“But Doctor we can’t afford a Kangaroo…”

MDGS copied from Born too soon report

If you are wondering what all the fuss is about and why the RCPCH has decided to send us out here, it is partly because of the famous United Nations Millennium development goals (MDGS).  I first heard about these goals whilst I was listening to a clever man speak at the University college of Ife, Nigeria summer of 2013. A week before I heard this speech I had my interview with the RCPCH Global links and was given an offer to come out here just before my flight to Nigeria. When I heard the speech I knew I had made the right decision, it was one of those moments when everything becomes clear.  The UN has 8 MDGS, it is a blueprint made by all the countries of the world to meet the needs of the poorest and improve standards of living globally.  MDG4 aims to reduce childhood mortality, the largest of which is neonatal death in developing countries.  A staggering 40% of under 5 deaths are neonates, Neonates are babies less than 28 days old, some are born too soon (premature), born too small (Low birth weight), stillborn or born in poor condition and unwell.

In low-income settings the mainstay of management of neonates involves good antenatal care, maternal education, good resuscitation at birth, WARMTH for low birth weight and premature babies as well as early recognition of infections. A warm baby is less likely to get unwell, more likely to gain weight and grow because they use less of their energy to keep warm. And how does the WHO suggest we achieve warmth in low-income settings?  By doing Kangaroo Mother Care (KMC).

 This quote best describes why KMC is appropriate: “Incubators, where available, are often insufficient to meet local needs or are not adequately cleaned. Purchase of the equipment and spare parts, maintenance and repairs are difficult and costly; the power supply is intermittent, so the equipment does not work properly. Under such circumstances good care of preterm and low birth weight babies is difficult: hypothermia (low temperature) and infections are frequent, aggravating the poor outcomes. Frequently and often unnecessarily, incubators separate babies from their mothers, depriving them of the necessary contact.”

Adapted from WHO pocket book, a mum doing KMC

KMC was first noted in Kangaroos who keep their babies warm by putting them in a pouch in front.  Once a baby is stable, i.e. no longer needing respiratory support, they can start KMC from as little as 30 minutes a day to 24 hours stretches. The baby is naked apart from a nappy, a hat and socks on for warmth, they are then put skin to skin on the mum’s skin (clean skin) in front of her chest and a cloth is wrapped round the baby. That way the baby can nuzzle in and be fed, mum sees the baby constantly and can report any concerns. This is done on the unit and after discharge. 

Last week we had a set of twins born in very good conditions with low birth weight of less than 2kg, they were both cold and ideal for KMC. Both I and one of the local paediatricians sat and explained to mum and dad that it would be beneficial for them to learn KMC and keep the baby warm before we discharge them. My colleague spent over 20 minutes explaining KMC to both parents and at the end asked if they were happy to learn, at which point the dad replied… “but doctor I cannot afford a Kangaroo”. I could not stop laughing! It just made my day, needless to say we started the explanation again and they agreed to stay and learn.

The twins, eyes blurred out for confidentiality 

My colleague Sarah and I are knitting hats for the babies to wear during their KMC, our first guinea pigs are these 2 twins born prematurely. They both weighed less than 1 kilogram at birth and are now 4 weeks old and going strong thanks to KMC, homemade CPAP (only respiratory support we have) and antibiotics!

Some good tidings….

We Africans are known round the world for our spiritually, and unshaken belief in a higher being of some sort. On a ward round, my first question to parents is, “How is your child?” Normally in the UK, I will get a definite answer, either “he/she has a fever, or he/she is getting better”, In Uganda parents reply “ Doctor, he/she will be fine” regardless of how sick the child is they mostly reply “ He/she will get well Doctor”. As a westerner as well I sometimes wonder if this unshaken faith is denial, naivety, far -fetched or irrational but some of events this week have shown me the power of positive thinking. For instance I lamented so much about the heat and now we are officially in the rainy season! Constant torrential downpour, I suppose I should have been careful what I wished for. I shall no longer complain about the weather I promise.

Street art in down town Jinja

A couple of events this week have been nothing short of miracles and I thought I should share them with you. Last week I wrote about the hospital and some of the challenges limiting adequate provision of care to the children e.g. lack of resources. During our week of oxygen scarcity or should I say drought, we admitted a 12 year old boy who was very unwell with fevers, seizures and was in a coma (completely unresponsive) on admission. He also had respiratory distress, needed oxygen, ideally he should be on an intensive care unit and would have had a list of investigations as long as my arm. Unfortunately we had no oxygen, he was too ill for transfer nor could he be transported to the main hospital to have some of the investigations I would have deemed imperative in the UK and of course we don’t have an intensive care unit here at Jinja paediatric Hospital, so instead we got a full blood count, we already knew he was HIV positive and at risk of opportunistic infections so we treated every infection possible covering fungal/viral and bacterial meningitis. For the last 2 weeks we have been seeing him on the ward round every morning with no real response to treatment, each day the local paediatrician will say to me, “he will wake up soon”. I must confess I very much doubted it and had prepared myself for his “passing”. However, this week this young lad did “wake up”, he is not speaking yet but he is alert and looking around much to my surprise and delight.

I love this colourful house

Across the bed from him is a wee lad who was found on the street by a good Samaritan – again, this 5-year-old boy was found unconscious, salivating, with unresponsive fixed pinpoint pupils and signs suggesting a chest infection as well. Now if this was in the UK, I would not have guessed what the diagnosis was but my very learned colleagues here correctly diagnosed organophosphate poisoning and by some miracle we had one of the antidotes; we also treated his chest infection. A day later this little boy was much better, he could walk around and introduce himself to me in good English. He told us his age! From chatting to him the nursing staff found out that his parents live 3 hours away from the hospital and that he had been missing from home for a while. He most likely was living on the streets and had eaten contaminated food products he found in desperation. To cut the story short, it turns out this boy was kidnapped over 2 weeks ago and his parents were searching for him, and after social and security checks we were able to re-unite him with his family! 

Fishing boats by the source of the nile.

Amidst the doom and gloom of high childhood mortality (total count of 9 deaths so far in the last fortnight), severe malnutrition and poverty; happy endings like these are also occurring and such occurrences make me so pleased to be here.

Living as a diaspora 1

 Here is the promised personal post…. I am enjoying Uganda a great deal but it is too HOT! So hot that I managed to get sun stroked on Sunday after sitting out for lunch for less than 30 minutes, I am pretty sure I am no longer vitamin D deficient as I am officially a different shade of black despite my regular application of Factor 50.  I take 3 showers a day, yep 3 cold showers and getting pretty good at dancing/ jumping up and down in the cold shower.  Imagine having to wear a white coat on your outfit in 33 degrees centigrade, unfortunately all doctors here have to wear one for identification. There is a light at the end of my scorching tunnel though; the rainy season is around the corner.

My bedroom with the essential Mossy net

I seem to be posing a bit of a dilemma for the Ugandan, I often find people staring at me on the streets.  They know something is different but are unsure exactly what it is, I have been told by Sarah’s house-keeper that it might be the speed at which I walk. Apparently I walk fast like a Mzungu (this is what all white people are called in Uganda) but obviously not a Mzungu.  It also doesn’t help that I am spotting an Afro these days, which is ironically unusual in Uganda! I have been asked if I’m mixed race (I had to show pictures of both my parents to prove I was not mixed race), Mudagof (African American) or Ugandan, anything but Nigerian. Most patients lunch into a whole speech in Lugandan with me staring at them blankly. My task this week is to learn how to say, “sorry I do not speak Lugandan” “So gera Lugandan”.

Loudest Rooster in the world

The nurses on the neonatal unit have taken it upon themselves to teach me how to speak Lugandan so I am sure in 5 months time I might be able to make out what people are saying to me.  After a bit of negotiation and drama, I have finally settled into my accommodation, it is a self-contained room in a family house behind where Sarah lives. There is an adjoining door between the 2 houses, so I spend most of my time at Sarah’s place. There are 2 medical students staying at Sarah’s, one from America and the other from Manchester too.  The boys arrived before us and are practically locals already; they have being good at showing us around. Taking us to all the “Mzungu” cafes for wi-fi, restaurants and supermarket etc. Oh I almost forgot to mention our other housemates, 2 Alsatian dogs and a very loud rooster (which might be the main course at Easter if it doesn’t stop soon) that insists on waking us all up at 5 am everyday without fail.

One of the Mzungu cafes

Luckily for us most of our meals are made by Sarah’s housekeeper at a reasonable cost, she is a great cook and like most African women  (self included) she is trying to fatten us all up. I am getting use to the food, which consists mainly of carbohydrates, the odd protein but lots of yummy fruits. The mangoes and pineapples are incredible delicious and are less than 25 pence per fruit. The only dish I struggle with is called Matooke (mashed green plantains!!), I am not sure I will ever like it to be honest, in general food is relatively cheap and tasty, there are lots of vegetarian and non vegetarian dishes available in most places (foreign or local).  Amidst all the pleasantries, there are the usual frustrations of random power cuts, occasional lack of tap water, scary public transports and extortionate prices for foreign sounding people but it is no where near as bad as I expected. I also had my first experience of the long drop toilets with cisterns; I did debate how desperate I was for over an hour much to Sarah’s amusement

The Golf Course

Source of the Nile

We haven’t done much touristy activities yet, but we spent an evening at the source of the Nile this week (see pictures) and I also found the said golf course as well as a comedy club. There are lots of foreign people here mostly from Europe and people seem generally friendly everywhere we go, I am sure in the next few weeks I can update you about our touristy adventures.  In the main time I will continue my quest for sustainability! See It can’t be that bad, I’ve still got my sense of humour….. Ciao/ Mwebara

Source of the Nile

10 days in and still standing

10 days so far in Uganda and I am still standing strong.  In this short while I have seen and learnt a lot, I could write pages but I do not want to bore you all. For this post,  I will update you about work first (since that is what I am here to do, after all); but I promise to write about my personal experiences so far in a later post. Before I proceed may I ask my UK readers, how is the weather in the UK? Is it raining? I weirdly miss the rain.  It has been scorching here, 31-33 degrees this week, I never thought I would pray for rain but that is exactly what I have done on my daily 20 minutes walk to and fro from work.

 Work started in full swing this Monday at Jinja Regional Referral Hospital. Prior to travelling to Jinja, we had a tour of the main teaching hospital in the capital Kampala; it is called Mulago Teaching hospital.  It can be compared to a UK tertiary hospital, for the non-medics reading this, think of Great Osmond Street or Royal Manchester Children’s as an equivalent. The paediatrics department is huge and incredibly busy but I left with a certain sense of disappointment.  

After seeing the hospital in Mulago, I set my expectations for Jinja a little lower and to my surprise so far Jinja has exceeded my expectations in many aspects. Don’t get me wrong it is nothing like any Hospital I have ever worked at but neither is it worse than any of the scary stories I have heard or read about pre arrival in Jinja. 

The hospital is one of the 3 paediatric regional hospitals in Uganda and is serves a large population of children, some travel as far as 5 hours to seek care.   Over the next 5months I will be spending 3 days a week on the paediatric side and 2 days on the neonatal side.  It is early days yet but each day so far this week has been filled with highs and lows.

The highs were,

1.     The warmth and welcoming nature of all the staff both on the Paediatric side and on the neonatal unit.

2.     Fantastic HIV Paediatrics service, on Monday we attended the HIV clinic and it was phenomenal. Jinja sees over 500 HIV exposed/positive children a year! The doctors saw approximately 30 patients and they were all incredibly well  and thriving.  We learnt a great deal about the management of HIV exposed/positive children. The clinic is organized, well staffed with an admin office, a counselor, as well as 2 doctors to see the patients.  There is also a separate adolescent clinic to give the young adults some privacy to discuss some of the more relevant social problems that a HIV positive teenager is likely to face.

Alfresco art work on the wall in the malnutrition unit

Wildlife mobile on the unit

Mosquito nets in the malnutrition unit

3.     Malnutrition unit- It is beautifully decorated alfresco African paintings and wildlife mobiles for the children, light and airy, child friendly and each bed had a mosquito net (Dr. O senior will be glad to hear)!!!

4.     What great work my predecessor Jess/Colin have done. There were laminated job aides all over the hospital made by these UK Global links volunteers, new protocols drawn out for managements of paediatrics/neonatal conditions common in Uganda. These doctors have done such great jobs and are spoken of fondly by all the staff; their achievements are encouraging but also makes me aware that I have such big boots to fill!

The lows are,

1.     The disparity between demand and supply, on arrival on Monday at 9.00 there was a sea of patients waiting to be seen in the triage department. Although there are more doctors in the paediatric department than the main hospital, the demand for care still outweighs the supply.

2.     Just like the UK there were the few worried well patients, however most of children present very late at which point they are incredibly unwell. Some have tried several care centers or non-medical solutions (herbal/religious) before presenting to a referral hospital.  (See Jess and Colin’s post about hierarchy of care)

3.     Glaring lack of resources, for instance this week we did not have any oxygen in the paediatrics department or the main hospital. Despite the fact that over 1/3^rd of the acute admission had respiratory distress with low oxygen saturations.  Some were low enough to get my pulse raising. It is incredibly hard to know what to do in these situations .

4.     High mortality- some of you might have read my Epic wobble post describing my doubts which was partly due to the high level of mortality seen in Uganda.  My predecessors from Global links Jess and Colin posted a great post about the difference. (Do click on their name to check out the post). To put it in clearer terms, in my 6 months in Blackpool I saw 2 childhood deaths, one had a malignancy and the other was a neonate with Fulminant Necrotising Enterocolitis (Gut infection). In 3 days in Jinja I have seen/heard of 4 deaths some of which I struggle to come to terms with, as they were due to the point I raised earlier, lack of resources and delayed presentation.

In summary in the short time I have spent here, I have been able to reflect on the things I can do to help.  GL (Global Links) aims to not only help with service provision but mainly to provide sustainable ways of improving health care with the ultimate goal of reducing childhood mortality.  For the next month I will be standing on one feet and writing down every idea I have.  It is important to not jump in all guns blazing to avoid making mistakes or alienate myself.

I will try to understand the rationale behind why things are done and work along side the other paediatricians to make sustainable health care improvement. The key word been sustainability, i.e. when all foreign aid and volunteers go, can the local staff continue to provide affordable care for the children. That is the task!