Week 5

14/06/10
We had to get some admin things accomplished today. The hotel manager had not yet written up the price agreement for our accommodations and meals and a week had passed. There wasn’t enough clear planning on the cost so initially the charge was per person then per room, then per person and per room. Well finally we agreed on 35000 UGX per room and 10000UGX per meal per person if we had dinner buffet. We’re still not sure about the cost for lunch. We printed the contract and a letter that we drafted for the clinic and we went into town to get some money out of the only atm in town. It was out of money and has been for about a week. We went to the grocery store to confirm that there was no other atm and the owner offered to help us. He asked for just Justin to come along and they went to see the bank manager. I’m not sure how things went or if because we were Americans the manager said there would be money in the atm by midday and someone would call to let us know when it was available.
The hotel had requested that we pay a deposit of 500k UGX per person, about $250, because the president is due to visit and there is a lot of prep work going into making the hotel look better for his visit. We could only come up with 500k UGX total, so we paid that and planned on trying the atm later in the day. I had mentioned it before but David, the person who picked us up in Kampala and whose car we are driving, wanted to sit down with us and coach us on what to say to the president about our work and the affiliation to his clinic. Interestingly, David is running for parliament. So far we have avoided it and we all feel like we are being used as political pawns in his interest and we don’t want any part of it. We have been told that we are on the VIP list though. Maybe we’ll be out in the field that day doing research instead.
The vehicle we drive is also an issue with conducting good research. Everyone knows David’s car and his affiliation with the clinic and that he is running for office. So we discussed it and we agreed that we should park the vehicle and walk into and around towns to reduce our status and to try to speak to people in as much of a normal setting as possible.
So we went to the clinic to shadow the staff and observe. The goal at the clinic is to make general recommendations on how to improve care, resource allocation, and efficiency. The staff was receptive and seemed to be going about things naturally without any concern for our being there. The doctor is only at the clinic Friday through Sunday, so the medical officer (equivalent to a P.A. in the US) sees patients on the other days. I was shadowing John the PA for the day. They had seen about 18 patients before we arrived about 12pm and there were about 6-8 more waiting. He said there was a mix of illnesses seen in the clinic that morning. There were patients with malaria, PID, PUD, TB, Poisoning, and an injury. I asked if they triaged and they don’t. It’s first come, first serve for the most part. The first patient observed was a young boy about 10yrs old and his father. John asked about complaints and symptoms. The father said he had a headache and he also complained of an injury on his foot. John felt the boys head and said he thought it was malaria, so he would have him tested. It was so hard to not say anything, but I was there to observe at this point. The cut on the boy’s foot was badly infected and he didn’t have any other symptom of malaria. It’s probably a good practice here to test all patients for malaria, but that was not what was happening here. He was assuming that the boys fever was from malaria. Well it turned out later that he did not have it, so he just had the nurse squeeze out the pus and clean the wound. I think the boys fever was a result of how bad the infection was. More troubling was that he did not prescribe antibiotics, which they have in stock, to treat the infection.
After that an older woman came in complaining of lower back pain, but the doctor was interrupted by the nurse bringing in a young woman who he thought was in respiratory distress. Someone had found her on the side of the road and brought her there. She seemed to me to be having a very severe case of hiccups. She did not look cyanotic, was walking, but could not speak. He took her to the next room and he said he needed to give her a bronchodilator to open up her bronchioles. I assumed he thought she was having an asthma attack. The nurse got her IV access set. He said he was giving her aminophenol, but I’m not sure I caught his pronunciation correctly. He pushed 2 syringes over about 10 minutes and there was no improvement in her hiccups. After he pushed the meds, he remembered that previous visitors had brought inhalers and he used two different types. One was a bronchodilator and the other a corticosteroid. One thing that concerned me at that point was that he had not auscultated her lungs, so I decided to borrow a stethoscope that was hanging on the wall to listen for myself. I asked for alcohol to clean the ear pieces, because I had heard staff members talk of alcohol and I the nursing assistant just referenced a bottle that was next to her as alcohol. It was actually a bottle of normal saline. I cleaned them as best I could with cotton and normal saline. Her lungs sounds were clear with no wheezing. There was no change in her hiccups after the treatment with both inhalers. He had her wait a while and receive some normal saline to see if she felt better. She did not, so he referred her to Pallisa Hospital about 8km away.
The older woman came in after that and complained of pain in her leg and back. He thought it was probably just her age. I was glad to see that he did check her blood pressure. It was 140/90. She said she did not suffer from hypertension before. He said he was having her tested for malaria, because he thought her pain might by psychological and having her confirm that she did not have malaria would make her feel better. The next patient was also an older woman who complained of a head ache, but the doctor said he knew her and checked her blood pressure right away. It was 160/96. He asked her and she said she had been out of medication for a week. While following the doctor around, he went to the lab to speak to the lab tech. I watched while the tech took a blood sample from a toddler by finger stick. He used an insulin syringe to pinch the child’s finger. I thought; it would be more cost effective to use the small plastic finger pricks, than to use syringes. It would also likely be less pain full for the patient. Chris later confirmed for me that what the lab tech referred to as alcohol was also normal saline.
The doctor took a break and went to check on if lunch was being prepared, so I poked into the treatment room in the mean time. The nursing assistant was administering a medication from a glass vial. She used a regular needle to draw up the medication and then using the same needle she went into the side of a bottle of normal saline to dilute the medication and then used that needle to administer the medication intravenously to the patient.
Lunch was ready about an hour later. We ate lunch and headed back to the hotel to debrief. I feel like I’m being critical of these people who are trying to help others, but at the same time I feel like some of these things are easily addressed and care could be much better as well as more cost effective.
15/06/10
We went to Gogonio village today and met with Asakad Sam, who was someone that we identified as having potential for being a good translator the on our last visit to Gogonio. We parked at the clinic, as to attract the least amount of attention to ourselves and we had already decided that we would be walking wherever we went the rest of the day. I called Sam and told him we would meet him at the subcounty offices which was a few hundred meters from the clinic. We walked there and he directed us to a building near buy to have a seat. The building belongs to a seed and livestock exchange program that works with the community to encourage and facilitate self sufficiency.
Sam introduced us to 3 other staff members there and we all sat down to talk and introduce ourselves. My gut feeling was that Sam would not be a good translator at this point because he belonged to an organization that served the same community, but I felt better as the conversation went along. It seemed that he would be able to stay objective and provide accurate translation. We asked Sam for his guidance in pointing us to homes where he felt people would be receptive and who could provide information on health needs.
We walked about 2km through some crop fields and came across a small village of a few mud huts. They received us warmly and we all sat in to talk. The theme that came to the surface immediately was malaria as we have encountered with others I the area. There were a few other issues, but the one notable thing was the reaction to HIV. When one of the members of the village said he was positive the others laughed at him. We have talked about this since and it is definitely something we need to continue to explore.
The next village that we walked to about another 2km away was also very welcoming. Again we sat in a clearing in between the homes to talk. This was more of a compound and while we hadn’t built enough rapport with them to inquire, it seemed like it was an older man with several wives. There was one younger male in the village, but he indicated that he worked in farming there. The older man was very outspoken about the need for money, which is what he says, facilitates the access to health care and primarily medicine. He referenced the conditions of his cows and that his crops did not earn him enough money. It seems though that that the first concern for everyone that we speak to is money, even the ones that clearly have more resources, in terms of livestock or crops. This also ties in with the immediate request for biomedical interventions as the solution to every health need. At each village we left mosquito nets for each home. It was our first focus group attempt and we were feeling good about the information we received.
16/06/10
Today the weather looked bad in the morning and we were all tired emotionally and physically. I didn’t think this type of interaction would take so much out of you, but the concentrating on the observation and the walking really take a toll. After breakfast we decided to take a walk in town and see if we could find some different foods to eat. The hotel serves the same thing every day, and it’s getting old fast. I realize how spoiled I have become. When I was younger and in the Army, we would go much longer than this eating MREs and it wouldn’t bother me. I would just make the best of it. Here the food is getting to me. The chicken taste fishy sometimes and gamey others. The goat is tolerable, but they figured out we don’t like the chicken so we are served goat often. It is a blessing when we get beef, but only if it is fried because if they stew it, it tastes fishy. The rest of the day we spent working on journals and typing up our field notes. UGGHHH!!Goat for dinner AGAIN!!
17/06/10
We had made arrangements to have the ambulance from Agule clinic take us to Mbale, to pick up anti-malarial medication for the “outreach” debacle we had been coerced into for Friday. While we waited for the ambulance to arrive we went to the market again, determined to but something different. We walked around for a while and finally found the fresh fruit area. We bought some pineapple, avocado, passion fruit, and what we thought was limes. The tangerines here look like limes and the oranges are green like limes as well.
The ambulance showed up about 12 and we headed out for what was supposed to be a 1 hour drive to Mbale. 2 hours later we arrived in Mbale. Tom the lab tech knew right where to go and we were able to get full dosage malaria treatments for adults for 3200UBX (less than $2). We had lunch there as well at an Indian restaurant. I ordered a cheeseburger knowing good and well that it would not be what I expected, but it was a cheese burger either way. It was on white toast and a bit undercooked but I ate it anyway, since I have come to accept that I will have parasites by the time I leave here. Meat here is butchered in the open and hangs exposed for at least one day. At least I like to think it’s not more than one day. We made the long drive back and we were all exhausted. We had dinner and it was pleasant. We had bought beans earlier in the morning as well, which we had not had here before, and the hotel cook prepared it for us.
18/06/10
Today was incredibly tense. We were supposed to go to Gogonio to participate in the “outreach”, but we heard from the staff that people had travelled all the way from Gogonio to our hotel to seek treatment. The hotel staff had managed to turn most of them away, but as we were finishing breakfast and older woman sat down at a nearby table and one of the staff members translated for her that she has several symptoms resembling syphilis. Dustin replied as best he could that we were not doctors and directed her to the clinic.
This was obviously a huge problem for our acceptance into the community and for obtaining good objective data. The message that we would be speaking with the community and providing some treatment for malaria had snowballed into people thinking that we were coming to provide treatment for everyone and for everything. So we decided to let the clinic staff to go ahead with the event and we would not go. We have actually decided that we will not go back to Gogonio for several weeks and the “thank you” nets will be given to the clinic to distribute so that we try to get the best data possible. The culture of dependency here is such that we feel it is the only way to attempt to remain objective.
The rest of the day we walked around Pallisa Towne as two separate teams, Dustin and Veronica as one team and Chris and I as another team. I don’t know if the tension from the morning was still there, but I was feeling pretty edgy. The day before I had gotten pretty upset about a blatant and rude advances by one of the local men towards Veronica; I was able to walk away from the situation and nothing came of it and I came to terms with the differences in culture. I thought I came to terms with it. Those feelings came back today as we were deciding how to split the groups, so we decided that it would be best if Veronica and I did not work together, at least while trying to gather information in town. I think the dynamic is different in the villages and the more personal interactions are less likely to lead to that type of incident. Either way I need to find a way to remain objective.
While in town we talked to a few people here and there. It is obvious that people are not used to Muzungos walking around town. We received several perplexed looks as well as some serious faces. We tried to wave and are friendly and it worked in most cases. The theme we keep encountering is malaria is the prevalent illness and medication is the solution for it. I have not heard anything about prevention as of yet.
The World Cup has been going on for about a week now and I had not gotten into it so far, even when the US played England. Today’s game was different. The US played Slovinja and I found myself excited and cheering on the US. It was a great game until the end and it was a draw. I’m looking forward to watching again.
We had planned on eating dinner in town and watching the game, but I fell asleep, and the Dustin, Chris, and a few Peace Corps people we met here left into town. They sent a text later asking if Veronica and I wanted to go to a club. I was reluctant since we had to walk through town at night and we didn’t know how to get there. We got lost, of course, and walked around most of the town. It’s not very big at all, but it was intimidating since we were getting funny looks. People here are not accustomed to seeing muzungos walk around during the day, never mind at night. Most foreigners drive around in cars and go to and from directly where they are working/staying. By the way muzungo is equivalent to white people regardless of your ethnicity and race.
So we found Dustin, who gave us directions over the phone, and walked to the club a few meters away. As we entered there we a few locals crowded around the door asking for us to pay for them to get in. Of course we got more puzzled looks, but people got used to us after a little while and we started mingling and dancing. At about 1am, Charles showed up looking for us. He said he was concerned that we were there and that we were not safe. He might have been right. We had to walk back to the hotel across town. Luckily the RDC (the president’s representative to the people) was there and he gave us a ride back in his car.
19/06/2010
Today the plan was to meet Sam, our translator at the hotel and head to Agule sub district near the lake shore. Sam showed up about 11am, but Dustin said he was trying to resolve some issues between Julia and David and would not be going with us. David insists that he understood that we were coming here to treat patients, even though the agreement with CBU clearly states otherwise. So Chris, Veronica, Sam, and I went on our own.
I was happy to be driving. It had been over a month and I think I needed to feel in control of something.
We interviewed three families at three different villages. They went fairly well, although I recognized where I needed to make some improvements in the way I asked questions and in keeping contact with the participants and not Sam, the translator. The themes are pretty consistent; malaria, no money for treatment, and treatment not always available. A few interesting things came from the older gentleman we were speaking with at the second village. He mentioned that mosquito populations increased after 1987, when a tribe from northern Uganda raided the area and stole their cattle. He mentioned that the mosquitoes used to feed on the cattle, but now feed on people. It’s more likely that once livestock was gone, people began to farm more as a means of income and survival, rice farming in particular. The stagnant water of rice fields is a perfect breeding ground for mosquitoes. He also mentioned a plant that was used before for treating malaria that is no longer in the area. He says development has caused it to disappear, although he thinks it can still be found further away in less developed areas.
At the last interview of the day we heard about a tree that the government recommended for treating malaria, but they said did not work. What is interesting about that is that it goes along with other observations we have made of the way the government and media conveys misinformation. There was a local news report a few days on a new trial of malaria treatments, consisting of avocado seed and some other herbs. The problem was that they closed out the segment saying that this was going to be the biggest breakthrough in malaria treatment and that people could hope to see it available soon as if the trial was conclusive and it was known to be effective. As we discussed this at our debriefing in the evening, Dustin brought up another good example of miscommunication. Not too long ago the President made a statement during a press conference that circumcision prevented males from getting HIV, when in fact his advisors had told him that circumcision reduced the rate of HIV transmission.
20/06/10
Sunday is our one day off, so we use it to get caught up on our journals, read, and any other work we need some quiet time to complete. I think we are the only quest at the hotel, so it has been very quiet all day. Tomorrow I suspect will be different, since the president is coming to Pallisa for a visit and he will be meeting here with other government officials here at the hotel.