Mwebale- Thank you!

I have not had much time to write in the past few weeks due to work, pesky diarrhoea and vomiting illness (I am much better, thank you all!) and of course social commitments.  But I thought it was very important to drop a note to say thank you to you all for your encouraging words,  well wishes and general comment. Some days are overwhelming here as you have probably gathered from my posts but all your wise words have been armouring me on.

I will also like to add that, although work can be emotionally draining. Sarah and I have made some good friends here and as you can imagine there are indeed some perks to living in Africa. Our daily early morning "ultimate workout" is keeping us sane. The beauty of this continent and it's every colourful way of life never ceases to put a smile on my face.  No matter how much I lament, I am not coming home till this "mission" ends so stay tuned for more of my adventures….

This is Africa (TIA)

Kenyan Coast

Last week Sarah and I took some time off over the Easter period to meet up with a couple of the other paediatric volunteers working in Kenya. We met at a beautiful part of the Kenyan coast and spent a significant amount of time sharing war stories.  It appears they both work in much better resourced hospitals (one hospital had a CT scanner!) and they were very shocked at how basic care was in our hospital.   This is not to say they did not have any challenges, they both had faced difficulties and dilemmas during their time in Kenya thus far.

Kenyan Coast

The break was a much welcome luxury; the Kenyan coast is one of the most beautiful places I have visited. Although the children at Jinja played on my mind constantly, I was very happy to have this time to relax and reflect on the work we are doing.  I have never prayed as much as I have in the last 2 months, each day I find myself quietly hoping that no child dies on our watch. I worry about the ones we have seen, the ones we couldn’t see as well as the ones I sent home because they were getting better and the parents could no longer afford to take time off work.

Most days, the work feels overwhelming and I wonder if we are doing anything to help. At such times I think of those children that have recovered, the once malnourished kids who are now a picture of health, the less than 1kg babies who made it home safe and are gaining weight and the joy on the faces of the parents as they thank you for the care you have given their children. Those famous words on the ward round “Well done, doctor”, is what has kept me going last week on our return to Jinja.  Despite the lovely break, the situation at work on arrival made the holiday seem like a dream. Things appear to be at an all time low, we now have less resources than we did a week ago!

Moonlight by the coast

We no longer have syringes, needles, or cannulas; parents have to buy these things so that their children can be treated, whilst you as the doctor wait anxiously, hoping that in that period nothing happens to the child. On arrival at work back off our holiday there was a child in shock who needed intravenous fluid immediately but we did not have anything to give the fluids, so we waited with bated breath whilst the mum ran to get them. Across the room a 6-day-old baby was having a seizure, ironically we had the medication to give but no syringes or needles to draw it out and administer it to the patient. Neither Sarah nor I were prepared for this, before we left we had syringes at least! We now “accidentally” have syringes/needles and cannulas in our pockets for such emergency situations or for those parents who do not have any money to buy these things.

I think the monkey understands my plight.  It stole my chair!

But I ask myself, is this sustainable? When we are gone who will “accidentally” find these things in their pockets? Where has the stock gone and who should provide them? These are all rhetorical questions; the resounding answer is “this is Africa” (TIA).  Such is our plight!

"Are you adopted?"

Easter is here and I am enjoying travelling around east Africa during the break. However, before I proceed with the rest of the post, I just want to reassure some of my worried readers - the noisy rooster is still alive and will not be the main course for Easter. In fact I now get concerned for the poor thing if I don't hear it in the morning. The noises from the rooster, the frogs, the random birds, crickets and the boda bodas (the forbidden motorbike taxis)have become part and parcel of everyday life in Jinja for me.  What I will miss this Easter though, are Easter eggs and daffodils; I do like spring at home.

On one of our escapes from the hospital a couple of weeks ago something very funny happened and I thought I would share it with those I haven't already told. We were out at a meal for one of our housemates’ leaving do before he went back to England. At the table, there were several people from around the world, a few Danish girls (young student nurses and student teachers), myself and Sarah, the boys and our Ugandan host family. One of the Danish girls was new to the group and had to be introduced to everyone. At the end of the meal, this 19 year old lady curiously asked me where I was from, she said she was confused by my accent. I did the usual explanation of my dual nationality, Nigerian by birth but have lived in England for a long time. She looked at me with utter confusion and said: "How come? Are you adopted?", at which point I nearly spat out the drink in my mouth as I could not stop laughing. Everyone at the table that heard this looked somewhat shocked. I politely explained migration to her and we all laughed about it.  My biggest regret was not replying with a line that Sarah later suggested... "Yes I was adopted, I am one of Madonna’s kids".

Interestingly, I was not offended by this young lady - this was her first time in this part of Africa, she works in a village teaching young children and to her all she sees of Africa is lack of education and poverty. She only knew one side of the story.  I do not blame her at all as I also often worry about the lack of education amongst some of the parents and children I see in the hospital. Uganda is an ex-British colony, this means that English is an official language in Uganda, in fact lessons in school from as young as nursery classes are taught in English. Despite this, more than 60% of the mums and children I see do not appear to speak or understand English - maybe the problem is mine and Sarah's accents. However, on top of the language difficulties, the majority of mums here are less than 18 years old, some as young as 14 years. This suggests they are not in school or at least not in Secondary school/higher education. This is a huge problem and it contributes greatly to the high child mortality rate we see in these hospitals.

Lack of education plays a major role in child mortality and of course has an enormous impact on the level of poverty these mothers and their children will face. An educated woman is more able to advocate for her family, more likely to seek appropriate health care promptly, less likely to be forced into unwanted relationships, less likely to believe health misconceptions, and be more likely to find a job and help provide for her family. This is why female education and empowerment is one of the millennium goals I wrote about a few weeks ago. The UN identifies how important it is to educate children and not exclude girls from school; in fact, we know that maternal education is the single most effective health intervention we can implement. My recent experiences have shown me the truth behind this statement. As President Kim said: "Education is not only a basic human right, it is a fundamental to ending extreme poverty". More work needs to be done in the community to encourage these young girls to go to school, though sadly, girls are often passed over for education and their brothers preferentially encouraged to attend school.

Whilst this educated young Danish lady can be easily forgiven for her blunder, what is ironic is her need for further enlightenment.  It is one thing to learn languages, sciences and art, it is another to learn about the world around you to avoid the problem of seeing only one side of the story (Click here to hear C. Adichie's TED talk). I am sure this lady will learn a lot on her travels.

Wishing you all a wonderful Easter.

Rant!

I will apologize in advance because this post is more of a rant than an informative post.  Both Sarah and I had a tough week last week; we both had moments of extreme frustration and upset. We had 8 deaths, 4 of whom were children less than 28 days old (neonates). I saw 5 children with severe malaria, 4 needing blood transfusion, and 1 child with cerebral malaria (malaria affecting the brain) and convulsions.  7 patients ran away because they were unable to afford the treatment and some because of the misconceptions I will discuss in this post.  Of these upsetting cases some were particularly heart breaking and it is those that stick in my mind. Sarah beautifully wrote about 2 cases on her blog (click here to read), and here I will write about some of the others.  The running theme amongst these cases is that the deaths may have been avoidable with some parental education.

In Uganda, parents associate 2 medical interventions with death. They believe these interventions kill the children as opposed to whatever illness had made their child unwell enough to require the intervention. They are:
Nasogastric tubes (a tube inserted through one of the nostrils into the stomach that can be used to monitor the stomach contents but also to feed children that are unable to feed. This tube passes through a natural orifice and although the initial insertion is uncomfortable for the child, it does not cause any pain or distress once it is in place)
A child being commenced on oxygen

For the last 4 weeks I have spent a significant amount of time explaining to each parents why these things are not the cause of death but lifesavers and essential for care. There seems to be an ingrained misconception about these 2 things. Death because of lack of resources, late presentation or overwhelming illness is one thing, but preventable deaths due to misunderstandings are incredibly upsetting.

One of the neonates that died this week had a gut infection called necrotizing enterocolitis (NEC). The mainstay of treatment is to stop feeds, rest the gut, insert a nasogastric tube and treat the baby with intravenous antibiotics until the gut heals.  We stopped feeds, inserted a cannula (which thankfully we had) and gave the baby intravenous antibiotics and fluids containing sugar and some of the salt the baby needed. We also the inserted a nasogastric tube (NG tube) to monitor the stomach content and help judge progress and aid reintroduction of feeds once the gut had healed.  Initially the baby improved, each day I stressed to mum why it is important not to feed, rest the gut and keep the tube in the stomach to monitor if the gut is getting better. I knew she was unhappy about the plan but there was no other way of treating this unwell preterm but to use the strategies mentioned above. After 2 days I was told by the nurses that each day they had to re-insert a new NG tube and a new cannula as the mum was pulling it out. She did not believe her child could survive with the tube in and no breast-feeding. Pulling the tubes out was her way of hoping she could avoid them going back in. What I did not realize was that she was feeding the baby when there were no medical staff around; 3 days into treatment this baby died of overwhelming infection.


The other case is a 2-year-old boy who weighed 5 kg and was on the malnutrition unit for stabilization and rehabilitation. At 5kg he weighs less than an average 6-month-old back home in the UK. After 2 weeks of intensive therapy following the WHO malnutrition guideline this boy was not gaining weight. On discussion with his mum it transpired that the little boy flatly refused the reconstituted milk containing the calories, micronutrients and fat he needed to gain weight. Whilst he would eat some dry food, he refused the milk as well as the plumpy nut (sweet-tasting calorific paste).  From his history, examination, a chest x-ray and some blood investigations, it was apparent that he had no other medical reasons to not gain weight or drink the milk, so it was decided that an NG tube was crucial as he was in fact losing weight on the nutrition unit. After an hour-long discussion with mum she agreed to have the NG tube inserted much to my delight. Unfortunately the following morning, this mum was nowhere to be found as she had ran away from the hospital with her little boy leaving me with a lot of dilemmas - should I have just left him without the feeds he needed? Would he have been better on the unit with some nutrition rather than running away? What will happen to him now?

In both these cases the mothers felt they were doing the right thing for their children and stopping the doctors from harming them.  This is a reoccurring theme; every day we fight a losing battle with parents about NG or Oxygen.  At the root of this problem is poor education and misconception, how do we go about educating such a large amount of people about these untruths in the short while I am here?   Shall I walk round my entire ward round with an NG tube in and see if that helps.  Maybe a radio jingle or a TV advert might help, either way something needs to change……

“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