Jan 2009 – Jim McWhirter

Kamuli Hospital, Uganda, arrival and initial impressions

P1020079-768x1024I set off on Thursday 8 January 2009 with Dr. Tim Jenkinson and his wife Gill who have visited many times before. The flight was uneventful and we touched down to hot English summer weather beside Lake Victoria.

We were met by Andrew Mutengu, a delightful Kampala Rotarian and he drove us into Kampala where we met Sr Gilder and Moses who drove us to the Hospital, 160 km away.

On Saturday we explored the hospital and met the medical director, Alphonsus Matovu, who is one of only two doctors staffing the entire hospital.  He begins work with a ward round at 6.00 AM covering paediatrics and surgery and then proceeds to an operating list in theatre!  It has been impossible to recruit more doctors recently as many leave for easier work with the government or NGO’s or are paid two to three times as much by governments in neighbouring countries. He has had no holiday for 7 years!

The hospital has a nominal 160 beds with wards for surgery, general medicine, TB, isolation, maternity, children, and also has departments for the treatment of outpatients (which doubles as a 24 hr emergency department), Aids and antenatal.  Measuring the size of the hospital by the number of beds is a little meaningless; for example the childrens’ ward recently had 80 patients who are accommodated on the floor at night and outside during the day. When a patient is admitted to hospital, the family come and cook and care for them.

The first day of work – Monday.  I say work, but it will be at least a week before I am in any way productive and am simply going round with the doctors climbing a very steep learning curve!

The paediatric ward round began at 6.00 AM and we saw 36 patients, most of whom had life threatening conditions.­ It was mostly cerebral malaria but with plenty of pneumonia and two cases of tetanus, one of whom had been in under heavy sedation since the middle of December. We then proceeded to the surgical ward round and then to Minor Surgery following a brief brunch.  “Minor surgery” consisted of 17 cases which were self referrals sent across from outpatients.  All of them were dealt with on the spot or booked for surgery within a week. The elective surgical list for the afternoon was supplemented by a strangulated hernia and we then proceeded to complete the minor surgery cases.  The day was rounded off reviewing a couple of paediatric cases although the medical director had reviewed the obstetric patients while I had a bite to eat!

Tuesday morning began again on the paediatric ward at 6.00 AM.  One of our children had died in the night and the obstetric wards had also lost a patient.  Neither would have died in the UK.  Sadly, these are such commonplace events here that they were not the subject of particular comment.

Today, Wednesday, I explored the obstetric ward and was particularly struck by the lack of continuity of care and social support for mothers in labour, the virtual absence of pain relief, lack of facilities for the newborn and frequent loss of life more often of infants than mothers.

I have tried to give a brief flavour of conditions here.  Initially I was very shell shocked but am beginning to think that I may be of some use in what is a completely different world.

Kamuli Hospital – the first 10 days                           Wednesday, 21 January 2009

I thought I would put together a few thoughts after my first 10 days here. After 3 ½ days working with the doctor running the paediatric ward, I took over responsibility for it and did my last day’s work there today.  Tomorrow I start a 2 day hand over on the obstetric ward where I will spend 4 weeks working from next Monday.

I must confess that I did not really enjoy the paediatric work.  I was looking after an average of 50 patients.  Most of the patients had malaria and quite a few had pneumonia and some had both.  On average one child dies each day.  Most distressing were the cases of tetanus, not least because this is a completely preventable disease through immunisation but also a very unpleasant way to die.  During my brief time there we had five cases, three of whom died.  Two of these were only a week or two old and at least one had had cow dung applied to the umbilical cord in the traditional manner.  It is hard to accept that in the face of repeated national publicity campaigns and widespread availability of the vaccine, there is not a better uptake of immunisation although we all know how false beliefs (eg the MMR controversy in UK) can easily spread, even in a sophisticated society such as our own.  They did have a very successful measles immunisation campaign here but this only requires one dose to be effective whereas tetanus requires at least three and preferably five doses over a significant period.

On one particular day there were three deaths all of which I witnessed personally.  This would have been difficult under any circumstances but with no experience of the cultural norms in bereavement here and no knowledge of the language, it was particularly hard. Furthermore, the staff felt impelled to continue resuscitation to the bitter end in the face of inevitable failure and this was done in the room which simultaneously acted as treatment room, office and the location for my ward round which was only briefly interrupted during the early stages of resuscitation. Even more distressing was how it underlined poverty as one of the deaths (meningitis) was at least partly contributed to by the parents’ difficulty in finding £4 a day for one of the antibiotics which is considered particularly expensive here (unskilled pay rates are 15p per hour and that is if you are lucky enough to get any work).  You might think, not unreasonably, that I could easily have paid for the treatment myself. That would be true but the issue arises many times each day and once having started, one would not know where to stop.  It is easy to justify what I have done (or not done) but that does not make it any easier to bear.

The same issue of my personal wealth verses their poverty arose in another context.  I was approached by a member of staff to sponsor the education of his child.  I had been warned that this would happen and had again made a policy decision not to get involved in an open ended situation where drawing any lines would be completely arbitrary.

On a happier note, everyone is very welcoming and friendly and grateful that I am here.  I am really looking forward to working on the maternity ward and have already done a couple of caesarean sections without mishap (my hopes for an easy first one were answered and I am most grateful to all those who trained me!).  Unfortunately the working conditions are primitive and unhygienic which means that a lot of patients get infections.  The maternity unit has about 3,500 admissions a year (which includes 700 gynaecology cases) and delivers over 2000 babies, all with staffing of one registered midwife, 8 enrolled midwives, a number of student midwives and usually half a doctor (duties shared with the medical ward).  Again, the cultural differences are huge and not easy to adapt to.  There is virtually no pain relief in labour.  A woman who is making a lot of noise will be told very firmly to be quiet, especially if her distress is disturbing the doctor’s ward round!  Even if the doctor is inflicting significant pain on the poor woman (and many procedures here are done without analgesia or aesthetic), she will be told very firmly not to protest or vent her feelings.  Again, the need to communicate with the patient via an interpreter (nurse) whose culture, agenda and mastery of the English language is quite different to one’s own, is not easy.  Interestingly one sometimes needs two interpreters as some of the staff come from other parts of Uganda and do not have complete mastery of the local language. Also, there is little or no social support for a labouring mother; the father is not normally allowed on the ward and female relatives are rarely present during labour and there are not enough staff to assign one to each labouring mother.  However, at least live births significantly outnumber stillbirths and neonatal deaths and so this is a much more cheerful place to work.  Large families are still the norm and many mothers have had between 5 and 10 children.  I asked the staff when the Ugandan mothers stopped having children and the answer was “never!”.

Shortages of basic things are a normal part of the working day – the electricity supply goes off at least once a day on average for a totally unpredictable period – there is a back up generator but the high cost of diesel means that this is only started if an emergency operation is needed so other routine functions like laboratory tests and oxygen supply to the wards are interrupted. Drugs are not infrequently out of stock; today the laboratory ran out of reagents to do blood counts; sterile gloves were in short supply; stocks of anaesthetic agents are perilously low; etc, etc.  On such a brief visit it is difficult to work out how many of these problems are caused by inefficiency and how much by lack of resources but the latter is obviously a very significant factor.

On the social front, I attended an “introduction” which is a traditional Ugandan wedding.  It was a very jolly, if rather long drawn out, ceremony that was a rather beautiful acting out of the bride leaving her own family and joining her future husband’s family in the presence of both extended families and most of the village.  I have been told that it is only legal if the groom has a letter from the bride’s parents confirming their consent!  Getting there and back was interesting!  The local equivalent of a taxi service is a seat on the back of a bicycle or motorcycle.  I have used the bicycle version into the local town which is less than a kilometre away but this time we had to go five kilometres along a deeply rutted and potholed mud track, so opted for the motorcycle.  The driver of my motorcycle had the rather unendearing habit of hanging his crash helmet over his rear view mirror for most of the journey and then reaching out and putting it on as a car approached from the opposite direction only to replace it on the mirror as soon as the hazard had passed!  However, as you are reading this email you will conclude that I survived!!  Unfortunately we missed the meal at the end of the “introduction” as we did not fancy the journey home after dark.

Kamuli Hospital visit progress report – third installment           Friday, 30 January 2009

This is the halfway point of my assignment having completed three weeks here.  I have just finished the first week on the maternity ward.  It has not been easy.

I had been lulled into a false sense of security by a few straightforward caesarean sections.  This week the complicated cases began!  In spite of the best efforts of those who trained me, I was well aware that there were a large number of situations of which I had had no direct experience.  Out here it is not uncommon for women to labour for a long time at home in the village before coming to hospital and only then doing so when the baby has got completely stuck.  If the baby is too large to allow a forceps delivery, then one has to do a caesarean section which is not technically easy.  I came unstuck on the first one I did and had to call for assistance.  The mother lost a lot of blood and I was very afraid that she would die.  There was no blood available for transfusion in our hospital, nor in the government hospital in town, nor in Jinja, 60 kilometres away.  In the past, we would have taken donations from friends or relatives or even staff but this is now prohibited at national level because of the prevalence of blood contaminated by HIV, etc. I was rather frustrated that they would not accept a donation from me as I knew my blood was safe as a regular UK donor, but it seems that bureaucracies can overrule common sense everywhere. Had my patient died, I would have been largely responsible.  As you can imagine, this significantly undermined my confidence and I seriously considered not doing any more surgery in order to protect the patients.

Fortunately, both the local doctors were very supportive and I have made sure that one of them is either with me or very close at hand during subsequent operations.  My confidence has grown again, not least in parallel with the recovery of the difficult case! This week has been character building and I have been grateful for the tradition of the stiff upper lip.  I have not had to work outside my comfort zone for longer than I can remember.  Perhaps it is a bit late in life to start character building, but hopefully some good will come of it!

However, it has not all been work.  Last Saturday we went to Jinja by bus (entertaining) and had local fish for lunch by the source of the Nile.  That evening the Sisters in the convent (it is a mission hospital run by a nursing order of nuns) entertained us to dinner followed by television news which was the first I have seen since arriving here.  On Sunday, the hospital transport took us to Kampala where we said goodbye to Tim and Gill who have been working with me for the last fortnight.

On the way to Kampala we visited a very inspiring project run by a Polish Salesian priest.  He runs a hostel for street children from Kampala and cares for 172 children aged 7 to 16 with a permanent staff of five and intermittent volunteers.  They have dormitories, playing fields and a small farm.  It is a wonderfully caring community which transforms the lives of those fortunate enough to go there.  The only qualification for remaining there are a commitment to study and learn seriously at school and to fit in – the older ones ensure that newcomers get the message!  After completing primary and secondary education they can go on to a technical college in Kamuli run by the same order.

Before I left UK, it was put to me that Africa was a lost cause and that we should put a fence round it and forget it.  I was told that the Chinese take a different view.  They carry out infrastructure projects here at no cost to Uganda. In return, they are gaining access to raw materials at minimal cost.  It seems to me that everyone is self interested in their approach to Africa but the Chinese appear to be rather more enlightened in their self interest than the West!

Talking of the Chinese, many of their manufactured products are on sale here and I bought two of their rat traps as my house is regularly visited by these dear little creatures.  So far, I have caught two and I appear to be winning the war but not before they had destroyed several of my socks and handkerchiefs trying to make a nest!

Now that Tim has gone, I have inherited the radio and so get the BBC World Service news.  There has been some reporting of the credit crunch, but from a different perspective.  The third world finds it difficult to understand how the rich countries can find such huge sums of money so readily for their own problems but have been consistently unable to reach the very modest longstanding target of 0.7 per cent of GDP for aid.  In the present context, the West appears to be completely ignoring the very real problems which the current financial turbulence is causing in the third world. A simple example is the cost of fuel – price rises may mean a few less luxuries for us but devastating here where unskilled labour rates are 1/30 of ours and most people are subsistence farmers or can only get occasional casual paid work. A staff nurse earns £85 per month for a 40 hour week after tax and social security payments. From this she must live, support a number of extended family members, pay school fees for younger siblings, etc, etc.

I am feeling much happier and more confident than I was earlier in the week and hope that for the next three weeks I will significantly lighten the medical load on the two resident doctors.                                                 Jim. Saturday, 31 January 2009

Kamuli Hospital visit progress report – fourth instalment Friday, 7 February 2009

Quite a lot of water has flowed under the bridge since I recorded my thoughts a week ago and I am delighted to say that I am feeling much better than I was then. This is partly because I have regained some surgical confidence (with much support from colleagues here) but most importantly I am beginning to work out what I am able to do and when I need to call for assistance. With new work it takes a little while to get to know what you are capable of and where your limitations lie.

On a short visit one has to be very realistic about what can be achieved in terms of changing things or improving practice and also very humble in the face of staff dedication which is quite amazing. The difficulties of attracting doctors and nurses to a relatively isolated rural situation are bad enough but then add poor pay and an incredible workload and you have a problem!

For myself, the process of adjusting to local conditions continues. So far no mother has died under my care. Following an extensive review of the world literature on maternal mortality and a detailed statistical analysis of my own cases, I have reached the conclusion that the most important factors are (a) my clinical and surgical skills (5pc), (b) good luck (10pc), (c) the extraordinary innate healing power of the human body and the incredible tenacity of the human spirit to survive and overcome whatever insults and abuses are heaped upon it (85pc). Unfortunately the babies are not so robust and most days see one or more stillbirths or deaths soon after birth. To reach adulthood in Uganda is no mean achievement. Malaria kills many babies both before and after they are born. Pregnancy and birth are hazardous where only 40 per cent of the population receive any antenatal care and speedy access to modern medical facilities for complications of labour are only available to a tiny minority. Even if a mother reaches hospital needing an urgent caesarean section which could be organised in minutes in the UK, she will be very lucky to wait less than one hour here and much more likely a good number of hours in most places if things go well. If they survive all that, then the motor car and another accidents are just waiting for them.

The concept of patient consent here is slightly different to the UK. Recently we had a case of suspected meningitis complicating AIDS and wished to do a lumbar puncture. Before the patient was approached, there were consultations with her sister, who had recently been her main carer, her husband and finally it was stated that only her mother could give full consent for the procedure. Fortunately all these people were in the hospital area as they were looking after her. Only after mother had agreed was the procedure explained to the patient and her views taken into account! This case brought home to me the serious limitations of not knowing the local language. I would have had great difficulty getting an adequate medical history and negotiating the consents using translation by the nurses. Fortunately I had summoned one of the local doctors to help me and it was fascinating to watch him at work. The local people are delightfully softly spoken and mutually respectful. This is in stark contrast to the harsh reality of many aspects of the lives they have to lead.

I am typing this at 34,000 feet over the Mediterranean! I have just had a very self indulgent week on safari with my son Chris who joined me 2 weeks ago. We saw a lot of Uganda, a great deal of wildlife and had a fun time.

So, how to draw it all together?

I believe Kamuli Hospital is providing a very valuable service to a relatively isolated rural population who would otherwise receive very little modern medical care.

The local staff were all keen that I should return as soon as possible, so my work must have been of some value and the doctors certainly appreciated some temporary lightening of their burden.

I feel that I could possibly make several future contributions:

Simply going for a period of work such as I have just done is of value. I plan to improve my clinical skills by further training in Uganda and Dr Maura Lynch has kindly agreed to help at Kitovu.

Their work is constantly frustrated by lack of equipment and resources. The latest problem is that their 20 year old X-ray machine broke down 3 weeks ago and is now probably beyond economic repair. Patients have to go into the town when X-ray is needed. I plan to investigate obtaining a replacement machine in the UK (hopefully one no longer needed in the NHS) and then working out how to get it out there. Other needs include a replacement ultrasound machine and equipment to enable the taking of blood donations.

The problems of organising healthcare with limited resources and all the other problems the hospital faces are considerable and I am putting out feelers to explore ways in which I might provide administrative support.

I plan to talk to as many groups as possible in order to raise the profile of the work done by Rotary Doctor Bank (who have sponsored and helped organise my trip) and to raise funds. That little lot should keep me out of mischief for the foreseeable future and provide a focus for my retirement. Trying to establish how to use my newfound leisure was, after all, was one of the main reasons for undertaking this little expedition!

So, all in all, I feel it has been a success and would like to say to each and every one of you how much I have appreciated your support which has been given in so many different ways.

Jim McWhirter, 27 February, 2009