Football, Fire and Fireflies

My elder son seems to think I don't work much as he hears more about the fun stuff.  I have assured him that I am working plenty hard--5 and 1/2 days a week and on call the rest of the time. I have "formal" teaching duties with the clinical officers where I prepare handouts, discuss cases etc in addition to daily rounds.  I also consult in maternity which is generally fun.  The maternity structure is about 25 yards away from the hospital and the midwife supervisor calls me when they have any non-pregnancy related problems with their patients.   Hasn't been too much work until the last couple of weeks when we had 5 cases of neonatal sepsis, 1 of meningitis and 1 of congenital syphilis. Last week the midwife told me there was someone about to deliver if I wanted to catch a baby.  I ran over but missed the delivery. As I walked in the translator fainted and was heading for the floor so I caught him instead.

Waiting for the game to start

As far as entertainment goes here it is pretty much a make your own situation.  A couple of weeks ago we decided to have a staff football (soccer) game as football is quite popular. On the way home from work everyday we pass a group of young boys playing soccer on a dirt field with sticks tied together for goals and all barefoot. When we get closer to home there are a couple of other fields with older kids/young men playing on them where we were able to borrow a field.  The idea was to have one team from health staff and the other from folks that work on the compound and drivers. Well the idea was a huge hit.  Everyone at work was talking about our team--we got interrupted during rounds to make sure our goalie would be off that day. I got asked over and over what position I was playing.  They even put me on the roster which was quite a joke as our real team was young 20's men. I told them after they ran up the score I would come in. People discussed the upcoming game on the way to work, during work and on the way home.  I have to smile at  how little it takes to make people happy sometimes.  On the day of the big match we walked over to the mostly dirt field with goal posts, but no nets, and a herd of cows grazing on one side.  We had decided that one team would wear red and one white.  Not enough people had the right color shirts so players coming on and off the field had to change on the run.  Most of the staff came to watch and even more people from the village next to the field showed up. Many players were barefoot and very impressive runners. My team won 1-0 and everyone celebrated with a beer or soda after the game.

Dry season has arrived and with it very dusty roads (sometimes it is like thick fog). Tall brown grass is everywhere. The practice here is to set fire to the dry brush so new shoots will come up for the animals to feed on.  It's a bit uncontrollable what actually burns so I'm told it's not unusual for houses to be burned as well as grass. In addition to dust in the air now there is often smoke as well.  The other night the guards alerted us there was a nearby fire burning out of control parallel to the side of the compound where there is an above ground fuel tank.  We all left dinner to go watch the flames leap into the sky.  Every once in awhile there would be loud crackling and sparks as a tree exploded in flames.  It reminded me of brush fires in Malibu.  Fortunately it passed by without turning our way and eventually died out. I miss the daily thunderstorms and amazing cloud formations!

I'm not enjoying the various bugs that seem to come in waves but I did have one nice bug experience. I went to bed (under the mosquito net) and read for awhile the other night.  When I turned out the light there were fireflies all over the room but outside the net.  It was a magical light show until I fell asleep!

Murchison Falls

Mud challenge on the way home--
he's about to hit the deep mud hole

My fellow MSFers

After a crazy couple of days at the hospital (seemed like there was a new seriously ill child every time I turned around) eight of us set off for a weekend at Murchison Falls National Park.  As we approached the park we were going up a hill and suddenly saw a big truck and a car side by side, both stuck in the mud, completely blocking the road.  There were many men working on getting the car out which they finally were able to accomplish.  Our driver took a look at the situation and said we should all get out of the car but he thought he could make it through.  It was crazy to watch and at one point it looked pretty dicey but he made it!  At the park we had to cross several streams covering the road, which turned out to be good for washing all the mud off the car, and exciting as water splashed up on the windows!


In the park we took a boat ride up the Nile, which was quite broad and serene at the starting point. Hippos were everywhere standing in the shallow water, and we also saw a couple of crocodiles and a few elephants. Towards the base of the falls they let us off on a trail and we hiked up to the top.  The views on the way were spectacular when I wasn't gasping for breath trying to keep up with the young folks!

We spent the night in the park at a place where hippos come up from the river to graze on the grass at night making walking back to your hut after dinner interesting.

Murchison Falls

  Early the next morning  we took a ferry across the Nile to the area where there are "game drives" (higher concentrations of animals). Beautiful animals everywhere!  We left to come home at noon but the way we came in was blocked by flooding (rain during the night) so we had to go back the long way through the park to another exit.  On the way home we again got out of the car to watch the driver go through the deep mud patch. We made it through but a bit later had a flat tire.  Got the tire fixed and then there was a torrential downpour...  Eventually we made it home.

New roof

New hospital roof--bamboo poles, plastic sheeting and grass

This week they decided to redo the hospital roof as it was leaking during some of the torrential downpours we have had lately.   We had to move patients out of the area they had unroofed and at one point we ran out of beds and had patients on the floor. Many of them bring mats and sit on the floor anyway so they were unfazed by it. The first day they took off part of the roof we had an incredible wind in the morning which is very unusual.  All of our papers went flying making work difficult.  Later in the week we had an afternoon downpour with a different section of roof off flooding that area and much of our covered space as well.  Definitely more challenging working conditions than I'm used too!
As it is late in malaria season the kids seem to be sicker when they get here due to repeated episodes of malaria. Many are very anemic and we did more blood transfusions this week than all of last month despite rain, wind and space!

Nyumanzi Transit Camp

I finally got together a few pictures of refugee life.  When they arrive by bus from the South Sudan border they are taken to the Nyumanzi transit camp where they are given housing by UNHCR (United Nations High Commissioner for Refugees) and MSF provides medical services. Within a couple of months they move to one of the more permanent refugee camps which are mostly divided up by tribe.
Ayilo 1 and 2 are the two refugee camps where MSF  provides medical care for the refugees living there, as well as any Ugandans living nearby that want to come.  Each family group is given a plot of land big enough for a structure or two, a latrine and to grow some vegetables.  The water supply is often a ways away so people carrying water containers is a common site.

Ayilo1 Refugee Camp and women carrying water home

Every month WFP (World Food Program, another UN agency) provides the refugees with beans, sorghum and cooking oil.  Some months salt or soap are also provided.  The distribution is done on a different day for each refugee camp but still involves thousands of people and tons of food.

Women coming back from WFP monthly distribution.
Dinka's are tall and thin!

Most of our food at MSF is purchased by our cooks locally and once a month some is ordered from a store in Gulu 2 hours away.  The food chain here is a bit more direct than at home.  Coming home from work Saturday we pulled over to the side of the road, bought a live goat, put the goat in the back of the SUV and drove home.  Goat showed up on the menu for our evening barbecue with our friends from UNHCR that evening.  Similarly the cooks buy chickens that run around the yard for a few days and then turn up as dinner.  The food here is good, all homemade bread, with very little that is not cooked from scratch. The oranges and grapefruits are green and a bit less sweet. Avocados, bananas and pineapple are wonderful!  Can't wait for mango season.

November

Have been busy compiling statistics for the monthly report that we send to Kampala. After they have reviewed it there they send it on to the Paris office where all decisions about this project are ultimately made.  There are five MSF operational centers in Europe and all MSF projects throughout the world are run by one of these centers.  Currently only MSF Paris and Epicentre (MSF's epidemiology division) are operating projects in Uganda.

One of my jobs is running a weekly hour long educational program for everyone who works at the health center.  This week I asked our visiting epidemiologist/MD, who is a world expert on sickle cell disease, to give us a talk. He gave a good presentation and got everyone in the audience wondering about their genetic status.  Uganda and the west coast of Africa have the largest concentration of people with sickle cell disease and most of the kids that have it here die by age 2.

Some of my patients this week:

-3 kids with severe acute malnutrition (SAM)

-a snake bite—did ok without anti-venom which we have

-toddler with burns on his chest, back and thighs (we get a new one of these every week due to the cooking being done at ground level)

-severe malaria (many cases, and a 17 month old that died from it after poor treatment at a drug shop)

-pneumonia (many cases in kids under 5)

-stroke in an old man (anyone over 40 is old here!)

-8 year old with a huge lump on the side of her cheek.  She's supposed to get surgery in Kampala but the United Nations agency which will pay for it is out of money until January

-2 young boys with broken arms

-women with a miscarriage, malaria and severe anemia (I typed and crossed the blood with the midwife and transfused her)

-adults with asthma with acute attacks from being out of drugs

-9 year old girl with malaria that had had cuts made on her upper arms and forehead to “heal the fever”

-possible TB in HIV+ woman

-child with large abscess under her chin
-1 week old with a large breast abscess

Happy baby recovering from pneumonia

Child with asthma in our "playground"--the dirt

During rounds one of the caretakers of a 5 year old with malaria started crying.  We asked her what was wrong and discovered that at age 14 she had been left to care for 5 younger siblings while her mother went back to South Sudan.  

It's getting hotter here.  Spent Sunday afternoon playing trivial pursuit and watching a movie in the air conditioned pharmacy.  When it cooled off around 6 we had a badminton tournament.  I was paired with our French logistician and we won!

Unexpected trip to Kampala

 Last Monday I woke up with a high fever, headache and vomiting. Called the other doctor here, who came right away, and started me on Cipro after determining it wasn't malaria (I do take prophylaxis).  I was pretty miserable all day--a fever in a hot place is a bad combination. When she and a Nigerian doctor, here on an epidemiology project, came to check on me that evening they decided I needed an IV and to go to Kampala.  MSF doesn't like leaving sick expats out here because if they get worse there are not any options but air evacuation. The next morning they put a mattress in the back of the land cruiser and the doctor and I traveled to Kampala--8 bumpy, sweaty uncomfortable hours.  Got to the MSF compound there, rested a bit, and then one of the staff took me to the International Hospital.  It was quite nice and equipped with it's own airport to med-evac people to Nairobi.  Saw the doctor there, got tested again for malaria and some other things and with still no diagnosis he advised finishing 5 days of Cipro.  I was much better the next day and after resting for a couple of days was able to come back here. Everyone was happy to see me and some of my dorm mates decorated my room with balloons.

Nile River on the way back from Kampala

Close to where I work there is a little shack by the side of the road with a sign saying "drug shop" and these shops are quite common.  People come in and ask for what they want or untrained people help them decide.  This often includes injectable and IV medications although they officially are only supposed to give oral medications.  If the patient doesn't do well they scribble what they've given (if we're lucky) on a scrap of paper and "go to MSF".  We get 3-4 severely ill children a week from them--sometimes comatose.  A mother brought a child in that had had both IM and IV injections and was given 3 different pills to take as well.  My favorite was "Spamicillin"  a combination of amoxicillin and cloxacillin.  While the Ugandan Ministry of Health will shut them down if they catch them they usually just relocate if they hear enforcement is on the way.
One of their referrals was an 8 year old that was brought in unconscious with cerebral malaria. I was pretty worried he was going to die as 2 children with similar stories did last month. His mother kept saying she had no hope but then asking why she couldn't feed him if he was alive. The only lab tests we can do are a rapid malaria test, hemoglobin and blood sugar.  We started him on IV antimalarials, and antibiotics, IV's fluids, did a blood transfusion for severe anemia and after 24 hours he woke up. Quite a miracle!  

Riding home after work one day I was sitting next to a translator who told me his "war story".  He was in Kampala studying computer science at the University, with one year to go, when war broke out in South Sudan. He left school to go home to help his family. He said that at that time he had 30 cattle he was selling off as needed to fund his education.  Due to the war his family fled to Uganda and he lost his cattle.  The family now lives in the refugee camp and he is working as a translator for MSF.  He hopes to save enough money to go back to school and finish his degree.  It’s unclear when or if his family will be able to go back to South Sudan.

Late Saturday afternoon after work a group of us went to Adjumani market to look for material and then to the tailor. Although six white women in the market are quite noticeable not one person tried to beg, push us to buy something or hassled us in any way. While there's not much one would want to buy here the fabrics are fun. We ordered pants and skirts for $11 dollars each and I got my scrubs hemmed for 40 cents. 

I have been going to Catholic church as even though the country is about 40% Catholic and 40% Anglican what's close by is two Catholic churches.  Last week we went to the larger one and got there when the English language service was supposed to start.  The previous service ran late and everyone patiently sat around waiting for it to end.  While we were standing there a group of little children came up to look at us.   Other children started to join them and eventually there were around a hundred of them--just quietly looking at us.  The service is mostly sung and the music is beautiful.

It is the tail end of the rainy season here but it still rains for a little bit most days. One evening we had an amazing storm and we sat out on the porch and watched  lightening in all directions amidst a terrific downpour.  Rainy (malaria) season should give way to dry (meningitis) season by December when it is supposed to get unbearably hot. Lately there has been an increase in the number of bugs around and we are talking big ones!  There was a huge flying one in my room one night and it wasn't clear who was going to die first from the insecticide spray I was spraying while chasing after him.