Jo Dunn Uganda

I'm still here

2011-01-30T10:03:00.000-08:00

It’s been a fair while since I updated my blog, so I suppose it’s about time to try to prove that I am still here in Uganda and actually doing some work. I left the hospice in Mbarara in October and after going back home for a few weeks to catch up with friends and family, started with the Palliative Care Unit at Mulago hospital and Makerere University in Kampala.

We have a small but perfectly formed team consisting of two other doctors in addition to me – Dr Mhoira who’s head of the unit and Dr Liz who’s the same level as me, training in palliative medicine.
We have 5 fantastic specialist palliative care nurses and a team secretary who’s fantastic.

Mulago hospital is the National Referral Hospital with around 1500 beds but probably around 2000 in-patients as many of the patients are squashed into and outside of the wards. We see patients on any of the wards who have life-limiting illnesses and require pain and symptom control, but due to the current morphine shortage are also seeing patients on other units with severe pain. In the last few months we’ve had many referrals from the burns unit to assist with pain control.

A Patient on the Burns Unit who we assisted with pain control

As well as my clinical role, supporting the nurses in reviewing the patients, I’m involved in developing some research projects, teaching undergraduate and postgraduate students and continue to work one day a week at Hospice Africa Uganda with the ongoing development of the BSc in Palliative Care. That keeps me fairly busy but is incredibly exciting and rewarding although a bit different to my recent work in Mbarara trekking through banana plantations to visit patients.

I should just briefly mention the recent morphine crisis which has been causing us lots of distress in recent months. Basically, the ways of ordering morphine through the government system have changed recently and the result has been that there has been no morphine available through the government sector for several months. The morphine is supplied to all hospitals and health centres across the country and also many of the non-governmental organisations such as some of the smaller hospices. This has meant that for the majority of patients in the country the strongest painkillers they can access are codeine or tramadol which are also very expensive and not the most effective analgesics for managing severe pain from cancer or HIV/AIDS. Hospice Africa Uganda (HAU) however imports its own morphine powder to make up into liquid and therefore continued to have a supply, although not sufficient to help everyone in need in the country. Our unit came to an agreement with HAU that they would supply us with morphine liquid so we could continue to help the patients in Mulago. With the support of many friends and family via Cairdeas (a Scottish charity of which Mhoira is the medical director and which supports Mhoira and myself over here), we managed to raise over £4000 which meant we could pay HAU for providing morphine for the patients in Mulago. Without raising this money HAU would not have been able to give us the morphine needed to treat all these patients. As for the future, it looks like morphine should be available to all the government hospitals in the next few weeks (hoping and praying lots!).

Supply of Morphine from HAU

Life other than work is pretty calm at the moment. I’m living on the same compound in Kampala as I was before but in a different house and have lots of fabulous neighbours. I’ve gone back to the very lovely Baptist church I was attending before so get my weekly fix of singing and dancing (and some spiritual input) which keeps me going. For once I don’t have lots of photos from exciting trips I’ve been on (although the UK at Christmas with lots of snow was loads of fun!) but so as not to disappoint I am heading off to India later this week for a palliative care conference and to do some teaching so hope to have more exciting photos on my next blog!

So I’m going to end here for now. The invitation is still open to friends and family who fancy a trip to Uganda – free accommodation in Kampala included! Until next time……

India and other exploits

2010-08-10T12:13:00.000-07:00

I’m aware the time between my blogs is increasing, my excuse is being very busy rather than just being on one long holiday though, although read on to discover if this is really the case……

So I should start off with my trip to India. As I mentioned in the last blog, I went with Mhoira to help out on teaching the Palliative Care Toolkit to some doctors, nurses and social workers in Lucknow, in Uttar Pradesh (UP) in the north of India. I arrived in Delhi to be met by Mhoira who’d already been in India for a couple of weeks doing some visits and teaching, and stayed with some friends of hers in Delhi for a couple of nights (Dr Chitra who came with us to UP and her husband). We went on a rushed shopping-trip the day I arrived to kit me out in suitable clothes for the 45 degree heat – loads of beautiful clothes and I had to stop myself getting too carried away. We flew down to UP the next day and were joined by Nicholas who is from the UK, and has been developing an organisation with Mhoira and others to sponsor Palliative Care education and training in developing countries. He came along on the trip to find out how the training toolkit works. On arrival, we were treated to a tour of Lucknow including a stop-off for bun-butter – a bit like cream buns, but with buffalo milk filling, and Indian chai, followed by amazing kebabs in the evening in a back-street kebab house.

Nicholas and I were also lucky enough to visit the Bara Imambara – a muslim shrine in Lucknow and had a whistle-stop tour by an Indian guide who spoke incredibly quickly and practically ran round the building, stopping periodically to spit – extremely random but quite entertaining.

The next 5 days were spent at the Sanjay Gupta post-graduate training institute (SGPGI) running the Palliative Care toolkit. This was developed by a team of Palliative Care experts from several different countries as an introductory course to PC for healthcare professionals and includes a manual for students as well as a training manual for those teaching to assist with the training. We had around 25 students for the week, mainly from Lucknow but also from other parts of UP. At present, UP has a population of around 160 million people, with only 2 centres who provide PC, so there is a huge need for training there. I met lots of inspirational people attending the course who are hoping to try to develop PC in their settings with very few resources and usually no extra remuneration for the extension of their role. It made me feel very humbled. We were also able to visit a couple of hospitals during our visit and met with other doctors and nurses hoping to set up PC services. Cairdeas, the organisation which Mhoira is sponsored by helps to fund some of the training and development for such groups.

A definite highlight of my trip was my visit to the Taj Mahal – absolutely stunning despite the 45 degree heat! The food was also incredible – so much flavour, spice and variety compared to the matoke which is served everyday in Uganda!

For the last few weeks I’ve been in Mbarara, settling into the hospice and really enjoying the clinical work. I think the trip to India training other professionals reminded me why I love the job so much. We’ve continued to see lots of challenging cases and it can be really difficult to know the right decisions to make sometimes, but the clinical team are fantastic and we can always come up with what we hope is the best solution for the patient and their family. One example is a 3 year old girl we saw a couple of weeks ago. She’d been referred to Mbarara hospital for chemotherapy from another hospital about 4 hours drive west where she’d been receiving treatment by the surgical team for about 5 months. At the age of 1, she’d had both eyes removed because of a tumour called retinoblastoma which is genetic and had affected both eyes. A few months before we saw her, she had developed a tumour on her right thigh, which had gradually increased in size, despite several attempts at removing it by the surgical team. She’d been under the care of the local palliative care team in the hospital who’d given her oral morphine as she had lots of pain in the leg. She was brought to hospital by her mum and dad who have 5 other children, the youngest of whom is only a few weeks old. Her dad had sold all their animals in order to pay for her treatment. We saw her initially on the surgical ward (children under the surgical teams in Uganda are kept on the adult wards, mixed in with either the male or female patients), when she was in loads of pain, despite her dad giving her the morphine regularly. The bandage on her leg had also not been changed for several days as the ward had run out of dressings. We increased the morphine and arranged for one of the paediatric doctors to see her and transferred her to the paediatric ward where we changed her dressing and discovered a huge tumour on her thigh which was bleeding as the dressing had become stuck to it. After lots of discussions with her parents, we eventually together made the really tough decision that no further treatment was possible. The tumour she had would be unresponsive to chemotherapy and her parents decided to take her back to the village where she could be with the rest of her siblings for whatever remained of her life, but with her pain better controlled. I’m continually humbled over here by the ability of people to cope with really tough situations and to never complain, but actually to be very grateful for the care they have received, even if it seems to me that the care has been inadequate.

Roadside Visits with my translator Carol
During the last few weeks I also went on outreach with the team again, but this time going ‘Roadside’, which means stopping every so often to review patients in small clinics, in rented rooms or under trees. As our patients live such long distances from the hospice, over the years they’ve developed mobile clinics so we are able to see our patients closer to their homes whilst not being able to visit all of them in their home individually. There is a fantastic system of community volunteers who have been trained by hospice to identify patients in the community who may benefit from palliative care, but also do lots of work on early identification of potential cancers and prevention of other illnesses. We visited one of their clinics where they bring the patients who we are reviewing every month and they had lots of posters they’d made about HIV prevention, healthy eating and checking for possible cancers – all very inspiring.

The Volunteer Team and Betty, one of the hospice nurses

The next few weeks are going to be fairly hectic for me here – back to Kampala to continue the face to face teaching for the BSc – first and second year students together this time though – action-packed couple of weeks! In September I’m off to Namibia for the African Palliative care association conference, then back to the UK for a few weeks in October to catch up with friends and family and prepare for my second year in Uganda – all very exciting.

Future Plans

2010-06-09T04:06:00.000-07:00

I can’t quite believe it’s June already – time is racing away over here. I had a fantastic couple of weeks with my sister Kate, brother Hugh and brother-in-law Steve a few weeks ago. Kate and Steve were here for a week and Hugh stayed for two. We spent the first week in Jinja rafting again, then we went to Murchison Falls on safari again (don’t think I’ll ever get bored of this). We had a fantastic week and I think Kate and Steve got to see a fair bit of Uganda and were entertained by Ugandan driving and the amount people can carry on the back of motorbikes! The second week was spent with Hugh, Mhoira, another of my friends from Kampala, Amanda, and her brother Andrew, climbing Mount Elgon in the east of Uganda on the Kenyan border. I would describe this as an experience – probably one never to be repeated by myself but something I’m glad I did. The climb took 5 days in the end, and we made it to 3945m – not quite to the peak but still quite impressive! It was my first experience of ‘rough camping’ very different from years of family trips to camping club sites in the Lake District! The first day was probably the worst. We started climbing a bit late partly due to a massive downpour on the way to the start-point, driving along a rather flooded and slippery road which was not my best driving experience so far in Uganda. The first day was walking through woods, which turned out to be very slippery when it was raining, and not much fun in the dark for the last hour. We arrived at our first camp which was a cave full of bats and giant rats with no latrine of any kind- we just had instructions to go behind a rock! Our tent was sited on a rock which the thin bed-roll didn’t really provide much padding for! I think we were so exhausted from the climb that we did manage to sleep for a few hours. We had considered just packing up the next morning and heading back home again, but with the sun shining felt more up-beat and decided to continue. The second day was the most enjoyable of the trek. The weather was sunny but cool, the scenery fantastic and company excellent. We also arrived at our campsite in the light and spent a few hours just chilling out (I was also able to wash my hair in a bucket of warm water – simple pleasures!). In the evening our porters entertained us with a ‘circumcision dance’. The youngest of them was 18 and was due to go through the procedure was real in a few weeks time – it was a very surreal moment.

We reached the Caldera on the third day – the highest point of the climb – which we had initially thought would be a valley with a small lake. It was a valley but contained plants like something out of space with giant lobelias around 6 foot tall and other weird and wonderful fauna. Our excitement for making it this far was somewhat dampened by the rain and the lengthy climbing uphill for what seemed like days. We were meant to complete our descent on the fourth day but it absolutely bucketed with rain so we decided to stay another night rather than complete the last section in the rain and the dark (a decision we were extremely glad we had made when we found out how long the descent was the following day). The last bit of excitement on our epic trip was when the taxi taking us back to our cars at the start point got completely stuck in the mud and needed many Ugandan men to physically lift it up to remove it from the big rut where it was wedged – quite impressive as they’d just spent the last few days trekking with us and carrying all our stuff! We stayed the night at Sipi falls and I don’t think I’ve ever enjoyed a hot shower and a waragi and tonic more!

After dropping Hugh at the airport, I spent the weekend in Kampala with my old neighbours then headed back to Mbarara and finally moved into my new house where I’m really settled now. The last few weeks at work have been really good. There’s still a lot of frustrations with patients not being able to access treatment for cancer that they would at home or even if they were in Kampala, but I still feel we’re making a real difference to the quality of people’s lives in relieving their pain and other symptoms. I had a really good meeting with about 15 of the senior staff nurse in the hospital where I explained about the role of hospice in the hospital, the need to try to refer patients to us early and prescribing of morphine by the hospital doctors. One of the senior nurses has recently been on a palliative care training course run by hospice Africa Uganda and is keen to start a small team in the hospital to identify the patients with palliative care needs earlier – this is an exciting development which I’m hoping to help out with. One of the things I feel really passionate about is trying to develop palliative care within the government sector rather than relying on NGOs, such as the hospice, to provide all the care. This leads me on to talking about my plans from September onwards. As most of you are probably aware, my placement here is for a year, with the plan to return to my palliative care rotation in London in October. However, I’ve been rethinking this plan and at the moment am applying to stay here for another year but return to Kampala and work with Mhoira at Mulago hospital and Makerere University, developing the hospital palliative care service and doing some research amongst other things. This isn’t definite yet but it really feels like the right place for me to be. One of the things I’m still working on is how to finance the extra year. This year has been financed by a bursary arranged through Hospice Africa Uganda, but I need to try to raise some funds for another year. I’m rubbish at asking other people for money but if anyone feels like contributing to keeping me in Uganda, all help would be appreciated. My brother and my dad are planning to do a sponsored cycle in a couple of weeks to raise money for HAU and Cairdeas (the organisation which support Mhoira’s work here and would be helping to support me - website is www.cairdeas.org.uk) so any sponsorship would be much appreciated – I’ll let you know the details when I get them.

I’m off to India next week to help out with teaching on a 5 day introductory course in Palliative care for health professionals (may also be doing a bit of sight-seeing during my trip – don’t want to dispel the myth that I’m still on one long holiday this year!) which I’m really excited about – more about that in my next blog. Until next time…..

Frustrations

2010-04-27T11:31:00.001-07:00

Thought I should try to update my blog before heading off on another holiday (don’t want to dispel the myths about this being just one long holiday!). I can’t believe I’m over half way through my year here – time is just racing by! I’ve settled into life in Mbarara really well and will finally be moving into my new little house tomorrow. It’s about 5 minutes walk from hospice and has 2 bedrooms and a lovely veranda. The view of the hills would be stunning if it weren’t obscured by a very high fence with barbed wire on the top to prevent any intruders – can’t have everything I suppose.

Life at the hospice here is pretty hectic with lots of staff changes so we’ve only got 5 full-time experienced clinical staff at the moment. The others are really enthusiastic but will little experience of palliative care so can’t really see patients without supervision yet. I’m loving seeing patients on my own though with the help of Carol – a volunteer at hospice who’s a trained counsellor but looking for a job – who translates for me and is also my dancing buddy. I’ve been going to the hospital a lot as the others find it rather tough and frustrating whereas I’m enjoying the challenge although have some rather frustrating weeks there too! We’d been reviewing a 14 year old girl who’d been on the surgical ward with massive neck swellings and difficulty breathing and had been referred to us for pain control. The swellings were getting worse and she was becoming weaker but unfortunately none of the doctors on the surgical ward seemed to think she was a priority. We thought she probably had lymphoma but she needed a biopsy to confirm this before she could start chemotherapy. Unfortunately the surgeons have rarely been operating for a number of reasons – no oxygen, no drips, no sutures…. and she never got her biopsy but died in the hospital. Absolutely heartbreaking and we felt so helpless. The junior doctors on the ward couldn’t do anything, neither could the ward sisters who were equally frustrated and we never see the surgical doctors in charge. There have been a couple of other young patients dying in the hospital over the last couple of weeks too. We have seen them and managed to control some of their symptoms but they unfortunately came to the hospital when their disease was too advanced to be able to have any treatment. On the more positive side at the hospital though is that they have morphine again from Kampala and the junior doctors are happy to prescribe it for the patients following the training they received from the hospice education team during their undergraduate years.

I’ve continued to go on some interesting home visits trekking through Matoke plantations (this is the staple food of this region – green bananas basically which are cooked and mashed a bit like potatoes but much more stodgy – I haven’t discovered a love of them as yet!). There are constant calls of Mzungu Mzungu from all the children we pass – the rest of the team find it really amusing that I attract so much attention. We see patients at all stages of cancer diagnoses and also patients with more advanced HIV although only about 20% of patients on the Mbarara programme have HIV – the rest have mainly cancer. As I may have mentioned before there is lots of funding around for patients with HIV – I think there are around 50 different organisations registered in Mbarara caring for patients with HIV. Whereas we’re the only organisation looking after patients with cancer and struggle to find donors willing to give money for these patients.

As well as the clinical work I’ve been working on a research study for which I finally handed the protocol in today. I’m also continuing to work with the BSc team – was marking draft assignments a few weeks ago and writing modules for the second year which starts in August. We’ve also been submitting abstracts for the palliative care conference in Namibia in September which I’m hoping to go to (another excuse for a holiday I know!). I also have plans afoot to go to India in June to teach on a palliative care course with Mhoira (consultant from Mulago and Makerere university in Kampala and buddy from my old compound) – should be lots of fun – will update more nearer the time.

I’m going to leave it here for now – only have one more day at work then heading off on holiday again with one of my big sisters, her husband and my brother – can’t wait!!

Mbarara at last

2010-03-21T06:58:00.000-07:00

I’m going to be quite controversial in this blog and talk mainly about work as I’ve not be off gallivanting around Uganda so much during the last month and have mainly been working. So, I’ve finally made it to Mbarara and have had just come to the end of my 3rd week here. The hospice here is much smaller with around 20 full-time staff and a much smaller clinical team. There are 5 nurses, 2 clinical officers (a position between nurses and doctors who have done 4 years of training and run a lot of the primary health-care around Uganda as there are many more of them than doctors), a dispenser to give out the medication from pharmacy, a doctor working one day a week and myself. We have around 500 patients enrolled on the hospice programme currently and see them weekly – monthly, depending on how stable they are. There is also no in-patient facility as hospice care in Uganda is generally home-based which is more culturally appropriate. We have 3 outreach clinics a month, run from community hospitals or church halls. As there are so many areas around south-west Uganda without palliative care, even though we official only cover an area of 20km radius around Kampala, in reality we see patients from a much wider distance. The outreach clinics enable us to reach patients who are unable to afford to travel to the hospice themselves, or who we are unable to go to their homes due to lack of time and resources. As part of the outreach clinics, as well as the team going to see patients in the community hospital clinic, we have a team who does roadside assessments where we arrange to meet patients or their relatives at a particular point such as next to a shop or clinic, then review them sitting under trees or in the hospice vehicle – not the best means of assessment but better than not seeing them at all. We always take a big suitcase full of medications with us which we then dispense by the side of the road to the patient or their relatives. It has been found to work well over the 10+ years it’s been running so far. I’m just amazed that the patients or their relatives will just sit waiting for hours by the side of the road for us to arrive, with no complaining at all if we’re delayed – quite refreshing compared to some of the moaning to be seen in GP surgeries at home!!

As well as the outreach clinics, we see patients at the hospice, in their homes and in the local hospital – Mbarara Regional Referral Hospital which is the major referral hospital for the south-western region. About 80% of patients under our care have cancer, most of the rest have HIV/AIDS. There are lots of organisations in Mbarara looking after patients with HIV/AIDS but we’re the only ones dealing specifically with patients with cancer. The hospital has some very good staff, but the facilities appear to be lacking significantly. Specifically for our patients, there is no oncology service. The only oncology is at the Cancer Institute at Mulago hospital in Kampala. Whilst we can refer patients there for treatment which in theory is free, the reality is that even if we assist patients with transport to and from Kampala, they are still required to take a family member with them to care for them whilst in hospital, they need to find money for food whilst they’re there and often need to pay for other tests and drugs which the hospital has run out of – an expense that most people can’t afford. I’m finding it extremely frustrating therefore that for patients who have conditions such as spinal cord compression, caused by cancer – either primary or secondary – of the bones of the spine which presses on the nerves to the limbs, potentially causing paralysis and incontinence, are unable to receive the proper treatment of radiotherapy to prevent the paralysis and incontinence as the 4-5 hour journey to Kampala is too difficult and expensive. This does mean that there is a huge need for palliative care here though as it really is the only treatment option for patients with inoperable cancers, of whom there are many as again many of them only come to see the doctors once the disease is very advanced.

I have again been amazed at how much people here in Uganda tolerate. I’ve seen several patients in my first few weeks who’ve come to the hospice for the first time, referred either by volunteers in the community or by local medical services. They have been suffering from severe pain for months without seeking any treatment, and just assuming they should put up with the pain. Even when they’re seen by other doctors or nurses no-one thinks to put them on even simple analgesia. Once we’ve seen them, we start them on small doses of analgesia – often morphine – and their pain improves within a few days and they can start living their lives again. It’s incredibly rewarding to be able to make such a big difference to people but frustrating that they should have had to put up with the pain for such a long time with no-one to help them. This just further confirms to me how important our teaching programmes such as the BSc are to really improve the services on the ground.

Mbarara is much smaller than Kampala but a fairly lively town. My social life has continued – I was out dancing until 4am last night – lots of fun! I’m currently staying at a kind-of RC priests guesthouse about 30 minutes walk from hospice. It was used as a seminary for priests in training until fairly recently but is also used as a retreat centre sometimes so is very peaceful apart from the incredibly noisy birds who wake me up every morning!! I should be moving into my own place in the next couple of weeks although it looked like it needed an awful lot of work when I went to see it a couple of weeks ago so watch this space….

I will leave it here for the moment but attach a couple of photos if they’ll upload - of myself and Mhoira on my birthday,of Martha who’s in charge down here and also works as a nurse on the clinical team, and of some of the BSc students during their face to face teaching, with Flavia who's the head of Education and was teaching on the course. Until next time……

Mum and Dad in Uganda

2010-02-20T07:58:00.000-08:00

I think my blogs have now officially gone from being weekly to monthly updates so I’m very sorry to those of you who were eagerly anticipating the next instalment and have been bitterly disappointed. It’s been a busy few weeks yet again but very enjoyable. Mum and dad came to stay for the last 2 weeks in January. For those who may not know, it was my dad’s first time on a plane and of course to Africa. We had a fantastic 2 weeks – exploring most of Uganda on a self-guided tour, arranged with the help of my neighbours. We travelled west to Fort Portal – about a four hour drive from Kampala – and stayed 1 night at a posh lodge overlooking one of the magnificent crater lakes – absolutely stunning. We had a relaxing day following the rather bumpy drive – mum and dad got very used to Uganda’s rather pot-holed roads – very entertaining at times. We then headed south to Queen Elizabeth national park and stayed a couple of nights. We went on a game drive bright and early in the morning, seeing a couple of lions, lots of buffalo and cobs and many amazing birds. In the afternoon, we went on a boat trip down the Kazinga Channel which runs between Lake George and Lake Edward and is a haven for loads of wildlife. We saw tons of hippos, loads of crocodiles and several elephants as well as loads more amazing birds. Dad decided to be brave and drive my car back to the lodge at the end of the day and had the experience of a herd of elephants stepping out in front of the car – about 15-20 of them with a few babies – absolutely more amazing! He’s more used to the elderly stepping out in front of the car at home – slightly less hazardous.

We then drove down through Queen Elizabeth park to our next stop – Ishasha which is part of the park and home to tree-climbing lions. The accommodation we were staying in was rather basic – a banda which is a round brick-built cottage – with rather basic facilities – dad’s first experience of a long-drop toilet! During dinner, I looked out of the restaurant to see 2 elephants wandering towards us in the dusk – rather amazing. Dad was kept awake by hippos and lions making lots of noise outside the banda, quite an experience! We went on another game drive the next day and saw a tree-climbing lion, we were able to stop the car just underneath the tree to watch for a few minutes. Our next stop was Buhoma in Bwindi impenetrable forest – the home of the mountain gorillas. Unfortunately, our budget didn’t stretch to gorilla trekking but we went on a very beautiful waterfall walk accompanied by two guards with big guns in front and behind. The final stop on this part of the trip was heading back to Bushara island on Lake Bunyonyi where I’d been for Christmas. We had two very relaxed days and managed a bit of swimming in the lake.

We arrived back in Kampala for a couple of days and had enough time there for mum and dad to come with me into the hospice for a couple of hours and experience morning prayers and meeting the team. For the last couple days of their stay here we headed of to Jinja to the Nile where I’d been rafting before. Having been unable to persuade them to raft we stayed in another posh lodge next to the Nile instead and ate ridiculous amounts of very good food. I think mum and dad really enjoyed their time here – dad in particular was very proud of his sun-tan, which he’s shown off to everyone at home I hear! So for anyone else who’s interested I can do a very competitive rate for my Ugandan tour.

I realise yet again that I’ve spent lots of the blog talking about time off work. However, since mum and dad left I’ve been really busy back at work helping to run the degree. We welcomed the BSc year one students – 21 of them – at hospice for 4 weeks of face to face teaching on the 1st February. There’s a whole team of lecturers made up of hospice trainers – both clinical and non-clinical, as well as other members of the education and clinical teams. We also have a couple of lecturers who work for other organisations across Kampala who’ve been helping out. I’ve been teaching on a wide variety of topics including pain control, audit and evaluation and ethics. The ethics teaching was definitely my favourite. We had a debate on euthanasia dividing the group into 2 to take opposing sides. Things got very lively with some very interesting ideas about euthanasia being integrated into palliative care as a money-saving initiative – not something we’re really going to put into practice though! We’ve got one more week left of teaching then the students all go back to their respective countries and the rest of the year will be distance-learning. The students are all really lovely – from 6 different African countries, and mostly already working in palliative care as clinical officers (this is someone who’s completed about 3 years training and can do some of the things that doctors at home do but isn’t as qualified) or nurses. I’ve been invited to go and work at one of the hospices in Malawi (very tempting but I really need to finish my training in the UK first) and would love to go and visit some of the others to see what they’re all doing with palliative care in their different countries.

So, I have one more week of teaching for the degree then I’m finally heading west to Mbarara for the other 6 months of my year here. I’m looking forward to getting back to doing more clinical work but will really miss my lovely neighbours in Kampala and all the friends I’ve made at the hospice here. However, I’m looking forward to meeting loads more interesting people and seeing more of Uganda.

I’m going to sign off now and see if my internet will work for long enough to enable me to upload this and hopefully some photos. Hope everyone at home’s doing well, thank you for all the lovely emails and messages for my birthday – I had a fab day which ended up with champagne and sushi with my neighbours – not that Ugandan but great fun!

Happy New Year

2010-01-07T10:28:00.000-08:00

Happy Christmas and Happy New Year to everyone! This blog is well overdue and part of it is because I have been working fairly hard but I’ve also been away doing some relaxing things and some slightly more crazy activities. I hope everyone had great Christmases and fabulous New Years – would love to hear how everyone’s doing – photos are always welcome.

Okay, I’ll start off with some of the work stuff first. I’ve spent the last few weeks concentrating on BSc stuff and not doing any clinical work as there’s a fair amount of work to be done and not very much time. We’re now a bit more on course and looking forward to welcoming the 1st year students in about 4 weeks time for their 4 week teaching block. I’m then heading off to Mbarara to start my job there belatedly which will be mostly clinical – lots of home visits and clinics under trees – can’t wait! I will miss the team in Kampala though. I feel like I’ve really settled in there and have met loads of great people. We had a couple of events before Christmas which were great for getting to know people – the patient’s party and the staff Christmas party. The patients party was really good fun. I spent most of the day with the children – both children who are on the hospice programme as well as children of some of the adult patients. They had a bouncy castle and no mention of health and safety – probably about 30 children on the castle at any one time and remarkably few injuries by the end. I also taught some of them to play Jenga which they were fascinated by and also very good at! A lot of the more unwell patients spent the day lying on mattresses under a tent in the sunshine which they all seemed to really enjoy. They all received presents from the hospice – for the adults this was a plastic bowl for washing filled with sheets, rice and other food – much appreciated. There was a bit of a stampede when we were giving out the children’s presents – they all had to be given tickets or they kept going back to the end of the queue to get a second present.

A week later we had the staff Christmas party which started 3 hours late (usual Ugandan time). We had a secret Santa which was not so secret as you were supposed to write your name inside the present so people would know who’d bought it. There was a huge ceremony involved in giving out the presents – you had to walk round with the present on your head dancing to find the person who’d bought it for you surrounded by members of your team. There was then lots of embracing and photos. I’ve become much more comfortable about public performances such as this since coming to Uganda! I got a very lovely traditional African dress from one of the drivers which I had to wear and then dance round in – I may not be doing a repeat of this when I come home to the UK.

For Christmas I went away with 7 others – Cliona and Mhoira two of the other doctors from work, Cliona’s parents and brother and a couple of others. We drove for many hours to Lake Bunyonyi which is down in the south-west of Uganda near the Rwandan border. We stayed on a small island in the middle of the lake which was absolutely stunning. We had candlelit 9 lessons and carols on the balcony of our cottage overlooking the lake on Christmas Eve, then woke up to sunshine and beautiful blue sky on Christmas day and paddled over to the church on another island in a dug-out canoe. We unfortunately only made it for the last hymn but managed to sing some carols with the villagers after. We spent the next few days generally relaxing, swimming in the Lake and playing games. Unfortunately Christmas morning proved to be the sunniest day and it was rather cool and wet for the rest of our time there (not quite as cold as it has been at home obviously!).

For New Year’s we headed off to Jinja again and I was the only English representative surrounded by 6 others all from Ireland (I was honorary Irish for New Year). We’d booked to go rafting again with Cliona’s family but a more sedate trip with guaranteed no flipping of the boat. It was a fantastic day and very novel to be going down rapids and actually staying in the boat and not being washed down the Nile. The evening was a bit more lively and was spent in the bar which overlooked the Nile knocking back a few Nile special beers and more local gin. During the evening we watched the rafting DVD from a group who’d gone down the Grade 5 rapids which I’d done a couple of months ago and included some people riversurfing. Cliona and I thought it looked like really good fun and were persuaded by a south-African chap that we should all go the following day. We had to stay up until after 3am so we could celebrate the start of 2010 at home as well as in Uganda and treated everyone to a chorus of Auld Lang syne. The next morning the riversurfing still seemed like a good idea despite my slightly sore head so we booked ourselves in, not realising fully what it involved. We had life-jackets, flippers (or whatever the proper name is for them) and helmets on and were given an inflatable body-board each. We were straight into the Nile and had a practice run on a Grade 1.5 rapid which was quite good fun before being told we were going to leap off the bank straight into a Grade 5 rapid (Bujagali falls which is in the photo above) and supposedly surf it! It was quite possibly the most terrifying thing I’ve ever done and I failed miserably at staying on the board and managed to end up completely sucked into the rapid and spun around much like being in a washing machine then chucked out the other side! This was repeated on 2 more Grade 5s before I got the hang of lifting the board up a bit to try and actually ride over the wave rather than directly into it. I think we’ve definitely set the bar rather high for the year but I blame the Ugandan chap on the DVD whose catchphrase was ‘Why not?’ something I’m adopting for the year I think!

Anyway, I’m now back in Kampala again taking life at a slightly slower pace again. I’m really enjoying doing all the writing for the degree as well as planning assessments, mentorship, timetables etc. We have students coming from probably 5+ African countries other than Uganda which is fantastic for palliative care as they’ll be able to continue developing Palliative care in their countries with the qualification.

I’m going to leave it here for now and will be continuing my trend of just one long holiday over here as mum and dad are visiting very soon – any excuse to go rafting again!!

More weekends away

2009-12-06T07:46:00.000-08:00

I was thinking before writing this today that I seem to be talking much more about weekends away than work, but am going to continue with this trend with this update I’m afraid. I am doing some work though – I have actually been in Kampala at home this weekend working on one of the modules for the BSc about Ethics and Law. I’m learning all about the Ugandan laws around making a Will – lots about how to divide property up when you’ve got more than one wife and many children – an extremely common occurrence amongst our patients. I’m not sure what the religious laws are around this practice but many of the patients with several wives (or husbands – works both ways!) are practising Christians or Muslims. It does contribute in a fairly important way to the spread of HIV unfortunately – not sure what the solution is when it’s such an accepted practice.

Think I should probably move on to a lighter subject – hadn’t meant to start off with that particular subject. I had a long weekend away last weekend at Murchison Falls which is in the north-west of Uganda near the Congolese border. There was another last-minute public holiday for Eid (only announced about 3 days before meaning last-minute cancellations of meetings etc.). We left early Friday morning – there was a group of 6 international volunteers from Hospice – on an organised trip. We had 3 days away visiting the top of the falls for a walk, then a game drive through the safari park, followed by a boat-trip up the river (another section of the Nile). On the way back to Kampala we stopped off at the rhino reserve. To give a bit of background, many of Uganda’s national parks suffered from mass slaughter of the animals during Idi Amin’s regime so the numbers of animals were hugely reduced in size. However, many of the species have been returning and there was certainly loads to see while we were there. One of the main species which was practically wiped out was the rhinos which is why we went to see them in the reserve rather than seeing them in the park. They currently have 8 rhinos which have come from Kenya and Disneyland in the USA (not quite what I expected!). We could only see 3 of the rhinos as one of the others has recently had a baby and it’s not safe to go too near as the mummy rhino tends to get a bit protective and there’s a risk she may charge – best to stay away! The baby rhino had to be called Obama as it has Kenya and American parents! The rhinos were absolutely amazing though – we were able to stand only a few metres away. They understand English and Swahili and settled down when quickly when the rangers spoke to them. During our game drive and boat trip we saw loads of animals – the highlights were a male and a female lion with their cub as well as loads of hippos which I hadn’t seen before.

Life at hospice continues to be really interesting and challenging. We were visiting a young guy in prison who had advanced HIV and Kaposi’s sarcoma (a cancer associated with HIV) who was really unwell. We were working with an NGO which supports prisoners helping to improve their living conditions, and managed to get him released from prison just a couple of days before he died. He was able to go home to his mum and die in dignity. He was in prison on remand and hadn’t been able to go to court as he’d been too unwell. There seem to be a large number of prisoners who’ve never been convicted yet stay in prison for years. The prisons project seems to be doing some really good work in this area and we’re trying to work a bit more closely with them to identify prisoners in need of palliative care.

I’m really enjoying seeing patients but also realising the way to make the biggest difference through my limited time here is by education. I attended the quarterly meeting of the Palliative Care Association of Uganda (PCAU) which was held at the hospice last week. We were given a talk by one of the health ministers who is a big supporter of palliative care and has helped to get palliative care provision written into the health policy – I think they may be the only African country to do so. It doesn’t necessarily mean that money will automatically follow but it’s much better to try to integrate palliative care into the government system rather than rely fully on NGO provision as it’s more likely to continue in the long-term (one of the words I find myself using a lot more often here is sustainability – a bit of a buzz-word). Anyway, it was pointed out that there’s still a substantial area in Uganda which has no access to palliative care including no access to morphine so many people are still dying in pain. One of the aims of the BSc we’re starting is to train health professionals not only in symptom management and holistic care but also to train them in developing a palliative care service to enable them to set something up where there is currently no service. I’m really looking forward to starting the teaching in February.

We’re now in the build up to Christmas over here – it’s strange not putting up the Christmas tree and seeing Oxford street lights but I might attempt to make some decorations for my house. We have a couple of Christmas parties at hospice for the patients and staff which should be entertaining. I’m going to be heading off to the south-west of Uganda to a very beautiful lake for a rather relaxing but different Christmas – can’t wait! Will try to write a couple more updates before then though. Until next time…..

Zanzibar

2009-11-23T10:33:00.000-08:00

I’ve had my first day back at work today after a fantastic week in Zanzibar. My week off was incredibly relaxing – great company, sun, sea, sand and amazing food! I think people may have thought that my coming to Africa was going to be very tough and challenging – it didn’t really feel like that week. However, it has been a while since I had a proper holiday so I think it was justified (I will stop making excuses now). I went with Jo, Amanda and Mhoira, all of whom are from the UK and have been working in Uganda for a couple of years and all live on my compound in Kampala. Our flight to Zanzibar was typically African. The flight was supposed to be direct from Entebbe to Zanzibar but about 20 minutes before landing an announcement was made that there was a problem with the plane and we’d be landing in Dar es Salaam rather than Zanzibar. I was pretty relaxed as was everyone else on the plane so this didn’t really bother me. We were initially told to wait on the plane, but after a short time had to get off and go into Dar airport. We were then ushered through customs etc. and were told to sit in the baggage area while they were sorting something out. After an hour or so, we were directed out of the international terminal and transferred to the local terminal. We then found out we’d be flying across on a 12-seater plane – not quite what I’d been expecting. The flight over was actually pretty amazing though – the views of the sea were fantastic as we were flying much lower. We then made our way to our hotel in Stone Town and went out for a fantastic meal looking out over the sea. We had fresh fish most evenings – absolutely gorgeous.

We spent the first couple of days wandering around the streets of Stone town. It’s famous for the amazing doors and winding streets. There are also some great boutiques and we spent a few hours shopping. We also went to the Anglican cathedral which is built at the site of the slave markets. It’s a beautiful cathedral, but as part of the tour we saw the holding cells where they kept some of the slaves before being sold. They were tiny, dark rooms which would hold up to 25 women and children or men for 48 hours without food and drink. Those who survived were sold for increased money as they were thought to be much stronger. It’s just amazing that it is in the recent past that it was abolished.

After two nights in Stone town, we travelled to Kendwa on the north-western tip of Zanzibar. We were staying in 2 rooms next door to each other with balconies looking out onto the beach and about 2 minutes walk to the sea. We spent the rest of the week mainly swimming, sunbathing, eating fantastic seafood and drinking a fair amount of beer, wine, Pimms and waragi (Ugandan gin which we’d bought in duty-free).

We spent one day on a snorkelling trip, about an hour’s boat-trip from Kendwa. I finally got the hang of snorkelling and only swallowed a small amount of sea-water. It was fantastic – loads of Nemo-type fish and beautiful star-fish. We even had a brief glimpse of some dolphins! I managed to meet up with Suzy, one of my friends from the UK who happened to be in Zanzibar at the same time as me as part of her tour of Africa – we had a great afternoon catching up on each other’s news.

The last day of our week was Jo’s birthday so we decided to indulge in some pampering. There was a tent on the beach with 4 beds, looking onto the sea where you could have a range of treatments. I settled for a neck, back and shoulder massage and pedicure, as did Jo. We were hugely relieved that we hadn’t chosen the same treatments as Mhoira and Amanda who provided us with much amusement. They’d chosen to have full-body treatments and fruit body scrubs. They were initially scrubbed all over with a mixture of cloves and vegetable oil, then made to stand in a bucket and washed down with sea water. Following this, they had mashed fruit rubbed all over and then wrapped up in a huge carrier bag. Finally, they had to walk down to the sea to wash the fruit off – all this with an audience of Tanzanian men – most amusing!

We finished the week off with another fantastic dinner and champagne to celebrate Jo’s birthday. I felt thoroughly relaxed at the end of the week and had got to know the others much better – I’m really appreciating the friendships I’m developing in Uganda.

So now back to the real reason I came to Uganda – palliative care. The week before I went away to Zanzibar was rather frustrating at times. We had a really busy weekly ward-round in Mulago, partly because most of the nurses in the palliative care team weren’t around for various reasons, meaning we couldn’t split up and see patients separately because of the need for someone to translate. The first 3 patients we saw were all youngish men with advanced cancer of the penis, all next to each other in the ward. They’d been in for a few weeks. They were all awaiting further treatment with either radiotherapy or surgery and we had been seeing them frequently to help with their pain control and provide general support. Unfortunately, the palliative care nurse who normally reviews them hadn’t been around and they’d all run out of morphine, even though it was in stock in pharmacy and no-one else had noticed and arranged for them to get a repeat prescription – all very frustrating, but something we were easily able to sort out. The next patient we reviewed was a lady in her early 30s with HIV and Kaposi’s sarcoma – a cancer commonly associated with advanced HIV which I’ve seen frequently in patients over here. She had 7 children and was separated from her husband. She was being cared for in hospital by her 9 year old son, who’d been taken out of school to look after his mum. He was having to go off to buy food for her and also helping her to get washed and dressed. It’s amazing how many children here have a limited childhood and no time to have fun. Hospice are hopefully going to try and give some support to enable the patient’s son to go back to school again. The problems here are just sometimes overwhelming. It’s difficult to know where to start when you have a culture where it’s just accepted that young children should be looking after their parents rather than having an education.

The last patient we saw that day was an 18 year old boy with advanced cancer, affecting his face leading to his eye protruding which caused visual loss. He was admitted for second line chemotherapy which has a limited chance of being effective. He was due to be taking his final exams the week he was in hospital and was devastated that the visual loss meant this was impossible. He was a really intelligent young man and wanted to become a doctor. We had our conversation in English which made it more difficult in a way as it’s easier to be removed from the situation when the conversation is being translated. Seeing these patients does confirm to me though that I can make a real difference here and that developing the BSc so we can train people to develop palliative care throughout Africa is so important. It’s also incredibly humbling and definitely makes me appreciate how lucky I am.

That’s all my news for now. Thanks for all the emails etc. will continue to try to reply to you all.

The Mighty White Nile

2009-11-09T10:44:00.000-08:00

I’ve finally got round to updating my blog – hadn’t realised it had been quite so long since I’ve written anything. Hopefully everyone has coped without an instalment. I may as well start off with the highlight of the last couple of weeks – rafting!! This was an amazing experience and one I’m hoping to repeat several more times over the coming months. It may be a compulsive activity for anyone coming to visit (so be warned mum and dad!). We left very early in the morning to head to Jinja where the fun began. The trip was about 30km long in total with about 5 grade 5 rapids and many other grade 2-4s. There were lots of sections in between the rapids for gentle paddling and general drying out from the complete soaking we kept getting. There were 7 of us in our group (all international volunteers from Hospice) which was just enough to fill one boat. We had a brief introduction and were then fitting with life-jackets and helmets before heading off in a cattle-truck to the river (Nile that is for anyone who wasn’t sure). Our guide was known as Coke (actually called Kirk but the Ugandan guides had trouble pronouncing his name) and was from South Africa but spent time in Uganda during the quiet season in South Africa. Once on the river, there was a slow stretch to start with where we were shown how to hold on to the boat while it was being turned back over after it had capsized and also how to get back into the boat (basically not very graceful – usually being dragged in by the life-vest and ending up falling head-first into the boat). Then the rapids! They all have interesting names – Silver-back was fairly wild with all of the Nile trying to squeeze through a very narrow gap. Bujugali falls had two sections and was our first experience of the boat capsizing. We were chucked out and floated off rather swiftly down the Nile. However, there were loads of ‘safety kayaks’ waiting to pick people up and deliver them back to their rafts. After the first swim I quickly got the hang of gripping onto the side of the raft when it flipped so as not to spiral down in the water too much. I think we capsized on 4 out of the 5 grade 5s – but it was such a triumph when we realised we’d actually stayed in the boat after going down a rapid. There were a couple of rapids which we didn’t do as they’re considered too risky – ‘The Dead Dutchman’ is fairly self-explanatory and one to be avoided! For the last stretch we had to walk round the edge of the river briefly to avoid one particularly scary rapid before getting straight into another. It had 2 sections and our guide fell out in the first bit whereas we all stayed in. Luckily he managed to jump straight back in again, just in time for a bit more paddling before one last triumphant flip!

The perfect end to the day once we’d got back to the camp and dried off was a barbeque followed by sitting in the bar sipping Nile special beer and watching the DVD of the day. I was very excited to be mentioned as ‘the woman with a broken arm’ – all very entertaining. I may be boring many people with the DVD when I come home – you have been warned! We stayed overnight in a posh tent (as in one you don’t need to put up yourself and which has proper beds and electricity) overlooking the Nile – absolutely beautiful.

Anyway, I will move on and mention some work stuff before everyone gets the idea that this year out supposedly working is nothing more than one big holiday. A lot of the last couple of weeks has been taken up with trying to get stuff sorted out for the BSc. We’re realising that there’s still an incredible amount of work to do. Our main focus at the moment is writing the course materials. The students will all get almost a mini textbook for their core reading. We are currently trying to write this which is a huge task although great experience. The particularly upbeat module to review is on death, dying and bereavement – think I may need a few drinks to get through that one! Once we’ve done the modules we’ve also got to plan all the lectures for the 6 week teaching block, sort out assignments and exam, write clinical placement guidelines etc. We have realised that it was too much work to be done without me being around to help out so I’ve had my plans changed and will now be in Kampala until after the teaching block ends in March next year, and will then head off to Mbarara. I’m sad in some ways not to be going to Mbarara yet as it is a bit more relaxed. However, I’ve also settled really well into life in Kampala and love my house and the others on my compound so things are still pretty good.

We continue to see managing challenging patients and the language barrier is very frustrating at times. Most people in Kampala and the surrounding areas speak Luganda as their first language. Most of the patients know a bit of English but I generally need someone to translate in order to fully assess people. It’s quite difficult to communicate with people in this way when you’re talking about really difficult and challenging issues. I’m trying to learn some Luganda but it’s a really slow process.

One of the other activities which has been going on over the last couple of weeks has been a course for international students on the development of a palliative care programme. This has involved lectures on pain and symptom control, communication and other more managerial topics such as applying for funds and developing a service. I was helping to chair some of the sessions and found it fascinating. They’re a really diverse group from different parts of Africa - a couple of bigger groups from Nigeria and Malawi as well as individuals from Sierra Leone, Sudan and Congo. They had a session on the final day which I was helping with on identifying the challenges in their individual countries and trying to think of the way forward. It made our problems at home seem really insignificant. A few countries have no access to morphine at all which makes palliative care practically impossible. They also had problems such as very poor road infrastructure making going to see patients at home difficult. Another huge issue is that a lot of the money coming from outside to set up services has strings attached. Loads of the funding is specifically for patients with HIV/AIDS and whilst a large proportion of patients we see do have HIV/AIDS, cancer is becoming much more of an issue. The organisations giving the money require loads of evidence to say it’s only being used for these specific patients. The treatment of HIV has improved massively and people are now living for many years on anti-retrovirals. However, there’s very little treatment for cancer. Many countries have only a few trained oncologists and very little chemotherapy. Radiotherapy, if available at all is usually just one machine for the entire population of millions. It’s all quite overwhelming really at times!

I feel I need to change the subject to a slightly lighter note now. I will briefly mention something about the randomness of Uganda, demonstrated by the photo I’ve included above – none of us could quite work out why it was morning sex in particular that should be avoided (please let me know if anyone’s got any further insight into this). I’ve also included the information from the side of my wine box – always good to know! Another random thing is the loads people carry on their motorbikes (or boda-bodas). The best one so far was a guy with a double bed on the back of his – no idea if it made it to its final destination!

I’m going to sign off for now, but to further continue the idea that this is one long holiday I’ve booked a last minute trip to Zanzibar with 3 of the other ladies from my compound. I’m off for a week which gives me another excuse to leave a bit of a gap before the next update. That’s all for now.

Pedicures and Mosquito bites

2009-10-25T05:57:00.001-07:00

It’s Sunday afternoon and I’m finally having a few hours at home to catch up on my blog after another busy week. My arm continues to improve although was the pain flared up a bit after pilates (thought I’d managed not to use my forearm but obviously difficult to avoid). The past week has been the usual mix of work and trips out exploring Uganda – it really feels more like I’m on holiday most of the time.

In terms of work, I’m continuing to see many people with advanced disease presenting for treatment when it’s too late to be cured. I saw a patient during the week with a skin cancer of the leg. The patient had been seen in hospital several months before and diagnosed with cancer. The proposed treatment was an amputation but this was declined. Unfortunately, the patient didn’t return to hospital until many months later and the cancer had spread to lymph nodes in the groin. When I saw the patient, they’d been admitted to hospital to have a blood transfusion as the tumour had been bleeding. They were also experiencing a lot of pain in the leg and back. When I examined them, I found their legs were weak and the spine was tender – I suspected the cancer had spread to the spine and was causing compression of the spinal cord causing leg weakness. We spoke to the doctors in the radiotherapy department and they decided to treat with urgent radiotherapy. Rather than sending the patient for x-rays which would have taken several hours and meant the treatment would need to wait until after the weekend, they agreed to examine the patient and plan the treatment this way. It’s not the ‘gold standard’ treatment but under the circumstances the best solution to help with the pain and hopefully to give some function in the legs.

We had a meeting with the surgeons and radio-oncologists (who give radiotherapy) on Friday. This is a weekly meeting which the palliative care team have started attending in the last few months and enables difficult cases to be discussed in order to plan the most appropriate treatment (surgery, radiotherapy or chemotherapy). As well as discussing the patient and showing the x-rays, the patient is brought down and examined in a separate room. It’s a really effective way of planning treatment. The more I see of the radiotherapy department the more impressed I am. They are using a very old machine which takes 3 times as long to treat patients as it would at home but work incredibly long hours every day and respond to emergency situations with great compassion and speed. There are loads of problems with the government health sector here but there are also amazing people who do a brilliant job and need to be supported. The sustainable way to sort out healthcare over here must involve supporting the government sector rather than providing a few private clinics or hospitals than treat only a minority of patients. (That my ranting over for now but it’s an area I’m starting to feel pretty strongly about as you may gather).

The morphine situation has also still not been sorted out. Hospice continue to supply the hospital with several litres of morphine each week but this is nowhere near to being sufficient to treat all those in pain. However, Dr Mhoira who is the palliative care consultant in the hospital returned from the UK this week and has been putting pressure on the important people so it should be sorted soon – until the next time it runs out….

It’s now only a few weeks until I change location and I’ve just had a handover from the UK doctor who was doing the job I’ll be doing in Mbarara (in the west of Uganda) until a couple of months ago. It sounds equally as challenging as what I’ve been doing in Kampala but with less support. I’m really looking forward to working there although I will miss Kampala – especially all the friends I have made on the compound at home and in hospice.

Outside of work, we went to Lake Nabugabo last weekend which is a couple of hours west of Kampala. On the drive there, we passed the equator where there is a café and lots of tourist shops. The café made fantastic muffins and I’m sure I’ll be stopping off there lots in the future as it’s the main road to Mbarara. We did the obligatory thing and took lots of photos at the equator and then carried on to the lake. It’s a fairly small lake but due to it’s low calcium content apparently has no Bilharzia (tropical disease transmitted from snails causing Schistosomiasis). We were therefore able to swim in the lake (which is not advised in lake Victoria due to the Bilharzia). This was absolutely lovely but obviously done with an audience as ever. We spent most of the weekend just relaxing and managed to work our way through a large bottle of Waragi in the evening whilst playing cards – such a wild life I know! On the way home the following day we stopped off at Mpanga forest and went for a guided walk through the forest. The guide thought we were very amusing as we kept jumping when various bugs flew into our faces. She’d only warned us when we were well into the forest that there were a few snakes around and it wasn’t advised to wear open shoes – not the most helpful! Anyway, the forest was absolutely beautiful and we saw loads of different birds, butterflies and a few monkeys. The only downside was being eaten by mosquitoes – my legs look like I’ve got chicken pox (restricted only to the back of the legs though) – not so attractive!

One of the other exciting events of this week was stopping off at Garden city (the big mall in Kampala) on the way back from Mulago for my first ever pedicure! This was incredibly relaxing but slightly unusual as it’s only blokes who give pedicures over here. The unpleasant bit was having my mosquito-bite covered legs exfoliated – slightly painful! However, my toes do look beautiful now (I realise I’m not building up the best picture of myself at the moment – will try to get some photos of me looking a bit more glam for the next blog).

Please feel free to add some comments to the blog if anyone has anything to say – especially if I’m waffling on in too much detail about stuff. We’re going rafting next weekend so I’ll hopefully give a bit of a run down on that in my next blog.

Bye for now.

2009-10-15T10:23:00.000-07:00

This week has been rather eventful, involving several trips to the hospital – more of which in a bit. Last Thursday evening we went out to Oktoberfest at the Sheraton hotel in Kampala. There was a fantastic buffet and lots of beer, as well as music from a German band, interspersed with another band performing what sounded more like karaoke. However, it was great fun and we managed to do some dancing. We ended the evening in the hotel bar which was full of Ugandans rather than Muzungus – all very civilised.

The following day we had been invited to the house of one of the nurses from work. Cliona and I managed to bake some cakes to take with us. We turned up about 3 having been told to come in the afternoon sometime to find a huge lunch had been cooked for us. One of the staple foods in this region of Uganda is plantain or ‘Matoke’ which is basically savoury bananas cooked and mashed. It’s a bit like mashed potato and is reasonably okay although having it daily for lunch at the hospice makes it less appealing. The Ugandans seem to need to have at least 3 or 4 different carbs. for every meal, so we often have rice, matoke, potatoes and maize flour mixed with water (known as Posha) for lunch at the hospice. I have managed to get into the habit of just having one carb. with beans and cabbage – a bit more manageable. Anyway, we had a lovely afternoon with Immaculate and her family meeting her 2 children, husband and various other extended family members.

Last Saturday was World Hospice and Palliative care day and the Ugandan Palliative care association organised a football tournament for several different healthcare organisations in Kampala. All teams had to have 5 ladies on the pitch at any time as part of the rules. I hadn’t taken part in any of the training in the weeks leading up to the matches as I hoped to be supporting rather than playing. However, when we turned up there were only 4 girls and I was persuaded into changing into the attractive white strip with long red socks (look out for number 10 on the photos). There were 8 teams in the tournament and we had 3 games each in the initial heats. My unfortunate fall occurred during training rather than the actual match. I energetically rushed to return the ball to someone else and managed to slip over, landing on my left wrist rather awkwardly. I assumed it was just a sprain however and continued training and then played nearly 2 matches. We lost our first match, won the second and drew the third. I was mainly marking the ladies on the opposing sides and trying not to score own-goals rather than demonstrating my amazing soccer skills! I did actually really enjoy playing though and may have found a new interest. I think I just about understand the off-side rule from years of coaching. There was supposed to be semi-finals before the final, but as we were on Ugandan time and running incredibly late an executive decision was made to just have a final. The eventual winners were Reach Out Mbuya who are an HIV support organisation (it turns out they actually play in a separate league which we didn’t know when we lost to them – no bitterness really!).

Anyway, back to my hospital adventures. I had still decided I’d only sprained my wrist and helped to carry various marquees and tables back to the trucks to return to hospice (with very little help from the lads on the football team I might add – they were all sat in the car waiting to go home rather than helping!!!!). On Sunday, we went to church at Namirembe cathedral in the morning (the Anglican cathedral – fantastic service although the sermon was all about treatment and prevention of breast cancer as it was health awareness week) and spent the afternoon wandering by Lake Victoria down by Dr. Anne’s house (more on her in a future blog, but she’s the founder of Hospice Africa Uganda for info. purposes). In the evening, Cliona and I decided the bruising on my wrist didn’t look great and I had some bony tenderness so we headed off to the private hospital. The x-ray was a bit suspicious but not conclusive so I ended up returning the next evening to see the orthopaedic doctor who immediately said I’d got an impacted fracture of my left radius (near the wrist) – no wonder it had been so bloody painful! I had to go back again the next day to get a splint from the physio which I need to wear for the next few weeks. They were hopeful that I’ll be able to go rafting down the Nile in a few weeks though as I was quite concerned about missing out! It is very common for people to say sorry about things all the time here so I’ve been told many times how sorry people were for my injury and have many people praying for my recovery – all very lovely for a rather silly injury.

Aside from my health though, I went on a home visit to see the lady with breast cancer who we sent for radiotherapy last week. She was very unwell at home – unable to sit up as she was so breathless so we had to adjust lots of her medications to try to get her a bit more comfortable. We’re going back again next week so hopefully things will be a bit more controlled then. In Mulago, there’s still no morphine so the hospice team are continuing to supply morphine for many patients there who are in loads of pain. It hopefully will be sorted out next week but I’m hoping there may be something we can do to ensure it doesn’t keep happening. It’s such a basic requirement in palliative care and I’m sure I’ll really appreciate the availability when I go back to work in the UK.

I think that’s probably enough for now. I’m enjoying a Waragi and tonic at the moment which is a slightly cheaper version of gin but tastes just as good. You have to get the bottles though as they also make it in sachets which you can sip in the street. The major downside of there is that some of them are contaminated with methanol and several people have died from methanol poisoning as a result – one to avoid…. and a nice upbeat note to finish on. Until next time…

Games and Dancing

2009-10-08T10:20:00.000-07:00

It’s been a busy week again at work and outside of work. At the end of last week we had a staff day out. This is a yearly occurrence and there’d been lots of discussion about where we should go. The final decision was to go to Entebbe which is where the main Ugandan airport is but also on the shores of Lake Victoria. We spent the day at a resort centre next to the beach by the lake – a beautiful setting. This year, they employed the services of a team-building coach called PK and had a very full program for the day. We started off with a game where we were all in a circle and had to count up to fifty. However, if you had a number with a 7 or divisible by 7 you had to clap and the direction of counting was reversed. If you got it wrong you were thrown out of the circle. When it got down to the final 4 people, the other staff had to line up behind whichever finalist they chose. By this stage it was just me and 3 blokes. As it came down to the final 2 of us we had long lines of people behind supporting us. There were a lot of calls of ‘she’s our woman!’ from behind me. I managed to win the game by some amazing luck and then had to stand in the middle of the circle and be interviewed about what I thought helped me to concentrate and win. Obviously this was the sort of situation I always feel very confident in, but I managed to give some fairly positive feedback. They then played 'Stand up for the Champions' and there was a bit of dancing! We had some more team-building in the morning followed by a very relaxing swim in the pool before lunch.

In the afternoon we had ‘cultural time’. This involved everyone dividing up into groups based on the regions of Uganda they were from. They then had to organise a dance typical of their region which had to be performed later in the afternoon. Not wanting to be left out we decided to form the Mzungu Massive consisting of myself, Tomas, Cliona (both from Ireland), Ruth – a GP from the UK and Dr Anne Merriman – the founder of hospice Africa. We had a few ideas about what dance we could do and eventually decided on a medley of Irish dancing followed by ‘The Locomotion’ – this choice was largely based on the available music. We didn’t practice quite as much as we would have liked but our dance did get a very big clap (possibly more in support of us having had a go rather than our amazing performance!). The rest of the dances were fantastic – lots of shouting and bum-waggling! We managed to come 3rd out of 4 (mainly due to scoring 9/10 for originality). The whole day was loads of fun though and great for getting to know everyone.

I’m continuing to see a range of patients at the hospital and at the hospice. There is the on-going problem with no morphine at Mulago hospital unfortunately. From further discussions with the palliative care team it turns out that this is not an infrequent occurrence. Basically, the government should provide free morphine for patients who need it and Mulago hospital is responsible for supplying the morphine for most of the country. However, they have to pay for it up front and then get the money back. At the moment, they have the morphine in stock but can’t afford to pay for the preservative to make it up with so the patients are unable to have it. The hospice makes their own morphine and seems to plan better so their stocks don’t run out. We therefore end up supplying patients at the hospital due to bad planning. It’s all very frustrating and awful to see patients suffering because of an easily solvable problem.

I did have a more positive experience involving the hospital this week however. I saw a patient at the hospice who had been referred from the hospital for ongoing palliative care following a new diagnosis of breast cancer which was fairly advanced. She was in her early 30s and came with her brother. She had 5 children and had been treated with traditional remedies at home for many months before eventually being admitted to Mulago hospital a few days before. They felt her disease was very advanced and gave her a few days of antibiotics and steroids then discharged her to us. She was obviously very unwell but I thought she would benefit from some radiotherapy as she looked to have compression from the tumour of one of her major veins. I therefore arranged for them to come up to Mulago the next day where I would be doing a ward round with the palliative care team. Basically, we managed to speak to the oncologist and they arranged for her to have radiotherapy that day. The radiotherapy department is fantastic. They have only 1 machine for the whole country which frequently breaks down but are there from 7am-10pm daily treating patients. One of the slight challenges is that they aren’t able to plan patients in the same way as at home so they put stickers on the patient over the area to be irradiated. However, as the patients may be waiting around for some time between being stickered and receiving treatment they sometimes move the stickers as they believe being treated over a wider area will be more effective!

Last Saturday we ended up joining a march to celebrate national breast cancer month. It was great fun walking through the city with a large group of others and not being singled out! It ended up at the Sheraton hotel in the centre of Kampala where there were many speeches. We made an early exit and went shopping instead!

I think I’ll end things here for now as this seems to be fairly lengthy. I now have a long weekend as it’s Ugandan independence day tomorrow and is a national holiday. We’re therefore off out to Oktoberfest at the Sheraton to have a few beers.

Until next time….

Driving adventures

2009-10-01T09:54:00.000-07:00

Have decided it’s about time to update the blog again. I’ve had a really good few days again – can’t believe it’s October though. I suppose the warm weather is fairly deceptive. I’ve been spending a bit more time at Mulago hospital as Mhoira – the palliative care consultant there – is in the UK at the moment. I continue to be amazed by how advanced the patients diseases are when they present to hospital. There were 3 patients this week in their 20s with advanced HIV / AIDS presenting with disseminated Kaposi’s sarcoma (a cancer associated with HIV for those not in the know). They have all been referred for pain and symptom control and the palliative care team are slowly getting on top of their pain. They are now all receiving anti-retroviral therapy (the drugs used to treat HIV) but may not receive chemotherapy – partly because it’s not affordable but also because their disease is so advanced that they may be too unwell to tolerate the treatment. It’s difficult to understand why people don’t present earlier to the hospital. Some people see traditional healers in their communities for a long time, or others just can’t afford the transport to hospital. There is also a limit to the treatment available. Mulago does have a budget for chemotherapy in order to supply it free to patients but they spend the years budget in a few weeks as they are looking after so many patients. The problems seem fairly overwhelming sometimes and it’s difficult to know what the answer is. However, there are many patients who have been on treatment for HIV for many years now and the disease has been kept under control – similar to patients at home.

The other problem which has occurred this week is that Mulago hospital ran out of morphine. A few of the patients we went to see were in more pain – we found out they’d run out of morphine in the pharmacy. Morphine is manufactured at the hospice and also at Mulago which then supplies other areas of the country. It turned out that the hospital had enough morphine but had run out of the preservative they mix it with so this had stopped production. There is a distinct lack of forward planning sometimes! Luckily, the hospice has a separate supply so we were able to take the patient’s details and were able to deliver some morphine for those patients most in need. Hopefully things should be sorted out in the next couple of days – the next step is to try to work out how to prevent it happening again. There’s a young boy who I’ve seen several times over the last few weeks with a bone tumour of one of his legs. The skin has broken down where the tumour is and his leg is massively swollen. He was one of the patients who had run out of morphine and was in lots of pain. We were able to get him some from a stash on the ward luckily and he was much more comfortable when I went back the next day.

I’ve also been teaching 5th year medical students this week. They have a week’s worth of palliative care lectures and an exam at the end. The teaching session this afternoon was on palliative care ethics. I only had an hour and we were trying to talk through informed consent, confidentiality and euthanasia as well as a few others issues. We managed to get a fairly good discussion going and I hope I convinced them that palliative care doesn’t equate to euthanasia. A couple of them did have fairly extreme views though – all very encouraging though!

I have also continued to have a bit more of a social life too. We went to Sipi falls last weekend which is towards the east of Uganda, near the Kenyan border. It’s a series of waterfalls up in the mountains and was absolutely beautiful. The journey there took several hours – the roads are fairly variable – but was mostly very scenic. It still amazes me how good the children by the side of the road are at spotting white people in a car – the familiar call of Mzungu as you pass! Not sure how it would go down if we tried that the other way round at home! We stayed overnight at a gorgeous lodge overlooking the mountains and plains and did a couple of short walks by the waterfalls with our guide – have attached some photographs. It’s much cooler in the mountains – I actually needed a blanket when I went to bed!!

The drive back was fairly lengthy again and we remained surprised by the questionable driving from other road users. The most memorable bit from this journey was from one particular section when there was fairly heavy traffic, causing everyone to slow down. The roads are mainly single-carriageway with lots of hills. We were driving up a hill when a petrol tanker overtook the long line of traffic – not bothered by the fact that there was a blind summit so no view at all of what was coming the other way. The traffic which was coming the other way was forced to drive along the mud-track (otherwise known as the hard-shoulder!). Everyone just seems to accept that this is normal driving though. I think years of driving in south-London partly prepared me for this!

I think this is probably enough for now. Feel free to email me – it’s great to hear how things are at home. If anyone hasn’t been put off and wants to come and visit I’m developing my tour-guide skills and would love to share the experience.

Goodbye for now.

Escape from Kampala

2009-09-22T11:03:00.000-07:00

I’m now almost into my second month in Uganda and have settled in really well. Work continues to be very interesting. The days at the hospice are fairly slow – lots of sitting around and then seeing a few patients. I do have someone to translate for me now though so at least I can see a few patients on my own without needing the nurses to interpret. Although English is technically the first language here most people speak Lugandan – I’m going to attempt to learn some over the coming months.

The days at the hospital continue to be very interesting. We’ve been seeing a young boy for the last few weeks with a bone tumour and an open wound on his leg. He’s been waiting for the oncologists to make a decision about treatment meanwhile his leg has become more swollen with increasing pain. However, the palliative care team are reviewing him most days and his pain does generally seem to be under control. I will hopefully see him again tomorrow when I go to the hospital. Mulago, which is the main government hospital, has a large oncology centre and at present houses the only facilities for radiotherapy in the whole of Uganda. The radiotherapy department is great – they operate about 14 hours a day and also have a hostel where patients from other parts of Uganda can stay while they receive treatment – it’s all fairly busy though.

I finally got outside of Kampala at the weekend. I went to Jinja with 2 other couples who are here volunteering at the hospice. I drove on the way there. The Kampala traffic is fairly horrific – loads of boda-bodas (motorbikes) weaving in and out of traffic – very few people wear helmets and the accident rate is fairly high. I’ve chosen not to get a lift into town on them! There are also random cows and goats wandering the streets as well as children – it’s all a bit of an obstacle course. Then there’s the police who love stopping people and are very open to a small payment (for tea apparently…). Anyway, Jinja was lovely. It’s where Lake Victoria and the Nile meet and has a spot where you can apparently see the source of the Nile. We chose to sit around the Nile gardens and watch monkeys playing rather than get the boat out to see the exact location. Slightly outside Jinja is Bujagali falls where you can go rafting or kayaking on Grade 5 rapids (not entirely sure what that means but am led to believe they’re fairly impressive). We plan to go back in a few weeks to go rafting (I’ve obviously discovered my adventurous streak after the coasteering earlier this year!).

I think that’s about all my news for now – will hopefully attach some photos of Jinja with this update.

Riots and power cuts

2009-09-14T09:54:00.000-07:00

Well it’s week 3 – time is passing very quickly. This week has been even more eventful. As you may well be aware, there were a few riots in Kampala at the end of last week and over the weekend. I could hear gun-shots from my house but avoided going out apart from to the local shops whilst the trouble was going on so didn’t really see much. I don’t really understand the full politics of it all but do know a bit more about the role of the King of Buganda now. It’s a fairly rare occurrence apparently so please don’t let it put anyone off visiting me – it is a fantastic country really!

The other excitement of the week was the 48 hour power cut – at work and at home, which is apparently a fairly regular occurrence. I have a back-up power supply at home so my lights and internet still worked but at the hospice work basically ground to a halt for the non-clinical staff as they have no back-up – not the most effective use of everyone’s time!!

I’m continuing to adapt to Ugandan time (and hospice time which is even more delayed!). All meetings start a minimum of 10 minutes late and everything stops for tea at around 10.30-11am. I’m learning to always have a book with me to read or something else to occupy me. The hospital seems to work slightly more to schedule – ward rounds start early and are finished by lunchtime so the hospital palliative care team have adapted to this to ensure we can communicate with the other hospital teams. Relations between palliative care and hospital teams are really improving and therefore the team are much busier. We’re seeing a lot of patients with really advanced disease. The most difficult ones are those without ‘attendants’ – basically any family member – to help them wash / dress / get them food and fetch medications from pharmacy. The other relatives help out as do the palliative care team but some patients are in a bit of a state with no-one really caring. There’s definitely a massive need for palliative care!! The really positive thing is that we’re now involved in teaching medical students and the MMEDs who are medical SHOs preparing for their equivalent of the MRCP (the medical specialty exams) so they learn about palliative care from the early part of their careers and can try to help the patients out a bit more themselves and not rely solely on the fairly small palliative care team – it’s all very exciting!

The other very interesting bit of my week was visiting patients in prison who are under the care of the hospice team. We went to both the male and female prisons – the staff are very open to our team coming to see people which is great. I found it all very fascinating – probably best not to disclose everything on the blog though!

I’m continuing to discover more of Kampala’s restaurants and bars. The food is variable, they don’t really do a lot of spicy food, although there is a fantastic Thai place. We went to listen to out-door jazz last night in a cocktail bar. Great cocktails although the music was a bit random.

I also had my first experience of a Ugandan Baptist church on Sunday – fantastic music – not entirely sure about the theology though!

That’s about all my news for the moment. Will update again in a few days – hopefully things will be a bit calmer again this week. Thanks for everyone’s emails – am slowly getting round to replying.

Rugby clubs

2009-09-06T10:41:00.000-07:00

Well, I've nearly reached the end of my second week here, time is racing away. I'm properly settled into my house although unfortunately a large number of large ants seem also to have been setting up home here as well - the more I stamp on the more seem to come into the house - Idon't think they are biting ants so I'll just put up with their company at the moment. I'm continuing to be woken fairly early in the mornings firstly by the chap from the local mosque with his very loud microphone. I manage to drift off to sleep again when the noisy birds start up (feathered ones - not quite sure what type but fairly large and very loud!), I'm obviously not meant to be having lie-ins! Apart from that though the compound is fairly quiet. I've met all my neighbours who are really friendly and appreciate both tea and wine which suits me very well! I'm sure people will be relieved to know that my sink is now back in place in my ensuite so I don't need to walk the few extra steps in the morning to use the guest bathroom.

I did a bit more exploring of Kampala this weekend accompanied by another doctor from Ireland who's also working at the hospice. We explored the delights of Garden City - a shopping mall near the centre of Kampala - it seems to be where all the Mzungus hang out. I made the very exciting purchase of some flipflops. We then went to meet her boyfriend who has joined the Kampala rugby team and was playing his first match in the afternoon. We unfortunately missed the match but arrived for drinking in the clubhouse - quite a fascinating experience. We only lasted until about 10.30pm - I think the evenings often carry on until 5am.

I have also been doing some work this week. Spent all of Friday starting to write one of the modules for the BSc - trying to adapt symptom control to an African context (fairly similar to at home but without the vast majority of the drugs, so a bit more of a challenge!). They do seem to use Frangipani sap for shingles rash though which isn't something I'd known before.

Anyway, enough for now, more in a few days....

2009-09-02T09:19:00.001-07:00

Hello again,

I'm now into my second week and have seen some patients finally! I'm settling into my new home - have put some photos and pictures up so feels more like my place. I did return from work yesterday and find the sink from my ensuite had been taken off the wall and left in my shower though - no note to explain why. There had been a funny smell coming from it for a few weeks apparently - not sure when it's going to be fixed!

I spent Monday and Tuesday this week seeing hospice patients - on home visits on Monday and out-patients attending the hospice on Tuesday. They mostly have cancer or HIV and are unable to have any more treatment. It's slightly frustrating not being able to firstly establish a diagnosis on everyone and also know if any further treatment would be possible. It's mainly symptom control with fairly basic drugs but it does seem to make a huge difference to the people I've seen so far. I was in the main public hospital in Kampala today which is a fairly crazy place. The patients are all over the place, their notes aren't always around and medications are a bit random. However, the palliative care team in the hospital has been growing over the past few months and is now working reasonably well alongside the medical and surgical teams. I'm going to be doing teaching for medical students as well as junior doctors which I'm looking forward to.

The next couple of days this week are spent in Education at the hospice - we're starting a BSc in palliative medicine in January so there's loads of preparation to be done which I'm involved with - all quite exciting!

I've met loads of lovely people already - have some really nice neighbours on the Mzungu (white person) compound who are hopefully going to be great drinking buddies. I'm developing a taste for Nile special bottled beer (much cheaper than wine and not related to special brew!) so that's keeping me going.

That's enough waffle for now - more later......

2009-09-01T12:07:00.000-07:00

Hello Everyone,

Thought I’d just update you for anyone who’s interested about my first week. I’ve had an induction to the hospice for the past week and haven’t really done much work as such so far – hopefully that will start properly from tomorrow! I’ve also had a weeks crossover from Jane who’s been doing the job for the past year which has been fantastic although quite daunting given the amount of info. she’s been imparting! I’m going to be doing half clinical and half education – helping to set up a BSc in palliative medicine – which is all very exciting and a bit of a change from working in south London!

Uganda from what I’ve seen of it so far is pretty amazing although rather crazy – especially the driving in Kampala! The people are incredibly friendly and I’m getting used to being stared at again and being called Mzungu (also known as white person)! Not my favourite thing being slightly reserved but to be expected!

My accommodation is really quite civilized – not a mud hut as most people expected I’d be staying in! There is electricity (most of the time) and running, hot water and internet. There’s also the American Recreation Association club up the road with a swimming pool and gym (all slightly colonial – I’m not sure I’m completely comfortable with it, but there’s limited facilities for exercise and as I’m eating huge amounts of rice / potatoes for lunch I don’t really want to pile on the pounds too much whilst I’m here).

Anyway, that’s enough waffle from me for now. Loads of love,

Jo