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.

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

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 3^rd 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.

The Coming Home Series

It’s never easy to sum up ten months of ones life in a brief and hopefully interesting essay, especially when one has been exposed to so many new people, places and other fascinating stimuli during that time. In fact, I have only tried it one other time, when I left China, and so now eight years later I will attempt to succinctly offer you a glimpse of our experience of living in Mbarara, Uganda. Furthermore, since we have been keeping the blog up to date all year, I will spare you a repeat of the highlights and instead try to pass on my thoughts regarding the intricacies of day to day life in a Sub-Saharan, East African country. I have a lot to ramble on about so I will break it up into a series of blogs over the next month. The first entry is actually an assignment I had to turn in a couple of months ago, but seemed like it would make a good blog entry, so don’t get thrown off by the use of the words “project” and “resistance factors” as they were terms needed for the assignment. Plus this will buy me some time to collect my thoughts in order to produce more coherent blogs.

Coming Home #1: The Project

My project is obvious in that my wife and I, in August, moved halfway around the world to live here in Uganda for ten months. There are numerous reasons why our life and work here is different from the everyday routine we established back home in America, but the major differences are pace of life, eating habits, social interactions and fiscal constraints. This endeavor was carefully planned before our arrival and has been meticulously managed during our stay to avoid any undue resistance mainly regarding the fiscal constraints.
Living in a foreign country for an extended period of time can be both extremely gratifying and sometimes frustrating. There are many wonderful aspects of living abroad, especially in Uganda, such as the overwhelming natural beauty, the gracious people and first-hand accounts of a developing nation, including a strong sense of the struggles and successes of a culture far removed from one’s own. The first big difference we have experienced here is the pace of life. Africa is well known for its slower, laid-back type of lifestyle which takes a bit of getting used to when one comes from a high stress job in a fast-paced society. After six months here we have definitely gotten used to and learned to enjoy the Ugandan pace of life, but some aspects can still be frustrating to us when we are used to a more orderly and regulated atmosphere. Second, several aspects of our eating habits have changed over the last six months, most notably, being that we prepare or cook meals much more often than we did back home. Being deprived of the convenience of pre-packaged food has actually been a very enlightening experience for both of us as we have had to learn to cook our meals from scratch, which is more time consuming but also, in the end, a more satisfying and healthy endeavor. We have also had to become creative with our meals because my wife being a vegetarian often finds very limited menu options at the local restaurants. At the same time, I have learned to survive on less meat than I typically consume at home, but feel healthier for doing so. Third, we have experienced a remarkable upswing in social interactions due to our living situation. We live in the MUST campus housing along with 15-20 other short and long-term visitors. And because we are all living in the same situation, close together and away from family and friends, we, therefore, share many of the same ideas and values and often get together for shared meals, drinks and good conversation. Although we have many friends back home, our way of life differs from here and, consequently, does not afford us as much time for the numerous friendly, social interactions we have here in Uganda. Finally, we have had to become much more fiscally conservative to be able to spend ten months here earning no money. Granted, it is much cheaper for us as Americans to live here than in our own country, but our savings was limited and so we have had to learn to live a more conservative lifestyle in order to survive.
Prior to embarking on this trip, we needed to make plans and situate our lives in a way that would enable us to successfully live overseas for ten months without having to worry about resistance factors from home. These plans, undoubtedly, revolved around finances, which most people know tends to be a high anxiety undertaking. We had to cancel credit cards and magazine subscriptions, open new bank accounts, make sure recurring bills were paid, pack our belongings away and then hope that we still had enough money saved to be able to live all year in Uganda. While living here we have kept a strict budget to monitor our spending in order to live in relative comfort, while allowing ourselves enough money to explore this wonderful country and continent because we may never have this opportunity again.
This project has encompassed many of the resistance to change factors including, fear of the unknown, need for security, contrasting interpretations and lack of resources. However, these factors plus others will always be part of any project and were quite expected by us during our needs assessment and feasibility study that we conducted prior to leaving. Furthermore, we have adapted well to these factors because we have worked together as a team to rise above the complications and when this project comes to a close on May 25th we will, without a doubt, be very pleased with the results.

Top Tens

Top ten things you can buy in Mbarara for 2000 USh ($1)

1. One kg of dried garbanzo beans (several kgs after soaking)
2. A third of a can of imported Pringles potato chips
3. 2km Bodaboda ride in and out of town. Twice.
4. A single blood sugar check in the medical ward of the hospital
5. Ten large avocados
6. A week's course of oral ciprofloxacin
7. A single pirated DVD rental (with a vague return date...)
8. A liter of petrol
9. Two large pineapples
10. A large plate of matoke (mashed plantains) and beans

Top ten things to do with visitors to Uganda

1. Boat trip down the Kazinga Channel: hippos, crocs, buffalo, birds galore...
2. Rafting down the Nile- survivable but may leave a mark
3. Seeing the tree-climbing lions in Ishasha
4. Drinking cold (always relative) Nile Special beer
5. Cautiously tasting "home-brewed" banana gin (oogie) from deep in the village
6. Swimming and Scrabble at Lake Bunyoni
7. Chimp trek in the Kyambura Gorge
8. Drinking sundowners on the deck at Ndali, overlooking the Rwenzoris
9. Waiting 30 minutes for a temperamental female elephant to finish lunch
10. Waking up in one of the tents at the Nile Porch- ahhhh!!!!!!!
    

Top ten favorties from my evening runs

1. Endorphins- enough said
2. At least 3 people saying "thank you for the exercise!" as I run by- I take it to mean "good job", but a great Uganda-ism...
   
3. The soft dirt roads that are perfect for a gentle jog most evenings
4. The 5-year-olds who drop what they are doing to run next to me until a better distraction comes along
   
5. The sky at dusk- stunning and different every night
6. The views from the top of the hill behind our house- 3600
   
7. The perfect running temperature- always
8. The offer of barbecued goat as I run past the old market- almost like a marathon aid station, I suppose
   
9. The hills- okay, I don't always love them, but I know I should...
10. The bodaboda drivers who always offer me a ride home in the middle of my run- do I really look like I need it???

Anita's Great Adventure!

Aside from several trips to Mexico and trip to Spain 15 years ago, my mom had not really traveled all that much, so when she decided to come visit us here in Uganda we were very excited, to say the least. Contrary to the naysayer’s who say I should not have, on the fourth day, lead my 65yr old mother into an Impenetrable Rain Forest and forced her to march for seven hours looking for mountain gorilla’s that could kill you with one swipe; I felt it would be a wonderful introduction to this fascinating place we live. Honestly, it was not supposed to take anywhere close to seven hours and the idea was for her to actually see the gorillas, but as we have come to learn in our long stay here is that anything can happen in Africa and what you expect to happen typically does not.






























Her trip started by hanging out in Mbarara with us for a couple of days to get over the jet lag while getting to meet both our expat and local friends. Lynn showed her the hospital and our amazing fruit and veggie market while I took her out to the village to meet some of the kids I coach. We also took her to the famous “Lords Bar” where only goat and chicken is served and the music is either country/western or ABBA’s greatest hits. She loved it! After a couple days R&R we set out on our first journey, and because I have already mentioned the gorilla debacle, I will move straight to the tree-climbing lions in Ishasha. These lions literally lay on the branches of giant fig trees trying to stay out of the sun and usually digesting something. They were amazing! Next, we headed up to Mweya where we were to do a game drive and a boat ride on the Kazinga Channel. The highlight of the game drive was definitely the lions, but we also saw many, many elephants, probably over 100 all together over two days. The boat ride is a favorite because you get to see many of the animal’s cohabitating down at the water. Buffalo chill right next to crocs, elephants share the waterfront with hippos and a variety of other animals and birds cruise around looking for a good time. Mweya is great because we sleep at the cheap (but nice) hostel, yet we spend our free time having drinks by the poolside of the posh lodge a few hundred meters away. We also have sundowner drinks and great dinners at this lodge allowing us to experience the best of both worlds. On our second night at Mweya we were having evening cocktails as the sun was setting when a hippo came walking across the lawn about 20ft from us. The funny thing was is that we did not even notice at first and our bartender had to casually state as he set down our drinks, “oh look, the hippo is coming”. Apparently this same hippo uses the shortcut through the lodge quite often and an employee will just follow him until he has left the grounds. After Mweya we came back to Mbarara for a couple more days before heading off to Jinja to raft the Nile.





We subjected my mom to public transport by taking the bus to Kampala because I figured “what the hell, she survived the gorilla trek”. I would say it was an unremarkable drive, but the fact that there were actually empty seats on the bus is truly remarkable. The 25min taxi ride, though, was different story. The bus park is located in one of the busiest and most disturbingly neglected parts of Kampala as well as being adjacent to their soccer stadium. On this day there happened to be a big match between Uganda and South Africa so the already overcrowded streets around the bus park were jammed with people and vehicles jockeying for square inches of space (it was like being in a Chinese supermarket after work), but our taxi driver got us through even though we think he left a piece of the car behind on the first pothole we hit. So after making a quick stop at the bank, we had not proceeded another 25ft when the front tire hit what we thought was a giant pothole, but when the rear tire went in and didn’t come out, we knew we had a problem. We got out and saw that it was not a giant pothole, but in fact it was a 10ft deep open manhole in the middle of the road, which would be shocking to some people, but not us. The driver looked at the tire and then called to some guys across the street that came over and lifted the back end of the car out of the hole. We jumped back in the taxi and off we went only having wasted literally 90 seconds on the whole ordeal. Unfortunately, the hole had not been kind to the taxi’s exhaust system and we slowly lost power accompanied by a distinct burning smell until the taxi died. Luckily it died about 20yds from the place we were staying so grabbed our bags, thanked him and walked on.































We hopped the rafting bus to Jinja the next morning and had my mom in a raft on the Nile by 10am. The Nile River has class 5 rapids to raft, but smarter people, namely my wife, thought it would be best if we opted for the “family float” as opposed to taking my mom down class 5 rapids all day. The family float is nice because it only lasts a little over an hour and you get to experience monkeys, birds and a leisurely swim in the Nile as well as a couple of class 2 rapids that it is impossible to flip the raft in. We stayed at a gorgeous place called the “Nile Porch” that sits 100ft. above the river overlooking Bujagali Falls. The self contained tents are brilliant allowing spectacular views of the falls from in bed, in the hammock, in the shower, or even sittin on the can. We spent two days, including Lynn’s B-day, at this beautiful spot on the river before heading back to Kampala to meet some friends for dinner and then putting my mom on plane to fly home.






























We had a great time showing my mom our little part of Africa and I think she really enjoyed herself also. Most importantly, however, is that she arrived home with the new found knowledge that Africa, Uganda in particular, is not simply a place of wars, deserts, and famine as the media tends to display it, but in fact is a place rich in culture, natural beauty and a resilient people who face up to great challenges on a daily basis.