Sunday, May 17, 2009

Coming Home #2: Survival, Choice and Opportunity

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So how do I begin to explain Africa? First, as you know, Africa is a phenomenally large continent. To give you an idea of how big it really is, check out this overlay of some of the other continents or countries that actually fit inside Africa all at once including, the US with Alaska, most of Europe and China.


We have only visited six of the 53 countries since arriving here so when I speak of Africa I am really talking about the small area referred to as East Africa, although we did make a quick jaunt up to Egypt and Ethiopia. Nonetheless, through my reading I have concluded that everyday life in East Africa is very similar to life in West Africa, Central Africa and southern Africa excluding South Africa itself. And what are the characteristics of this “life”? The simple answer is that life in Africa is all about survival. Of course, as in any place, there are those who are surviving quite easily here, but the overwhelming majority of the 800 million inhabitants of this continent live a daily life of struggle and survival. One can see this everyday on the faces of the women working in the fields, or the kids who are skipping school to gather wood and water for cooking. It’s absolutely amazing to see the responsibilities that are thrust upon the children here. It is all too common to see three and four year old kids hauling the yellow jerrycans of water from some far away well or spring, or come across a three year old girl with her one year old sister strapped to her back. While I wish that the kids could be in school instead, I am also constantly impressed at how practical people become in many facets of life because of their lifelong survival skills.

If you ask me, “What exactly are Africans lacking that we in the west are not”? The answer is not democracy or money or food, it is the choice and opportunity to realize those very same aspects of life. Choice and opportunity are two things that not only do we in the west have in abundance, but, unfortunately, we also take for granted. I live in a country where the life expectancy for a man is 48 years, and I am considered an elder. We have friends who have grown up their entire lives, to this day, without running water or electricity, or have spent half their lives living in refugee camps. There are thousands of places in this country that do have running water and electricity; our place has it. Do you think my friend chooses to not have running water or electricity? No, his family simply has not been afforded the opportunity to acquire, what some would call, such basic necessities. But are they really necessities? Apparently not, as illustrated by the fact that he is a bright, athletic kid who finished secondary school, and who is also ambitious and motivated. He is willing to work, but job opportunities are few and those that are available require either 3-5yrs. experience or, more importantly, knowing someone of stature that will give you a job because he knows you, not because you are qualified. I have several other friends in the same predicament, young, healthy, smart and nothing for them to do. However, my friends are special because instead of falling into the vicious trap of loitering around the local pool table, drinking and waiting for the next Premiership football match to be aired; they are actually donating their time to charity. Yes, these guys who have so little have taken it upon themselves to start a community based organization that disperses donated goods and provides health & sanitation workshops to some of the most vulnerable people in the country. I imagine there are thousands of people in this country like my friends who look beyond their own needs and truly believe Uganda has the potential to help itself, but the opportunity to be heard is drowned out by the “cha ching” of aid money flowing into the government coffers.

Choice is also about the most fundamental things like what clothes to wear on a daily basis. Did you know that about ¾ of all the clothes that get donated to places like the Salvation Army are packed up and sold to dealers who then ship it here to Africa to be sold even cheaper in the markets and stores? I didn’t know that, just like I didn’t know there were so many thousands of Eminem and 50 Cent fans in Africa, but I see their shirts everywhere. I don’t think the boda driver I saw the other day chose to wear a red knit Christmas sweater with dancing reindeer. I don’t think half the colleges in America know they are advertising their schools on African bodies. And, I don’t feel gratitude when I see my friend wearing a nicely pressed button down shirt that happens to be from McDonalds. But, this stuff, that’s already been thrown away once, gets dumped over here at ridiculously low prices, killing the local textile market and removing the opportunity for many people to even choose what to wear. My friends can and will go very far in life, but it will be a struggle everyday because of the lack of these and other types of choice and opportunity.

Friday, May 8, 2009

Again...


Is it really happening again? We can not tear ourselves away from the online footage of the Jesusita Fire. Another nightmare it seems. The accounts are terrifying tonight. Our thoughts and best wishes to everyone affected. Thanks to the Independent and Noozhawk for keeping us informed in Uganda. And, of course, a million thanks to the firefighters. Again.
Lynn and Danny

Thursday, May 7, 2009

Today

Today, I woke early. Made my morning cup of tea. And read over the lecture I was scheduled to give at 8am. The main road between our house and the university was quiet and easy to walk across, and I arrived on time. Over the next 10 minutes the classroom slowly swelled, filling with 3rd year medical students ready for a thrilling (?) lecture on cardiomyopathy, part of their core medicine lecture series. As usual, their interest and enthusiasm made being the lecturer enjoyable. We ended on time, and I wished them good luck on their upcoming exams.

After my lecture, I wandered home and had my second cup of tea and a quick chat with my lovely hubbie. He had been up very early himself to complete a project related to his thesis in development studies. The question of cause regarding Mbarara’s litter problem was to be tested by Danny, who placed a large, obvious rubbish bin in the middle of the busy bus park very early in the morning to see whether, if given access to a bin, people would elect to use it. Does the fault for litter lie in the hands of the local government who don’t provide adequate bins, or in the local culture where littering is acceptable? We shall see…

After a cup of tea, I was off again for my daily ward rounds, and walked across the now slightly busier street, dodging bodas, matoke trucks and, perhaps most dangerous of all, SUVs belonging to international NGOs. Upon reaching the ward, I met with the PG, Obayo, who works on my firm. Together we are currently responsible for half of the female ward (~16 patients). We gathered the medical students who are currently working with us, and began to sequentially see and evaluate our patients. The general format includes a brief (hopefully) presentation by the medical student responsible for each bed, followed by a focused physical exam by either myself or Obayo and a group discussion and decision regarding the plan for the day for each patient.

The first patient of the day was a 70-year-old lady who would be called a “frequent-flier” by residents in the US, and while she is now well enough to leave the hospital, the tragedy of her situation reflects bigger problems for Uganda. Due to both culture and a lack of government-funded social services or nursing homes, people in Uganda expect to care for their elderly or ill family members at home indefinitely. Indeed, this attitude is carried inside the hospital itself where medical care is provided but all ancillary services, such as toileting, cleaning and feeding must be provided by a patient’s attendant (usually a family member). The assumption that the health of family comes above all else, and the expectation that your family will care for you, is a beautiful part of the culture here. The problem, however, arises when there is no family, as in the case of our patient. Every day for the past week, as well as every day of the last 3 admissions, she has had a new symptom or complaint which we have diligently investigated, with little to report except mild, chronic hypertension. She finally revealed that she has no family and at an ancient 70 years of age (life expectancy in Uganda is 46), has found herself alone with neighbors who are tired of her asking for money or help. While I understand the comparable attractiveness of a private room and TV at Santa Barbara Cottage Hospital over returning to the homeless shelter, the fact that this lady would prefer to sleep in a TB and HIV filled ward with 36 other women rather than return home reflects the real heartbreak of her situation. Today we finally discharged her, but I suspect I will see her again soon.

The other cases were as diverse, interesting and frustrating as always…

  • A 65 year old lady with a severe heart valve problem, now in heart failure. Diurese, diurese, diurese!
  • A 38 year old, HIV-positive woman with TB meningitis. Nearly always fatal without treatment. Due to a problem (i.e. complete absence) with the national supply of TB medication for the past 6 weeks, she and many like her have been without ANY treatment for several weeks.
  • A 23 year old woman with end stage kidney failure. Reason not known. Dialysis unavailable.
  • A 28 year old woman, also HIV-positive, with septic shock and a chest X-ray revealing military TB. Thank god the TB drugs finally arrived last night.
  • A 30 year old woman without HIV, admitted with severe wasting. She is disappearing before our eyes. With her vomiting, we are worried about stomach cancer, but the endoscopy needed for diagnosis is prohibitively expensive. The differential diagnosis is short: cancer which we can not treat or disseminated TB which we can. Today she will begin TB treatment, but I suspect she is not long with us.
  • A 20 year old, HIV-positive girl, on TB treatment but not yet on ARVs. Weight 65lbs.
  • A 45 year old, HIV-positive woman with anemia due to her HIV medication and pneumonia. Got blood, got antibiotics. Got better. Going home. Yay! Victory.

After my rounds on the ward, I walked into town with a friend (a visiting resident from Boston). Hit Pearl supermarket for the typical juice, cheese and canned food. Moved on to the Central Market, where I visited my usual three stalls and picked up eggplant, carrots, onions, chili peppers, green beans, tomatoes and bell peppers. A steep $4 gone. I’ve become picky about the size of our eggs, so made a special stop at a shop that sells the big ones. After a quick visit to the DVD rental place, we jumped on bodas and headed home.

And, yes, as I walked in the door of our little apartment on the compound, I put the kettle on for another cup of tea.