Lessons from Kampala

It is very strange to be sitting opposite a Ugandan and be referring to ‘mum’ and ‘dad’ as if we were brother and sister. I had met Kenneth only once before but he has been part of the Austens since my sister taught him at secondary school in 1992. Even so I’ve known little about him and was a little overwhelmed when he showed me photos of his wedding, his daughter, and his son, Austen! - named so that the Professor’s memory will live on… (the professor’s daughters have clearly not done a very good job at this).

While I have nonchalantly taken our parents sponsorship of my education completely for granted…Kenneth is over the top with gratitude and sentimentality. But as he tells me about his life over ugali and chicken, I realize what a dramatic difference my parents have made in his life. By sponsoring him through university, he’s been able to get a job, support his family, pay school fees not only for his kids but his brother, and hope to sort out environmental sustainability in Uganda. Back in 1992, he tells me he would never have dreamed of being able to buy someone else lunch in Kampala.

So having my own attitudes challenged by my Ugandan brother has been one highlight of my time in Kampala so far. Otherwise, the HIV/TB teaching has been pretty incredible. My two favourite diseases over two weeks including some top of the game speakers, a nobel prize winner, a demonstration of adult circumcision (cuts your chance of infection by 60%) and lots of real live patients with real problems. I have felt slightly drunk with the experience, as well as bewildered by the problem of HIV in East Africa where every day more people get infected than start treatment.

Kampala is pretty mad. The roads are a bodaboda and taxi jam. There are these ridulously large ugly dinosaur-like birds everywhere. The campus where I live is alive with students, gathered in little groups: break-dancing/ singing/ playing football/ making fire/ praying/ campaigning. And finally the rain. It’s like nothing I’ve seen or heard before. It makes our walk home from school very amusing to the kids chasing after us as we literally slide down hills of mud and rubbish. And so the Kampala experience has given me some new resolutions – to become more like Kenneth in appreciation of life’s graces, to find a cure for AIDS, and to learn to walk like a Ugandan; always staying completely clean and dignified however much mud there is on the road.

Asante Sana Tazania

Half-term holiday. What an excellent invention. If you’re asking, like me, what exactly I have done to deserve this having spent 6 weeks sitting back receiving world-class teaching, living in a fantastic city with a view of Kilimanjaro out of the window and going on obligatory nights out, safaris and trips in order to complete my ‘hidden curriculum’ – the answer is not much. But I’m not complaining. As here I am on Zanzibar with the very difficult decision of whether to spend the day on the picture postcard white sands of Paje beach, swimming in the bath-warm crystal clear water, or taking a wooden Dhowe trip to snorkel round the corals. It does feel a little wrong.

So has this joker ‘diploma’ crew achieved anything in 6 weeks? Well, apart from making a thorough assessment of most of the restaurants, cafes, music and dancing venues in Moshi, we have definitely learnt a good bit of tropical medicine and done a fair amount of grappling with issues of access to healthcare in resource-limited settings such as Tanzania. This is a constant underlying theme of every module. Inevitable really when studying together - Tanzanian doctor, whose national health expenditure is around 2.4% that of the UK doctor’s they’re sitting next to.

It makes for some interesting discussion on the gold standard management of stroke when a head scan is unlikely to be an option, or for the treatment of malaria when first-line medicines are just not available. Inevitably we have to come up with 2 solutions to every problem: this is what we would like to do (and what would probably happen in the ‘West’), and this is what’s ‘appropriate’ for a ‘developing’ country like yours. It does not feel comfortable. But it is, sadly, real life.

And then there is the other dichotomy of experience between African and Western doctors. A definite highlight so far was when half way through an interview about access to healthcare in mountain villages the group realized the lady was actually in labour! One of the Tanzanian doctors, without any fuss, monitoring, sterilization or equipment calmly delivered the baby and carried on the interview. The ‘Western’ doctors looked on in wonder.

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I will really miss Moshi. Tanzania is a truly beautiful country. The people I met, despite their militant insistence that I speak Swahili at all times, were incredibly friendly. They took time to show us the best priced tailors, crossed the road to tell us to be careful with our bags (ok – so not everyone is friendly) and threw us an amazing party when we left to say thank you for our custom! I will miss the warm but breezy climate, my (downhill) run home from hospital along Jackaranda lined roads with the mountain overseeing, and the flamboyant wedding parades complete with roaming brass bands around town every Thursday, Friday and Saturday. It is a quirky town, well worth a visit, and was an excellent place to settle in to the diploma. Somehow I think the capital cities of Nairobi and Kampala will have some very different quirks on offer… I’ll let you known how that goes.

An extremely serious situation in the Serengeti

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Tropical Medicine is amazing. Two weeks into my diploma I find myself on Safari in the Serengeti with 6 men! Our learning objectives: to have an adventure (oh and complete a project on rural healthcare, but that will come later). A large emphasis of this course is on the ‘hidden curriculum’ of sharing life, academic interests, medical experiences and beer with our African colleagues. There are 20 doctors from East Africa on the course and 39 ‘Westerners’, and so far we have been blown away. While the ‘wazungos’ tend to gabble away analyzing this and that, fumbling over new terms and concepts, boasting about their ‘near miss’ clinical cases and NHS disasters, the East Africans tend to sit back, nod wisely and speak softly, silencing us with nuggets of profound wisdom. Some of the most interesting discussions have been over clinical case reports that we have all been asked to ‘bring and share’. A Ugandan microbiologist was asked what he would do with a case of internal bleeding that the NHS with its defensive and under-experienced docs, and over-advanced scanners had spectacularly missed. ‘Well actually I had a very similar case,’ he says nodding wisely and we lean in to hear what happened ‘I was the only doctor in the town and we had no scanners… so I opened him up’. Wide-mouthed we look at each other to check he must be joking because a microbiologist providing life-saving surgery would never be heard of in any of our ‘resource-rich’ countries.

I was a little concerned about how well the cultural exchange would go on safari, when our Tanzanian colleague started reeling off ways we should avoid meeting any dangerous predators whilst in the park. He was well kitted out for the experience with black shined shoes and brief-case and liked to tell us at regular intervals of the various ways that we might not survive the trip and what are chances of escaping alive were likely to be. I wondered how he’d react when he realized we were actually going with the sole purpose of seeing dangerous animals and so asked him what he thought of the situation as we were sitting watching some lions lolling about a few metres from our open-topped car. ‘Well’ he said, shaking his head, and with a glint of fun in his eyes ‘this is extremely serious, we are unlikely to make it out alive’.

And to Tanzania...

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‘I really like England’ one of my students told me, as I sat down for hot sugar with a bit of tea (the SouthSudan way) before class today. “Oh really, why’s that?’ “it is where my favourite scientist is from… Dr Darwin” he replied as if I should have guessed. It wasn’t the answer I was expecting. I was anticipating having to fake an interest in David Beckham or Arsenal’s place in the football league to be able to ‘connect’ with a South Sudanese male whose life so far I could only imagine. John lost a leg in a land-mine explosion when he was ten. He apologized for not turning up to class one day because his stump had become swollen it wouldn’t fit his prosthesis (that old excuse again). But as I sat there in the heat talking science and medicine, it struck me that while I cannot understand what it is like to live in a war-torn country, to lose limbs, homes, brothers and parents, to be shifted about the place with little clue of what the future holds, medicine had become a common language.

The Introduction to Medicine course is coming to an end and I am about to move to Tanzania to start a bit of studying myself. Having never heard of an OSCE (clinical exam) before, the students will sit their first tomorrow. I’m hoping that after a month of me nagging them to wash their hands before they touch and stop asking their patients if they are ‘alcoholic’, that some might pass.

Over all it has been an incredibly rewarding and fun month, but with various rumours flying around about what might happen to the medical students, and some resistance to us teaching from the university faculty there have definitely been some frustrations. The future for the Harvard teaching group is pretty much as unclear as it is for the students. The difficulty of setting up a simple service in Juba – treating patients and teaching students for free, has been confusing. We have been told one thing, then another, been welcomed then ignored, found locked doors and unexpected bills, come across disagreements, suspicion and confrontation. As well as being a bit depressing, this has made me consider how hard it can be to give and receive ‘help’. While I find it hard to understand why anyone would turn down a free service, especially with the name ‘Harvard’ attached to it, how would I feel if my country was full of hundreds of NGOs and charity do-gooders, if every piece of equipment in my hospital declared it had been ‘donated’ by some government other than my own, and if my workplace and community was the target of various ‘projects’ and ‘programs’. Although it doesn’t justify some of the encounters we’ve had, it does me good to put myself on the other side and realize that I have just as much if not more pride and resistance to being helped.

Any negative responses have by far been exceeded by the incredible graciousness of the students, who have gone the extra mile to make us welcome and let us know how much our efforts are appreciated. Whether or not we can carry on working with them, their wide-eyed attention in lectures, their insistence on paying for our lunches and their elaborate and earnest words of gratitude, have made it all worthwhile. (but no, don’t get them extra OSCE points).

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The medical students of South Sudan are organizing themselves. After sudden rejection from their medical schools in Khartoum where their universities had been funding their training, they have had no teaching, no support and most frustratingly no information about their future since December of last year. Some are living with friends and family in the city in order to be part of this short course in Clinical Medicine run by the Harvard Global Health Division (who have kindly adopted me as a ‘fellow’ – apparently it will look good on the CV). Many are staying in student dormitories - rooms, crammed with bunk-beds, with no running water, no electricity and no sewage system. It is a wonder these guys turn up for class at all but the fact they turn up looking smarter and fresher than me – I just don’t get how they do it. During this time of uncertainty (the government having not yet named ministers or assigned budgets), nobody knows yet if the medical school will re-open in Juba With no faculty, no funding for teaching facilities or support services, even the basic ‘accommodation’ is under threat. There were notices on the dormitory doors that morning announcing that they had 6 days to vacate the premises. The students called a meeting – complete with an eloquent president, a logo projected onto the wall and a power-point presented agenda. I was most impressed.

Apart from these major set-backs the students are brilliant, though their knowledge and experience vary greatly. Some put me to shame reciting tropical causes of hepatomegaly I’ve barely heard of, while some of my greatest achievements have been showing one guy how to put his stethoscope in his ears the correct way round, and another how to measure a pulse. I guess they’ve just been making it up until now. They make up for any lack of knowledge or experience by an incredible eagerness to learn despite the difficulties they face, turning up in droves to overcrowded classrooms sometimes two hours early to make sure they don’t caught out by unreliable transport links. I also see a great humility in the way they accept their predicament, making the most of every opportunity without complaint. The importance they place on their learning was brought home to me this morning when a student, John turned up to my tutorial. I had met him during my first week here teaching on the wards and had heard that his 15 year old brother had died unexpectedly with fever and jaundice the next day. I didn’t expect to see him again after that, yet here he was just over a week later practicing abdominal examinations with his classmates.

Other than teaching, I’ve been enjoying Juba. Having a role here makes a big difference and I like to walk through the dirt roads on my way to hospital saying ‘how are you, fine’ to the kids on their way to school, going for ‘fulle and esh’ (oily beans and bread) with the students after teaching, and doing random things you do in a place like Juba like attending basket-ball tournaments, meeting minor celebrities and shopping for saucepans in the market.

I made a small assessment of another local health care provider at the weekend when I went to get a tetanus booster. I had cut my hand on a metal fence during a panicked evacuation from the worst bar brawl I have ever seen. Apparently the bar we were in was a ‘bit dodgy’ anyway, and when tables started turning over and bottles flying through the air we decided it was time to leave. Being in South Sudan means a few smashed bottles quickly becomes a cause for panic and mass evacuation, which meant a quick exit was not easy. I found myself stuck on top of a 15ft wall watching Chris man-handling a large ladies buttocks as she tried to squeeze through a small hole in a fence. An interesting night out in Juba. And no mum, we won’t be going to that bar again.

 

  

New home, new capital: JUBA

I went for a walk around Juba this morning. Mainly because I like to get my bearings in a new place, but also because with Chris working 10-12 hour days and me currently committed to 2 mornings a week teaching in the hospital, I am at a bit of a loose end. Walking for an hour and a half in a bustling capital city I did not see a single other white person. I may have been an unusual sight, but on the whole people smiled, said hello and carried on as normal. Then I came across a man so captivated by my presence he decided to follow me closely, hands in pockets, shoulders hunched against the world. I wondered what the heck he was doing, and finally realized that he was mimicking me! And so I tried to act a bit more like this was the type of walk I take most days of the year.

I got my first impressions of Juba back in June when I visited Chris in the Tearfund compound. The first thing that hits you as you arrive in the chaos of the warehouse-style airport is the intense heat. Not the sort that makes you sigh when you arrive somewhere beautiful on holiday, but the sort that makes you grit your teeth through immigration and wonder how anyone could possibly live here. Now 6 weeks later, equipped with USB fans, a hammock, a blood pressure machine, a cafetiere, some mango chutney, a kilo of stilton, a bird book, balsamic vinegar and a bottle of gin, live in it I will.
The other initial impression of Juba is that this is not your average capital city. Up until a few years ago there were few concrete buildings in Juba. NGOs and businesses were run out of metal lorry containers and most people lived in mud/bamboo walled tin roofed housing or thatched tukuls. Although concrete buildings exist now, they are still in short supply. Consequently renting a one bed room costs as much as our 2 bed flat in Batterseeya, and metal lorry containers are still widespread – such as ‘Glory’ hotel I walked past today. I can only imagine the glory of being inside a metal box in 40 degrees heat.

Up until a few months ago there were no paved roads in Juba. Now there are a handful – proudly displaying solar powered street lights, as well as numerous signs and banners which blanket the walls and roundabouts. Some of my favourite are for the elaborately named ministries such as the ‘Ministry of Culture, Communication, Youth & Sports tourism & Hotels, Archives and Antiquities’ (that's one overworked Minister) and for national events such as ‘National Breastfeeding Week – Theme: Talk to the Breast’

 

South Sudan’s ‘flagship’ hospital is in Juba and people walk hundreds of miles to get there. Unfortunately, although they might get a bed in a fairly clean tiled ward, they are likely to find the doctors have already left to work in their private clinics, and there is no equipment available to do what I consider the most basic of diagnostic tests. A blood pressure machine, for example, is hard to come by, and an ECG is out of the question. Juba has not run a medical school for over a decade due to civil war and South Sudan’s aspiring doctors have been taught in Khartoum until last December when the funding for South Sudanese students in the North was abruptly stopped. Up until a week ago, most students were back in their villages wondering if they would ever be able to complete their courses, when some doctors from Harvard University arrived and started teaching a course in basic clinical medicine, hoping to negotiate the beginning of a functioning medical school once again. The response has been amazing. Almost 300 students have come out of the woodwork, signing up for every teaching session, cramming into small hot lecture theatres and hanging around through power cuts that would have provided a perfect excuse for an afternoon off back in my days as a student. I helped out at one of the bed side teaching sessions last week and was amazed at the wealth of ‘teaching material’ – weird and wonderful things wrong with people on the ward. I tried my best to keep my cool as I came across a massive spleen poking through someone's abdomen, whilst my students shrugged and casually told me that ‘it’s quite big’.

My overwhelming impression of Juba is of a sense of hope and opportunity for this new nation. With their flags and banners, building-work, business people, Americans springing from nowhere and starting medical schools within a few days, there is definitely an optimism for change and the creation of a better functioning capital city. So I’m excited to be here and hopeful that by getting involved I might be able to make a bit of difference, become a better functioning doctor, and transfer the title of ‘accompanying spouse’ to my peace-builder husband.