Town, apartment, and hospital

I deliberately stayed in town one weekend to be able to see Mbarara and to take a few pictures around the place. Documenting stuff for the blog is particularly good in that it makes me take the pictures, and I have a record for myself as well.

Home and food:

I live in a cinder block/concrete two bedroom house. The other bedroom is occupied by my Ugandan roommate, one of three astrophysicists in Uganda. Very nice man. We have a living room, dining room, and kitchen. The bathroom has two toilets separated by a partial wall. One of the toilets has a bath in it as well. The sink (just one) is separate, so potentially three people could use the bathroom simultaneously.

The kitchen has a strange stove with two electric elements and two gas burners. Only the electric elements work. The fridge is not good at all; weak. Anything that really needs to stay cold I need to freeze. For that reason, I buy milk in little 500 ml (slightly over a pint) containers so that I use it up before it can spoil.  Milk by the way, is sold in plastic/paper containers that are sealed. Sterilization is achieved, I believe, with radiation.

Food is, well, not so great. None of the restaurants here are anything to crow about, so I cook for myself. There is a limited array of vegetables (tomatoes, onions, potatoes, sometimes eggplant, sometimes green peppers and I end up making various egg, pasta, and rice concoctions. The Ugandan rice is actually quite tasty. Pasta comes from Egypt.

Water is sometimes sporadic. It has a pretty high particulate content. I put it through a particulate filter, and then I put it through my trusty First Need microbiological filter. (The First Need could get rid of particles too, but this way I don’t shorten the life of the filter.) Electricity is also sporadic. It’s generally on, but occasionally isn’t.

As you can see below, I sleep under a mosquito net.  Pictures are below.

 

Kitchen

My bedroom

Living Room

Town

I walked into town this morning. It is an absolute madhouse. The primary means of transportation is the boda boda. This is a motorcycle with an engine displacement usually between 100-200cc. The driver drives, and the passenger sits on the back. Women in dresses ride side-saddle. Some people hold onto the driver. Some people hold onto a handle that is behind them. Some people don’t hold onto anything. Some people, including me, don’t ride them.  Anyway, they are everywhere. Almost all the motorbikes you see in the pictures that follow are not for personal use, they are boda bodas.  The streets are lined with shops and stalls. The side streets have little stalls and shops as well. I must say that I felt sufficiently different and uncomfortable that I didn’t venture down the side streets, just stayed on the main drag.  I don’t know if any of you get solicited by Finca, the microfinance NGO, but I have a picture of their Mbarara office below.

This is the town center. The bull is the "famous" Mbarara cow statue, commemorating the famous Ankole cattle in the region.

Yup, Finca really does more than just solicit funds.

Typical street scene

What a great picture. Asleep on your wheelbarrow.

View into residential areas

This is actually quite typical. Folks will ride their bikes to where they need to pick up whatever, and then walk their bike back, piled full of bananas, milk cans, whatever.

Costs vary widely. A 500 ml bottle of Tusker beer (4.2%, not terribly high), is 3000 Ugandan shillings, slightly under 1 USD. The exchange rate is approximately 1 USD = 3300 Ugx. I can buy two small eggplants, 4 tomatoes, and 4 purple onions for about 2000 Ugx. However, breakfast cereal made in Kenya under British license is about 15000 Ugx, which is quite a bit. Toilet paper is about 1300 Ugx per roll. An albuterol inhaler made in India is 45000 Ugx.  A CT scan of the chest is about 200000 Ugx.

Hospital and University

The hospital and university are a sprawl of primarily one story buildings, many dating from the colonial era. There is some newer construction as well. For a person from a resource rich environment, it is very jarring to walk around. The hospital provides sinks for patients and families to do laundry, and every morning the lawns are covered with drying sheets and clothing. Wards are long, narrow affairs with no privacy, and they tend to smell. Handwashing is very difficult to achieve, and everyone carries alcohol gel. Attendants (family) either sleep on the floor next to the patient or outside. People here were not nearly as interested in posing for pictures as they were in Bhutan, so I shot a couple of quick pix of a part of the emergency room and the female medical ward with my tablet, so it looked like I was looking something up.  Sorry, everyone.

What’s really interesting to me and somewhat puzzling is all the global development stuff here. Mbarara and environs are funky enough to be decidely classed as resource poor, but ultimately it’s actually pretty safe and sane here. A bunch of universities and hospitals in the U.S. have partnered with the hospital here; Mass General even maintains a “guest house” here and they send residents here. University of Virginia sends their internal medicine resident with a global health concentration here one a year. All kinds of HIV related initiatives are here, funded by private sources and WHO. Everyone’s nipping and chipping off little pieces of the problems here and it’s not clear to me that systemically things change. Certainly, there is a boost in AIDS care—patients get medications because the US and others pay for it. There’s a TB program, and all kinds of meds, but there is no program for directly observed therapy. Some folks come here clearly thinking they have “the answer” but that usually fizzles out pretty quickly. There’s also people who come here with an academic agenda. Collect research data, punch your global development overseas ticket, and go home and write about it. Whether this has any direct benefit for local people is not clear, nor is it the purpose of the visit. To be honest, I worry about that. So, it feels hit or miss. All these people just churning away, but does it really improve life. I don’t know.

The local docs are very smart. I mean, very smart. The residents know far more about physical diagnosis than I do, to the point that it is embarrassing sometimes. They are not taught good critical thinking and presentation skills, but they catch on very, very fast.  Working with the residents has been wonderful. We really have learned a lot from each other.

Anyway, enough sociopolitical and economic philosophizing. Here are pictures of the hospital.

Typical morning scene outside the wards. Laundry drying, and you can just barely make out a group of ladies sitting and chatting at about 2-3 o'clock.

I love this. Everything is free, except for the stuff that isn't. Unfortunately, the stuff that isn't is the good stuff.

View of  a portion of the ED

View down middle of female medical ward.

Yesterday’s rounds

Thought I’d give folks a taste of what I am seeing here

·         Disseminated TB in HIV+ patient sufficiently severe to cause shock and multiorgan system failure

·         HIV+ patient with cryptosporidiosis diarrhea and pancytopenia

·         HIV- older lady with hemorrhagic stroke

·         Severe headache in HIV+ patient. CSF analysis is negative, one of the services provided for free by the hospital. However, the patient cannot afford a CT scan, so it is impossible to conclude the workup. She remains undiagnosed

·         Post-partum cardiomyopathy with heart failure and multiple embolic strokes, HIV-

·         HIV- patient with cerebral malaria, temperature 42.7 C, which is 108.8 F. These were not typos. She died shortly after I saw her

·         New HIV+ with AIDS defining illness cryptococcal meningitis

·         HIV+ woman with a case of condyloma acuminate from hell

·         Elderly woman with lymphangitic carcinomatosis from breast ca, large pleural effusion

·         HIV- patient with recurrent pericardial and pleural effusions. Probably post-TB but not definitive.

This is not cherry-picking to make it look bad. This is a fair cross section of what I see.

It is hot here, and the rains have not yet come. It is supposed to be rainy season, and we’ve only had occasional sprinkles. Not good. However, it allows families to sit out on the grass and spread their laundry out to dry over bushes and over the lawn.

Below are some pictures from near my apartment. The storks are Marabou storks. They are ugly as hell and noisy. They stand easily a meter tall and roost in trees around my apartment. In terms of ecological niche, they are half pigeon, half rat—ubiquitous scavengers.  One sex has this big globby thing that hangs down, like a turkey wattle on steroids. As I was writing, I heard this thumping around on the roof and one of the critters was up there. He's the guy standing on the corrugated roofing material. 

The street is a major street that goes into town (we are on the outskirts). The big yellow thing in the middle is an overpass from one side of the campus to the other.  More local pix this weekend.

Note wattle on front.

In a tree. Nests are these big, sloppy affairs.

Another picture of our seriously ugly friend.

Street outside my window.

I went to Lake Mburo National Park Saturday and Sunday. At the outset, let me say that it is extremely difficult to do good animal and bird photography. However, I did my best. This is mostly pictures.

Lake Mburo is surrounded by semi-arid savannah dotted with clumps of acacia trees and termite mounds. The park is by and large dangerous predator free—no lions, so it is possible to even take a walk (did that Sunday morning) if you do so with an armed guard. The concern is the Cape buffalo, who can get very nasty. The lake has hippos, and we saw some. We saw tons of ruminants. It was easy to come within about 10-20 yards of the animals. More than that and they would take off. When all was said and done, I got some nice pix, though they are a minority of my shots.

Also took pictures of my lodgings, a road scene, and sunrise.   Enjoy.

Zebras!! Apparently only park in Uganda that has them

Baboons

Ankole cattle, local to western Uganda. Not a wild animal.

Bat. Can't see the critter's head.

Black faced vervet monkeys. Quite assertive, try to get food, will get into lodgings if you let them.

Topi

Cape buffalo. I'll do better at other parks. They are ubiquitous in East Africa, and nasty tempered.

Crested Crane. National bird of Uganda. Quite beautiful

Eland, largest antelope

Giraffe. A little bit of a story here. Giraffes are not native to the Mburo area. However, the park has too many acacia trees, and giraffes love acacia. They brought in 10 females and 5 males, and are hoping to establish them in the area.

Hippo. They stay in the water during the hot day. At night, they will travel as much as 3-4 miles on land grazing. apparently they have no sweat glands, and the sum makes it hard for them to be outof the water during the day

Hornbill, shot at a distance

Impala. Beautiful animal.

Lawrence, my guide when walking, next to an antelope carcass. The rains came late and light this year, and there's been quite a die-off. Note AK-47

One view of my lodgings at Mihingo lodge. Just beautiful

Small nile crocodile, about 1 meter long

Pair of African fish eagles. Female is larger

Typical road scene.

Sunrise from Mihingo Lodge over the lake

Topi

Wart hog, coming out of a mud hole. Cools them off and protects them from insects.

Not from the park, but from outside my apartment. That round thing in the middle is a nest, and the birdie hanging upside down is feeding her chicks.

A little more in depth look at things.

I have been crazy busy. The days are long, I come home tired, and it is HOT, which drains the life out of me. Barely have the energy to cook supper much less post a blog. However, quiet afternoon after getting home from Lake Mburo National Park, and I can do some posting

First, really didn’t get a chance to see Dubai. However, my impression was that the culture was relatively intact, the place was clean, you could eat the food, and they were quite tolerant.  Could have been a lot worse, and the free hotel was actually quite nice—clean and comfortable. Meals weren’t bad either. The hotel came as part of my air ticket since I had a long layover.

This place is so different it is hard to create context. I have been treated with utmost courtesy by all the Ugandans. I live in a compound associated with the University. The white people here in the compound are a mix primarily of Brits and German/Scandinavian, with a few Americans thrown in. Whites are called mzungus, which can be endearing or degrading depending upon context. The UgandansI have had conversations with are socially very conservative.  They recently dropped the death penalty for homosexuality. There are several expats here that are simply doing research. They come here to collect information about development in the developing world, medicine in the developing world, social issues in the developing world, AIDS in the developing world, etc.

The medicine is unbelievable. Tremendous amounts of AIDS, TB. We’ve also seen some utterly weird stuff that no one can figure out. This is partly because no testing is done. The patients simply can’t afford it. There’s a strong tendency also to work up problems and then do nothing about it. I’ve been trying to gently argue against that. We also do weird testing. There’s a white lady doctor who sounds from accent like she’s from Canada. Every Tuesday and Thursday she schleps around a hand-held ultrasound machine so any problem that can even remotely be addressed with ultrasound gets ultrasounded, and she happily wanders from patient to patient with her probe. A couple of times it’s been very helpful.

The wards are massive. I have been working on female ward. When it is full, there are patients on mattresses on the floor. Sheets provided by family. There is no effort made to provide privacy for anything except inserting a foley or doing a pelvic. Women routinely sit around topless; there is apparently little or no inhibition about this, at least on the wards.

Had my first chest clinic. 10 X 12 room with a desk, a few chairs, a spirometry station, an exam table, and a bunch of file cabinets. Add the PFT tech, a resident, and Dr. Muyanja (learning to have specialized respiratory knowledge, who’s a nice guy, really nice guy.) the nurse, the patient, the attendant (patient’s family member/friend/translator), and me. Often there is a patient getting a PFT while a patient is being seen, and at one point when we were falling behind, the resident was seeing a patient, the doc was seeing a patient, and the PFT tech was doing spirometry all in the one room. No regard for privacy.  I clearly helped Dr. Muyanja, who soaks it up like a sponge. 

The way medical education works here is that there are students, interns, and post-grads. The medical students are, well, students. The interns are there because they have to be; they can’t get a license without doing an internship and some of them don’t seem to be giving their all. The residents have to pay to do a residency, and because of that they self-select. They are smart, motivated, and a lot of fun to work with. I really enjoy them. They like working with American docs because we are approachable and are accepting of and encouraging of interaction, questions, and letting the residents gently push back when they disagree.  We are much less hierarchical than locals or Europeans/Brits. My lectures are a mixed bag. Some have been good, but I gave one that really came off awful, to the point that I apologized.

I now have an apartment mate. He is one of three Ugandan astrophysicists (honest, I’m not making this up), got his PhD at Cape Town, the real deal. Came down from Kampala to teach physics and astrophysics at Mbarara. He’s a really nice guy and I couldn’t ask for a better roomie. 

I am personally feeling somewhat overwhelmed. I’ve been fighting a cold that I brought from Maine, just about over. I’ve had trouble with the heat—any effort on my part drenches me. I’ve been cooking for myself (got taken out a couple of times) and have gone pretty much vegetarian—vegetables, eggs, cheese. Today I had a small tin of sardines which was wonderful. I don’t plan to cook any meat here for myself. Ugandan beer is acceptable.  The food is not particularly interesting in restaurants, which is what I fully expected.  I am VERY glad I brought my water filter. Bottled water is expensive and I won’t even rinse my toothbrush in the tap. Occasionally the water comes out with yellow/brown particulates—I think it is road dust because the two are the same color. There’s a pre-filter that came with the kitchen, that gets out the particles, and then I filter with my microbiological filter for drinking water. The eggs often have flecks of bird turd on them, so they are getting iodine water treated as well as the veggies. (I am making a dilute iodine solution and soaking my veggies and eggs in it before cooking. Iodine works as well as bleach but is more concentrated, and comes in these teeny tiny little bottles…)

Everyone here, expat, local, the game ranger I walked around with this morning, an Indian on the plane I sat next to, is worried about the US election. They all talked to me about the US election. They really, really worry that Trump will get elected—genuinely fearful of what might happen. The reaction I’ve encountered is clearly worse than when I was travelling during the height of the Iraq war, where showing your face as an American was not such a hot thing to do.

I will put up animal pictures as a separate post.

This is definitely not Kansas.

I got into Mbarara yesterday, a 5-6 hour ride from Entebbe. It took a bit longer than I expected because (1) the university employed driver, Kato, needed to have breakfast (obviously, had to be my treat) and (2) he needed to buy some charcoal for cooking. Apparently one does better outside town than inside town, so whenever he’s coming back from Kampala or Entebbe, he stops, negotiates, purchases and schmoozes with the widowed lady that sellls charcoal. Kato knows everybody, including some of the police that stopped us at the half a dozen or so roadblocks. These are good roadblocks, not political/suppressive. They are to find unlicensed, uninsured drivers, drivers hauling large loads on a truck on a motorcycle permit, etc.

My apartment was supposed to be shared. The other guy never showed up. Serafina, the housekeeper tells me she will keep me informed. There is no knowledge as to why he hasn't shown up.  In the meantime I have a large, comfortable dining room and living room, two bedrooms, and a bathroom split into three: one cell with a toilet and bathtub, one cell with a toilet, and an outer room with a sink. My room has a double bed and a single bed. There are bars on all the windows, and I can lock both the front door and my bedroom. There are rifle toting guards both in our compound and basically near any entity of any value. After 24 hours, it’s just part of the scenery.

There are birds all over the place. There is a huge, insanely ugly bird called a maribou stork. I will definitely get pictures. They nest all over the place. There are also small cute birds. I will try and get some of those too, but they are fast. There is happily a supermarket within walking distance—(Bhutan blog fans: think of the 8-11.) It is a little light on veggies but there are a couple of stands where I can buy stuff.

There’s a large expatriate community at the hospital: volunteers, Peace Corps folks, professional do-gooders, some academic types doing research on global health, and probably a couple of folks wasting away in medical Margaritaland.  Not sure about the latter, but it does feel like a place where you could slowly slide under the surface and simply forget to come up for air. The great majority of expats here are genuinely good human beings concerned about the welfare of the community and are struggling against crazy odds.

Sooo… first day on the wards. Residents are smart, very smart. The residents PAY for the privilege of being residents. Yes, you read that right. And because of that, they self-select to be smart and work hard. The medical students and the interns are either completing school or finishing training and licensing requirements, so that self-selection hasn’t taken place yet. The hospital is typical developing world—extremely limited formulary, families take care of patients, overcrowding to the point that the patients are on mattresses on the floor. If the medication is not on formulary, patient’s families have to buy it in a pharmacy and bring it in for administration. If the lab test is not in the basic, covered suite of tests, the patient has to pay for it. This gets tough when non-covered labs include blood glucoses and electrolytes. Thus the problem is not that the docs are not good, but patients can’t pay for the care so they reject testing and management. Fortunately, anti-malarials are on formulary, and the government distributes anti-retroviral therapy and TB meds that are provided by international grants.

We saw about 25 patients in 4 hours. Malaria, glomerulonephritis from acute hepatitis C infection, every manifestation of HIV under the sun, and three cases of TB of the spine with paraplegia, and a woman with an ejection fraction of 17% and creatinine of 8.9. I was literally just stunned. I will need to work hard to find how I can be of help when I have so much to learn.

Well, I made it to Entebbe.
Smooth flight from Boston to Dubai. Stayed in Dubai overnight on Emirates' (the airlines') nickel. Got to snag a little Middle Eastern food at dinner and breakfast the next morning. A little weird in that they were wildly insistent on just a single carry on bag. I had to take my attache case, empty it, stick it in my luggage, and pray that stuff that I thought was semi-important (as opposed to wildly important) didn't disappear. Happily, it did not. I also was completely unprepared for what happened, and didn't think well on my feet. Thus, I ended up having no change of underwear, etc etc and was pretty ripe when I landed in Uganda (yeah, TMI, I know.)

Prearrangement of a visa was really helpful, got me through immigration very quickly. Got my money exchanged and got a sim card for my phone, and off we went to the Boma.

Lovely hotel, highly recommended. Grounds are beautiful, and there's a rifle armed guard at night. Sounds good to me... No air conditioning, but they had a pool (well chlorinated) and it was an absolute godsend after all that travel. Dinner was good but relatively uninspired. I think that will be the story across the continent.

Had a chance to take some pictures around the grounds.

Main House, Lizard, and a couple of birds 

Drive to Mbarara tomorrow.