Back to work

I am back to work… and back to the main task at hand, namely trying to seed quality improvement teams at each health center. Quality improvement can take place at any level but tends to happen in large organizations with external pressure to meet certain goals (think indicators set by insurance companies at practices with support staff at Mt. Auburn). The task here is quite different; helping small rural health center staff to identity problems that are within their control by brainstorming and collecting data, making a plan to change the process, and follow up. In my first scheduled meeting for this week, I found one midwife completely alone in the health center with two mothers in labor and a line of mothers waiting for antenatal care outside. She had been alone (except for the gatekeeper and cleaner) for 6 days. At one point in the morning, she put down the first newborn in front of me- we found the suction bulbs I had brought with me and put one to good use- prior to jogging back to the delivery room. Not only was there not a quorum for a quality improvement ‘team’ but after 6 X 24 hours on call (and often up), she was clearly not in a place to participate in my project. Thursday’s meeting at another health center was a bit more successful- we had a group, we got through the agenda, and we planned for the next step- despite the whole concept being unfamiliar, the language barrier real, and the path of finding problems that are actually in their control daunting. The pictures are of the 4^th level health center and one of my co-facilitators, Lillian, with her partner Sylvia examining a mother at a 3^rd level health center (where Lillian delivered 5 babies in 5 hours on Tuesday!)

Mombasa to Nairobi

At the risk of conveying that all I ever do is go on vacation, I will report on my latest and last trip with Holly. We met up in Nairobi, Kenya this week- she from South Africa where she went for a conference and I from Uganda- and went to Mombasa on the Indian ocean. Mombasa, as a port city, has a long history of conflict between the Portuguese (remember hearing about Vasco de Gama in middle school?), Turks, and Omani Arabs- later the British and Swahili. It continues to be the conduit for oil for Kenya, Uganda and Rwanda; and the stopover for international navies protecting tankers from Somalian pirates to the north. The 'old city' was built by the Portuguese in the 1600's and is a maze of buildings with narrow alleyways. The community is mostly Muslim but very multicultural- including Masai, Swahili, Indian, and Arab. Our driver, whose ancestors were from Yemen, spoke Kiswahili, English, Arabic, and Urdu. We went to a fort built by the Portuguese in the late 1500's that gave a real sense of people living there. While walking through it, I wished for pictures of the soldiers so I could imagine them more clearly- and then we came upon drawings on a stone wall done by Portuguese soldiers (like doodling) of boats, animals, each other, and the Turkish soldiers. We went to the spice market and the owner scooped one after another spice for us to smell- completely intoxicating. After Mombasa, we spent 2 days on the beautiful beach to the south, then took an overnight train with sleeper cars (I've seen enough old movies to have always yearned for this experience) back to Nairobi. The train was built in the 1950's and has not been updated since-our cabin looked a bit like a kitchenette from that time- and was great. The hot, humid start gave way to cooler, dryer air as we left the coast. In the morning, after breakfast in the dining car (white table cloths!), we hung our heads out the window for hours. We passed small villages and saw hundreds of zebras, gnus, and impalas and a few giraffes. My favorite part was seeing ostriches running from the train. And Nairobi was great. Despite it's reputation as 'Nairobbery', it seemed energetic, clean, and organized. The pictures are from the fort wall, the spice market, and the train.

Election

The presidential campaigns are heating up with the election scheduled for February 18. President Yoweri Museveni appeared last week at a rally 100 yards from my house. I was initially turned away at the security gate because of my camera-there’s a strict rule against unauthorized photos of the president- so no pictures. It’s widely believed that Museveni will win, both because there are at least 5 other candidates to dilute the opposition vote and there is general belief in voting ‘irregularities’. Museveni has been president since 1986, taking over in a military operation. In 2004 he changed the constitution to do away with term limits. The country has had considerably more stability since 1986 than in the 20 years prior, during which there was the Idi Amin era followed by civil war- and a huge amount of suffering. However, some people have become increasingly disenchanted with the government and I’ve heard some very angry descriptions of the current regime. Most people think it is unlikely that there will be widespread rioting/unrest after the elections, especially in Mbarara and Ruhiira, though there are contingency evacuation plans. And no one I’ve talked to thinks it’s wise to be in Kampala during that time. The rally was like those in the US, I think. There were musical celebrities (including Bebe Cool for those up on Ugandan rap), traditional dancers, lots of speeches, and then the arrival of President Museveni, standing through the sunroof of an SUV and waving. On his arrival, masses of people ran up to the car and alongside as the car approached the podium. He has cultivated a campaign image of ‘the elder’ and always wears a hat so that his silhouette is quite recognizable. In a clever PR move, he did a rap song a couple months ago (with a refrain of, “Want another rap?” and a group says, “Yes, Sebo (Sir)”), which is widely played, including at the wedding I attended. During his one-hour speech (my housemate, Moses, kindly interpreted), he made very many promises to very many constituencies, including subsidies to the boda-boda drivers. More to come. The lone photo is from the gates of Makere University in Kampala.

Murchison Falls

Max is safely back in the US. Holly and I finished up her time in Uganda with an excursion to Murchison Falls, the largest national park in Uganda. We traveled with a backpacker hostel group, who organized the transport, lodging, and activities- a lovely break from self-sufficiency. The falls are at a place on the Nile river where the river bed narrows to a 6 meter wide crevice in the rocks and falls 45 meters so there is wild, crashing and roiling water. The falls scene in "The African Queen" (can't wait to watch this Humphrey Bogart/Katherine Hepburn movie again as I was imagining them in the little boat approaching this maelstrom) was filmed here; and Ernest Hemingway's first plane crash occurred here. We took a game drive in one of those vans in which the top raises and you can stand (when not being thrown around the van by the potholes or driving overland). We started at 6:30am and saw small herds of giraffes as the sun was rising. We found a lioness under a tree with a freshly killed Ugandan cob with a thousand cob, hartebeest, oribi, bushbuck, and waterbuck (all antelope type animals) grazing behind her on the savanna. On the afternoon boat ride that goes upriver towards the base of the falls, we saw huge crocodiles- we got close enough to one that was lying very still with it's mouth wide open to hear it breathe. We stayed in a tent and were told not to 'freak out' if/when we heard or saw baboons, hippos, or warthogs at night (this changes decision-making about bathroom trips in the middle of the night, by the way). On the second night we heard the chomping of hippos pulling grass outside our tent. It was so dark outside, I couldn't see much but as we continued to listen and watch, we saw the silhouette of a hippo (like a shadow puppet lit from behind by the lantern in front of the tent next to us) walk from the front of the tent to the back before nudging the back of our tent.....And then there were the falls. The last morning we hiked to the top of the falls. Without much in the way of safety precautions and with low density of tourists (our small group was alone), the experience was breathtaking and reverential as we approached and sat with this power of nature.

Ugandan family Christmas

Christmas in Uganda is widely celebrated but is much more privately observed than in the US. People from Kampala return to their villages en masse just before Christmas so the transportation- buses and roads- is packed leaving the city. Once in the villages, church and family feasts are the main events. Presents, lights, decorations, performances, parties, and trees are occasional parts only. So Max, Holly, and I had a family holiday a la Uganda (without presents, stockings, or tree) in a beautiful lake resort. Lake Bunyonyi is a deep lake (the sign at the resort says more than a mile though my guide book says 45 meters!) that was thought to have formed about 8000 years ago when a lava flow blocked off a river to flood a valley. It is surrounded by high hills with terraced farmland and is the only lake in Uganda that is thought to be reliably free from a parasite disease called schistosomiasis. I did bring my swimsuit (despite my travel clinic doctor telling me NO swimming in fresh water) though the weather was just too cold to consider a dip. We stayed in furnished tents on platforms with electric lights, comfortable beds with cozy blankets and quilts, and beautiful views from our deck. So on Christmas we walked, talked, read, and played games. Throughout the days and evenings we were there we heard almost continuous drumming coming from the many churches around the lake. My Christmas dinner was crayfish curry (crayfish have been stocked in the lake and there has intermittently been a large Indian population in Uganda). The photos are of the lake once the morning mist cleared and before the rain clouds moved in, Max and Holly, and Akampene or ‘Punishment Island’- the story is that in past times unmarried girls who got pregnant were taken to the island and left there; a man without enough cows to pay a bride price could rescue the woman and marry her but failing that she would succumb to starvation; yet another reason for personal gratitude.