with their Singer treadle machines - I think they’re made in either India or China for the african market. I’m always amazed at the beautiful clothes produced given the facilities; there is no workshop space, just the surface around the machine, and there’s always lots of toddlers and customers milling around. Customers just stand in the street to be measured!
There’s little diversity when it comes to training; basically it’s tailoring or carpentry, possibly brick-making. The most popular employment for boys and young men seems to be running a boda-boda bicycle or motorbike. There’s always large groups of them standing on street corners. I’m not sure there is the demand for so many!




A couple of photos of our sewing class:









Another event this week was the African Day of the Child.
This was essentially an event where hundreds of selected school children (possibly the ones with a decent uniform!) marched around the common all morning in the scorching heat in front of dignitaries (sitting in the shade) and then in the afternoon the said dignitaries gave lots of speeches.
At least it was all very colourful - see photos!

















My day at the library was quite challenging as Ritah couldn’t be there. The younger ones are not so proficient in English (or perhaps it’s my accent they can’t understand!) so I read stories with a book in one hand and the swahili dictionary in the other! It was encouraging that a few of the older ones came in during their free time to look at reference books. Thankfully the teacher accompanied the class of 140 children who came in the afternoon!
Maggie

mangoes, monkeys and Meryl!

We were wondering what had happened to the troupe of monkeys we’d previously enjoyed seeing in the garden. Well, now it’s the mango season again and they’re back! That is, if Akim and Udetha will allow them anywhere near the mango trees. I occasionally hear the boys charging across the compound and wonder what on earth is going on, only to see them chasing the monkeys away. It’s been a good harvest this year with literally hundreds of mangoes between the six trees. We and our neighbours can’t eat them fast enough and we’re really enjoying the smoothies, the cakes, the desserts, etc. Of course, they’re delicious on their own too!
The monkeys are not our only visitors. Last week we said goodbye to Kate, a medical student from the UK, who was staying with us for a month and then two days ago we welcomed Hayley, also a medical student from the UK, who will spend the next month with us.
Yesterday a film crew from VSO UK arrived to make a promotional video to show potential volunteers. They are focusing (no pun intended!) on volunteers in health placements so came to Masindi to meet Chris and Pam the community nurse working here. They are also keen to portray daily life in Uganda so Chris and I were followed around the town and the market buying our provisions. Chris kept calling me Meryl Streep (of Out of Africa fame) but I don’t think she need worry about the competition! I must admit I couldn’t quite see the likeness in Chris to Robert Redford either!! It was good fun but, of course, it was only afterwards that I thought of all the things I really should have said.
We managed to spread Chris’ birthday celebrations over two days last week. One night was spent with our VSO friends and another night some other friends arranged a small party for him. Of course he had a birthday cake and the flavour was …………..mango!
The library sessions went well this week. It was really encouraging to get kids coming in to look at books in their spare time and not just when they were told to. During a session with a P2 group of about 60 children I asked how many of them have a book at home and no-one has! This library is going to be such as important resource to the community.
Maggie

As well as getting older and being a film star I have also been obsessed with diarrhoea this week, at least it makes a change from malaria. As part of the Miirya Project Pam and I have been running workshops for the volunteers on prevention of diarrhoea. Obviously sanitation and hygiene is the basis of this work. It is only when you are out in the villages that you realise how difficult many peoples lives are here. We take latrines for granted but households without latrines are common here, many people just defecate in the bush. There are strong taboos especially regarding pregnant women and the use of latrines.Hand washing is not regularly practised and few latrines even in the hospital or health centres have hand washing facilities. We showed some practical ways of arranging hand washing using “ Tippy Taps” and hope we have convinced the volunteers to use them.
They were impressed with SODIS or solar disinfection of water. This is a system using plastic bottles and sun light to make safe water. One thing Uganda is not short of is sun light and using this system should save people time and resources as it means they do not have to boil water. We have stopped buying bottled water for drinking I just put bottles out in the morning and can use them the next day.
After lots of e mails we have managed to get ARVs. I am not sure if it is coincidence or whether my contacting USAID and the ministry did the trick but I am pleased that we did not have to discontinue anybody’s treatment. We still need other drugs but it is a start.
Chris



Above, Akim playing with one of his favourite toys in our garden.


Also of Akim when he cheekily put on my pair of glasses. I took one photo of him and then without saying a word to each other he just started posing to have more taken - about 20 in all!

polio outbreak

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THIS IS A PICTURE OF A TRAINING SESSION FOR STAFF INVOLVED IN DELIVERING THE POLIO CAMPAIGN


THIS PICTURE SHOWS THE MARKET WERE WE FOUND THE PATIENT BELOW. HE WAS THE POLIO SUSPECT.


THE BOY AND HIS MOTHER AT THE MARKET


THE PATIENT NOT VERY IMPRESSED WITH THE MUZUNGOS HOME MADE BALLOON


This week has been full of interesting medicine. On Monday I sent two patients to Kampala for opinions. One little baby was confirmed to have a hole in the heart and will need corrective surgery and the other young boy was for follow up of his Burkitts lymphoma.I also sent some x rays for an opinion from Richard my VSO colleague in Kampala. One of the xrays was of a young man with HIV who I thought also had a lymphoma. Richard suggested he may have TB a much commoner diagnosis and this was confirmed when I aspirated some pus from his lymph node. It is a much better diagnosis and with the right treatment he should do well. I also saw two patients with extensive Kaposi sarcomas. This is a horrible tumour that occurs in advanced HIV and is almost impossible to treat here so they will do badly.There was of course the general run of malaria including a young baby who was desperately anaemic. Again we had no blood available and I expect the parents took her home to die. Malaria still regularly kills children usually because of severe anaemia and our inability to provide transfusions. That is why prevention is so important.
Wednesday was Martyrs day a public holiday held to commemorate some christian martyrs. It was my intention to stay at home and catch up with some work but at 9.30 I had a call from the district health officer saying that there had been a suspected case of polio reported and would I go as part of the team to check it out.
Uganda has had 7 cases of polio in the last few weeks after being declared polio free a few years ago. This has prompted a huge immunisation campaign to try and prevent an outbreak. This week end is the last of the emergency sessions and there has been a great effort to mobilise people to take their children under 5 for immunisation.MTN the mobile phone company has been sending text messages to every one telling them to take their children. The government has threatened imprisonment for parents who do not take their chidren for the immunisation. It is a huge under taking staff have to be trained vaccines obtained and delivered to numerous out posts. the vaccines need to be kept cool. Unfortunately it is difficult to evaluate the success of the campaign as there has never been a register of all children. This time they are trying to register each child so the per centage up take can be calculated. Last time some of the clinics recorded uptakes of 120% which is a worry!
The case we needed to check on was a 2 year old who had stopped walking a month ago. In the same area there had been another child with paralysis of one leg. This child had been admitted for assessment but from the history it looked like this was nerve damage after a poorly given injection a not uncommon problem here. Mutondo is at the far end of Masindi district and it took two hours to get there. When we arrived at the village the child was not there but had been taken to the market. With the help of one of the health workers we were able to track the child down and take him back to the health centre for an examination. This examination took place under a mango tree. He was not happy to be examined by a strange muzungo doctor but it was soon pretty obvious he did not have polio. He appeared to have a painful swollen knee and a heart murmur so I wondered if he had rheumatic fever. I gave some treatment and arranged to see him in a weeks time. Because he had been listed as a suspect we had to arrange for stool samples to be taken to Entebbe for checking. The surveillance here is good but does depend on people getting to health centres and health workers reporting their concerns.
This trip did take me to a part of Uganda I have never seen. While we were there we visited the site of an orphanage being set up by a US medical missionary. This doctor had found a site of 500 acres next to the Nile. He has funded the purchase through churches in the US and is setting about building a school, orphanage and hospital in the middle of nowhere. You do meet some inspiring people here.
Library up-date:
The day that I had planned to go turned out to be Martyr's Day and therefore a national holiday. At the last minute I re-arranged everything to go on Friday instead. It turned out to be an interesting day and not at all as I had expected. Our first group to visit the library that day was one of the P1 classes. One of the two P1 class teachers hadn't turned up for work and the other one really wanted to go to town, leaving about 60 children without supervision. After a lot of chasing we managed to get a group of them in the library - together with a stray chicken! I decided to do a 'warm up' action rhyme with them but this took the whole session. At least they seemed to enjoy it. The following two sessions were with P5 and P7 classes and these turned out to be discussions on topics such as emotions and various sex education issues. As a teaching aid I was using a newspapers produced for primary school children. It has an Agony Aunt page and, because of cultural differences, the letters were nothing like what you would find in the UK! They were difficult topics to cover because the classes have pupils of all ages. Children progress to the next school year based on their ability rather than age so it is not unusual to have older teenagers in a P1 class.
Ritah, the librarian, invited me back to her house in the village at lunchtime. The house is actually a one-room brick building with a metal door, no bigger than most garden sheds, but typical of the way most people live here. There is just enough room for a single bed and a wooden chair with pots, pans and jerry cans piled up in the corner. Her latrine is shared with several families so she prefers to go down the road and use the one belonging to a colleague. Cooking and bathing are all done outside. As she prepared her lunch of fried cabbage and smoked fish we exchanged lots of culinary titbits - I picked up lots of tips! Ugandan cooking is not as easy as it looks. I find it quite tricky wrapping the matooke (a special variety of bananas) in banana leaves in such a way that it makes a tight parcel to steam over the charcoal. Then keeping the charcoal at the right temperature is also a skill. Chris is quite happy for me to not perfect the technique as he hates matooke anyway and thinks I should stick to pasta!
Maggie

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Time flies

THE PICTURES ABOVE ARE OF TWO BROTHERS WITH EARLY LEPROSY BEFORE NERVE INVOLVEMENT. THE PHOTOS SHOW EARLY SKIN LESIONS.

THE PICTURES BELOW ARE FRANCES THE OLDER BROTHER WHO HAS HAD LEPROSY FOR SEVERAL YEARS AND HAS ADVANCED DISEASE WITH SEVERE NERVE INVOLVEMENT. HE HAS ANAESTHETIC HANDS AND FEET WITH LOTS OF DAMAGE.





EARLY TREATMENT WOULD HAVE PREVENTED THIS DAMAGE.

Some how we missed out on last weeks blog. As we enter our last four months time seems to be going quickly and a week can pass by with out you noticing it. It is also hard to find something new to write about. Things that seemed really novel and interesting this time last year are now not even noticed.
Money has always been a big issue here in all sorts of ways. Even as a volunteer you are seen as much better off than every one else which is true. This does not appear to provoke jealousy but does mean that people regularly ask for money. This week the children have returned to school so school fees are due. Although primary education is free many families opt to send their children to private schools as they hope that the education will be better. Many schools are boarding schools so for much of this week people have been away from their jobs delivering children. It seems to be accepted that a few days off work to take your children to school is reasonable. Families make real sacrifices to send their children to school. Any member of a family who has a job will be expected to support not only his own children but other children as well. Unfortunately the local government has not paid salaries for the last two months so all health workers, school teachers and police are struggling to meet their school fees. It is hard to believe that salaries can just not be paid but it is not uncommon here. When I ask colleagues about it they just shrug their shoulders and say “this is Uganda”.
Most patients are from the villages and are basically subsistence farmers. They have little spare cash but health care here costs money. The health service is supposed to be free but only if the drugs and resources are available. We have not had any X-ray films for over six months and there is no ultrasound. If a patient needs the investigation they have to go in to town and pay 15000 ush for an x ray or scan. I frequently see patients in need of x-rays especially to rule out TB. If they have not got the funds I am able to use some of the money that was donated before I left Hull. This month I have been dipping in to that fund quite a lot. There was the case of the women who had been bitten by a dog that was ill and acting strangely. There is rabies about in Uganda even though cases are rare. The government should supply rabies vaccine but there is none available in the hospital so it has to be bought from a private clinic. There is no chance that this woman could afford 120000 ush for a course so the fund stepped in. It would have been difficult to send her away. Tomorrow I will use some of the money to pay for a special hire taxi to take a baby with a heart defect and a young boy with Burkitts lymphoma to Kampala for assessment. Unfortunately I think the baby has a serious problem requiring surgery which is unlikely to be available here.
By chance this week there has been a team of American medical missionaries visiting. One of them was a nurse who works for a charity in the states that takes babies to the US for corrective surgery.It is just possible that Rita the infant may get her surgery there.
I managed to get out on Wednesday to follow up some of the leprosy patients. One of them asked to see other members of his family. It was an isolated homestead but it was worth the effort as two of his brothers had definite leprosy. Luckily they were early cases and did not have the severe nerve damage that Frances has. It is satisfying to find new cases, I am afraid without my encouragement the leprosy nurse would not have bothered to chase them up. There is a major problem with searching out new cases and getting them on treatment early. One of my aims before I leave is to get the district to recognise that they have a problem with leprosy and must be more active.

LIBRARY UPDATE
On my first day we got off to a slow start. First of all, I should have been going on Wednesday but as Ritah had to go to a burial we postponed until Friday. It was a common 'man with the key' problem. Once we'd gone round the houses, literally, to find the key it was almost lunchtime. As it was the first week of the new term the children were occupied with cleaning classrooms and digging the compound. This meant that the library was not open for business as usual but it did give us an opportunity to start sorting the long awaited shipment of books.It seems that this shipment from the UK has been stuck at customs in Entebbe for quite some time. Also, Ritah did not want the children in the library until some of the girls had taken the mats down to the well to be washed.
My second day, today, turns out to be Martyrs Day and therefore a national holiday so the school is closed. I will hopefully get to work on Friday. Flexibility is the name of the game!
Maggie