Jonah in Uganda

Thursday, July 13, 2006

Hello again from Uganda, where I am already less than a week from my return home. As it would figure, this last week has been by far the most productive in respect to the project I have been working on, meaning it looks like I'm going to have a photo-finish to the end here to get everything I hope to accomplish done. I have made some good contacts at the government hospital in Iganga, including a doctor I've been shadowing a bit, which has led to both advancement of my project researching training, and some personal enrichment. The cases I have seen with him at the government hospital - a larger facility than the clinic where I am in Ibulanku - have been very different than what I would see on a "ward walk" back at OHSU. For example, yesterday we rounded on a patient with stab wounds, two who had been in collisions (including one who was on a motorcycle taxi), a boy with some sort of nephrotic syndrome complicated by TB (for all you medical nerds out there, the CXR showed a unilateral fluid line in his left lung that was almost 75% of the entire lung!), and numerous patients with AIDS and complications (TB, malaria, even Kaposi's sarcoma). While all these were fascinating, the most interesting was a 21 year old man who had attempted suicide via poisoning. Apparently, he had fallen in love with a 16 year old girl in his village and made arrangements with her family to marry her, including paying a 1,000,000 shilling dowry (around $550, a lot of money here). They were then married, and he took her back to his village, until one day her parents came while he was at work and took her back. He went to her house and unsuccessfully first requested his wife, then the dowry payment he had made. He was given neither, and in his own words, "was so ashamed I didn't know what else to do." The story was a sad one, and obviously delicate, though being discussed openly in the large one room male ward. The nurse leaned over and told me, "This thing wouldn't happen if we had a social worker at the hospital." Then both she and the doctor began berating the man, telling him he needed to get up and go back to work, it was only money which he'll remake eventually. The treatment idea was to get him to stop feeling sorry for himself via brute force - a horrific idea juxtaposed with the training I recieved when working on the psychiatric unit at Seattle Children's. As we moved to the next patient, the staff continued to laugh at the man's stupidity, and kept repeating that he needed to get up and go to work.
All in all, the experience was an eye-opening one, and gave me a good idea of common doctor-patient, doctor-nurse interaction, none of which would fly if I were to try their methods in my clinical rotations. There was little explanations given to patients or parents of patients, they were jerked around like ragdolls, and the staff seemed to have almost a contempt for many of them. Keeping in mind this is only one experience at one hospital, it was nevertheless a disturbing and discouraging one.
Unfortunately, discouragement has been a large part of my experience here. I am here to learn. I am here to experience. I am here for the selfish reasons of wanting to feel like I am doing something good in the world. I am here to take in every foreign moment and process it and use it to make decisions about what I want to do with my life and the opportunities I have. I came in a month ago full of enthusiasm about what I hoped to accomplish and what I hoped this trip would be, and have seen that die down every day. Part of it is no doubt due to the frustration of a slow-moving, ill-defined project. But the part of it that worries me, and the part I've spent a long time turning over and over again in my head and in conversation with people here, is more a collision of passion with perception. The perception with which I am struggling is the lack of Ugandans who are truly invested in bettering their own situation. At least in the rural area where I am, there seems to be little push towards any sort of development, be it better education, better healthcare, or simply better quality of life. Don't get me wrong, I am the last person who would impose on all people a Western way of life, complete with Levi's, new cars, and air conditioning. But when lack of family planning leads to malnutrition, when you are guaranteed to have at least one of your children die before the age of 12, when you are paying what little money you have for malaria medications that the rest of world knows is ineffective, where is the desire to see these things changed? No doubt there are those who have tried, and been unsuccessful, which doesn't encourage others to spend their own time and energy to correct societal ills. But still, it is a revolutionary spirit, a passion for a better life that moves past those failures and pushes until change occurs. I have yet to see that here, from anyone. The healthcare workers I spend my days with are here because it is a job, and many who are working in the village are here only until they can get a better job at a government hospital. The doctors I've talked to seem to do this less for humanitarian reasons and more for status and salary.
All of this then begs the question: why should I give up the posh life that a physician's income and status in the US could give me in order to come to a place like Ibulanku and try to help a community whose concept of helping themselves is getting as far away as they can. For many, the answer IS money. The concept is that cash, perceived to be abundant among us foreign whites, will solve their problems - be it school fees, new clothing, or a purchasing a cell phone. Also common is the request to help them immigrate to the US: buy them a plane ticket, write them a letter of invitation, find them a job. It's an odd carousel, where people with big ideas for a poverty-stricken community pay their way into a country where a majority of the community they have arrived to assist are doing their damndest to work their way out, preferably using the money the expatriates bring with them. It's what I see here in this clinic on daily basis, from the highest level of local management to the lowest of nursing assistants, and it's frustrating.
I don't yet have the answer. I maintain that every humanitarian effort has some degree of selfishness involved, and I think that it's a big challenge to get past that and theoretically, be selfless in one's donation of time and energy into a project or community. It's a daunting task to be an individual up against hundreds of years of poor politics and economy, very real corruption, and the generally less-than-ideal motivation of the people you wish to serve. At times, it looks impossible, and those are the moments where I am very honestly discouraged and disheartened.

Well, I hope this post wasn't too depressing, but these are the things that honestly run through my head during the hot Ibulanku afternoons and the candlelit nights on our front porch...

Until next time,
jonah

Monday, July 10, 2006

July 9

When first considering life without electricity, it is a romantic idea that sounds like a good time. Candlelit dinners, reading with a headlamp, a village gathered around campfires. And really, it is a good time...unless you're trying to contact home. Then it becomes a pain in the ass. As noted below, I've been in Ibulanku for a while now, and our little village is a 30-40 minute walk from the closest place to catch a taxi, and another 30 minute ride into the closest town of Iganga. Theoretically, we're supposed to have electricity, thus internet, every other day on the power grid we're on, but in reality it's maybe 12 hours every four days. I have had a couple of trips where I have gone into town with the intention of using the internet or phone, only to find out that for whatever reason ("complementary" service outage, someone stole conductors off the poles, etc.) there is no power, and the internet places do not have enough petrol to run their generators.
Nevertheless, I have survived, and it hasn't been that bad. The gloss of Uganda has most certainly worn off, mostly thanks to the matatu (shared taxi) drivers who enjoy the opportunity to rip off foreigners without apology. Nearly everyone else has been very good to us, which has been a bonus. I might even say that some, namely the children in our village, have been a bit too good to us in certain ways - I now understand what it must feel like to be famous. Everytime we walk by, they yell out the same three English phrases they know, and sometimes follow us for a while, no matter where we are heading. Again, a situation that sounds fun at first, but gets old fast, especially when one of their favorite phrases is "Give me my money!". When they gave me their money I cannot remember, but I should probably find it soon, cause those little punks are pretty persistant about it. . Up to this point, the project I’ve been working on has been focused on the one clinic we are next to in Ibulanku, but the reminder of my time I’ll most likely be commuting between our village and the government hospital in Iganga. My focus has been the training of the health workers in the district, and as there is only one part-time doctor in the village clinic, I’ll be checking my information against the better-staffed hospital (meaning they have four doctors total for the hospital serving the entire district). The project has been both slow and enormous, with a little frustration due to the enormity of the problems faced. For example, in the day I spent shadowing the doctor in the Ibulanku clinic, we saw a patient who he hastily diagnosed with allergic rhinitis * just common allergies. His prescription? Cipro and tetracycline, two powerful antibiotics. For all his knowledge of allergies and their lack of microbial cause, he still felt it important to prescribe these drugs, a cardinal sin of sins in the US where we are hammered with the dangers of propagating antibiotic resistance. Thus, the problem starts with training, is continued with lack of service, and compounded by the dearth of funding. It’s huge, and it’s sometimes difficult to fight off the feelings of helplessness and fatalism that are at times not uncommon among the people with whom we speak and work. Upon writing this, I have only about a week and a half left, and I think the timing of my return to the US will be about right. I am anxious to spend some time with my friend Ben before his wedding almost immediately after I return, and then I have a test I need to take to formally finish my first year of medical school which is causing me a bit of anxiety. I have so much more to say about my time here, and will certainly be processing it for months to come, but don’t really know where to start at the moment. I think most importantly at this point is the recognition that I will not be saving the world in these four weeks. This experience is much more of a prelude for me of things to come. Though my school schedule will prohibit me from really traveling for another 7 years or so, I hope to be able to do rotations abroad in my fourth year, and if I find myself in Africa again, I will have some idea of what to expect when I arrive. For all my reading and imaginings prior to this experience, I would have never expected some of the things that have impacted me the most, and those that have disgusted and frustrated me. These will be what gives value to this experience, and will give me a greater idea of context as I consider where my life heads as I continue forward with my education. My apologies if this is choppy, the internet cafes here in Jinja are not the best places for thinking much. I hope to be able to send out at least one more message before I get back to the States, and of course will post a prologue and pictures upon my arrival in the US. My best to everyone back home * I will miss this place, but it will be good to see familiar faces again. Until next time, jonah


June 29

From two of Uganda's metropolitan cities, Entebbe and Jinja, I am now in Ibulanku, a village of around 1,500 not far from the Kenyan border. As always, our transportation was as interesting as the destination, as we took a local bus from Jinja to Iganga - the closest city. The bus was of course packed, and as the only seven white people, we provided good entertainment for our fellow riders and driver. Upon our final arrival in Iganga following a long, dusty, diesel-fumed experience, we were each individually laughed at as we fought our way to the door and out into the mud and pouring rain in the bus park. Though to be honest, if I were Ugandan I would have been just as entertained by the sight of our backpacks and white faces out of context in the sea of dark faces...

Once in the village, we were immediately greeted by the children who have become both the joy and bane of our existance ever since. From the moment we stepped out of the car and were greeted with shouts of "mzungu!" we have been surrounded by them - initially doing our best to converse with them in our limited Lusoga, then playing soccer with them, then impressing and entertaining them with our digital cameras, and most recently, becoming the newest attraction in the mzungu zoo - there is rarely a moment when we are sitting inside our house when little heads pop up outside our barred windows watching our every move. A couple of them actually threw some nuts in through the window, only cementing my caged-animal feelings. Still, they are as entertaining to me as I am to them. A man in the village named Aziz who has befriended many of us has a son named Haddad whom I am convinced might be the funniest kid on the continent. Maybe five years old, he is constantly following myself or Ian around, holding our hands and begging for us to lift him off the ground - pretty easy considering he must weigh no more than 40 pounds. Each time his eyes get huge and he laughs and laughs; I told Aziz that since he already has three other kids I will take this one back with me, and he agreed. I think it will make a great souvenir of my time here.

The village life in general has been slow, compounded both by the increased heat and the lack of electricity. We are supposed to have power every other day, but our "on" day was eclipsed by an unintentional blackout throughout the country, leaving us now three days in the dark. Our house is nice by local standards, meaning we are not in a mud hut but a house with actual walls and occasionally running water. Tonight we ate our first meal prepared by Robert, our local cook, consisting of beans, rice, and greens, which will soon become our staple. Our project planning is also entering its final stages, as we have toured the clinic next door, and will start our interviews and investigation on Monday. In the weekend between now and then, I think a couple of us will try to make it to Sipi Falls, one of the natural landmarks of Uganda.

Things here are well - I am happy to be in a place where I can build relationships that will last more than a day. There are two our of team members who are sick tonight with vomiting and diarrhea - perhaps due to our first locally prepared meal - leaving me to suspect that my turn will come soon. Yet if it is the worst I experience here, I will be okay. So for now, I am safe and healthy...

Love is sent to everyone back home. I am starting to miss some of the comforts and people of the US, but am still realizing that what I am doing here is important both for the community we are in, and for my development as both a doctor and a person.

Until next time,
Jonah

Wednesday, June 28, 2006

Jinja is the second largest city in Uganda according to one man I talked to
today, but to walk around, I have have to question his statement. The town
where I now am is famous as the source of the Nile, meaning that now I have
seen essentially both the beginning and end of the Nile (in
Cairo/Alexandria) - and can say with certainty that the headwaters are much
more beautiful. One overwhelming feature of Uganda that I have ignored up
to this point is the surreal green that coats the country like a fine dust,
unless of course you are on the shoddy roads that run through this more
rural area, where it is actual fine dust that coats everything.
Nevertheless, the green of the country is overwhelming, sort of like a
tropical Northwest, without all the Starbucks.

It's difficult to sum up my few days here in Jinja, other than to say it has
reaffirmed some of my fondest thoughts about the country, and upset some of
the early negative feelings I once had. My perception that people were
friendly because of what I could give them has been ultimately shattered.
There have been a few instances, but they are by far the exception, and
usually come from children. Instead of money, I give them what little
broken Lusoga I can speak to them, usually consisting of "How are you?" and
"What is your name?". Then, speaking the universal language of the World
Cup, I try to ask them what team they are rooting for, which either results
in a shy smile or a look of utter cluelessness. Not so for the adults here
in Uganda, who seem to live and breathe the World Cup - at least until Ghana
lost last night. It was one of my favorite experiences thus far: Ian (the
OHSU classmate I am traveling with) and I watched the first half of the game
with the majority of the piki (motorcyle taxi) drivers standing outside an
electronics store peaking in through the barred windows. After a quick meal
from a street vendor, we went to Jinja's local hot spot which had a
projector set up, and enjoyed the rest of the game in a crowded outdoor pub,
where every Ghana mistake was laughed at, and every near-goal was
accompanied by an increase in cheering. Add this to my list of things I
will never see in America.

I have had the ill fortune of not being able to sleep very well in the heat
and too-short beds, but it has allowed me the ability to get up early in the
morning everyday. I usually wander the streets until I find someone to talk
to, and once a conversation is started, the only thing that has limited the
telling of my new friend's life story is their ability to speak English.
Today I treated a new friend Jamil and his silent cousin to a cup of Ugandan
coffee over a discussion of economics and education in Uganda, and finally
my first actual conversation about the situation in the North. It's all
very confusing, both for him as a Ugandan, and for me as an outsider.
Still, it was good to find someone who was willing to discuss it. As is
typical when you make a friend here, we exchanged mobile numbers, so
hopefully if I make it back to Jinja we can meet up again.

A quick note about coffee here - there is a shop that serves "European
coffee", which is what we are all used to, and it is amazing. Honestly, the
best French-pressed coffee I have ever tasted, and made from beans grown
here in Uganda. Juxtapose that with the "African coffee" I had today, which
is little more than instant coffee in milk or water. Why? I don't
understand how a country with such amazing beans and such a huge export of
coffee would prefer such nasty brown water.another irony. Along with the
constant sweeping of dirt - which could fill another entire email.

Again, my time is almost up, and today we leave again for Ibulanku, the
village where I'll be based for the duration of the trip. Yesterday we
began our planning for the healthcare operations project, and I will be
responsible for collecting information on the training of healthcare workers
in the PADI clinic in Ibulanku, as well as two other local clinics around
Iganga. I'm looking forward to getting started with the project, but can't
say I'm looking forward to the matatu (minivan taxi) ride out to the village
again.

Much love to everyone at home. I am safe and healthy, and plan to stay that
way. As always there is so much more to say, but it will have to wait until
I can find an internet cafe again, which might be a while.

Until next time,
Jonah

Sunday, June 25, 2006

Hello again. I am tying on what is officially the world’s worst keyboard (found right here in Entebbe), so please forgive any errors. Another day in, and a few more adventures to speak of – as will be the case for most days I am here, Im sure. I tried to exchange money, but forgot it was the weekend so have had to borrow everything thus far, which is making it really hard to do the necessities, like make phone calls and buy lukewarm Coca Colas, but overall nothing horrible. After lunch yesterday I walked into the “Private Wing” of Entebbe Hospital, and started wandering around until a nurse found me and wondered why I was there. Her English was not very good, but a woman with her began talking to me, and after I identified myself as a medical student took me a little more seriously, but was still very confused as to why I was there. I suppose I didn’t have a real solid reason either – which was no doubt part of the problem – but she agreed to give me a tour, and asked me if I’d like to meet some of the patients. Shortly thereafter she handed me a chart, and we walked into the room of a 40 yo man with AIDS, complicated by pneumonia. I had the chance to talk to him for a little while about his treatment there, and how he found out he had AIDS, and what his life has been like since. He was friendly and answered the best he could, but his English was also rough, and our conversation was short. I walked around a bit more with the woman who was with me, eventually landing on a patio where I got the chance to talk to her more about HIV in Uganda, and the role that ARVs (anti-retroviral drugs) are playing for HIV+ Ugandans. She was surprisingly blunt in saying that she thought condoms and ARVs have done more to harm the country, by extending the ability for people to spread the virus. Her answer to the pandemic? “Only God will save us.” When I implied that many people from outside Africa think more along the lines that God has forgotten Africa, she dodged the question, and sent me on my way to the public hospital.

The public hospital was straight out of a UNICEF video – overcrowded and dark. I found a Ugandan Red Cross volunteer to take me around the hospital, though we spent most of the time in the children’s ward. He told me that most children are there with malaria, and most women come to the hospital because of botched home-abortions. The public hospital is state-funded, and therefore will take anyone, but the standard of care and quality of the space was drastically different between the two. Still, interestly neither hospital had doctors there. After all, it was Saturday, and doctors work Monday to Friday during working hours. And people ask me why I want to practice medicine in the developing world…

My time is almost up in this café, but know that I am safe, and have plenty more to say that I don’t have time to write. I leave Entebbe tomorrow, and will not have the same access to email as I have had recently, but if you’d like to send me a note, feel free to send it to: attebery@ohsu.edu. No guarantees on a reply, but I would certainly love to hear from familiar voices…

Until next time,
Jonah

Saturday, June 24, 2006

I’m here.

I can’t really tell you when I began on my journey, only that it’s 10:54 am here as I’m writing this, and the West Coast it’s 11:54 pm. Somewhere along the way I lost a day, and I think my body probably hates me right about now thanks to my lack of any rhythm whatsoever. Aside from the length, the trip was noteworthy for my two and a half hour late departure from Dulles on Ethopian Airlines. To be fair, we probably would have left on time, if their computers had been working, if passengers such as myself were actually on their manifest, and if they didn’t have to handwrite boarding passes – many of which had us sitting on each other’s laps. And then we had pushed off from the gate and were heading for the runway only an hour and a half late, before they realized that the 20 or so people standing in the aisles didn’t actually have seats. I really thought they were just going to have subway-style handles come down from the ceiling for all those folks, but I guess the FAA has some sort of problem with that.

I sat next to a man from Malawai on the flight, who was taking his family back to spend a month with his parents. He had finished his college degree in Malawai, but ended up at Purdue for a Masters and Ph.D. in Plant Biology. Now he works for R.J. Reynolds in Virginia, trying to genetically modify tobacco to eliminate the carcinogens. Really, the quintessential American dream. He was actually a very engaging and friendly man, and we talked a lot about education in Africa, especially the “brain drain” and why he is contributing to it. To make a long story short, he simply wants the best available infrastructure – education, healthcare, etc. – for his children, so why would he want to go back to Malawai? It was hard to argue, yet for an idealist like myself, I suppose the same question could be directed to me. Why do I want to be here? Why did I leave the air-conditioning and flavorful meals of Portland to come to this country where I will undoubtedly stink all the time – and this is before I start crapping my pants thanks to traveler’s diarrhea.

I got in around noon and spent a while getting a ride to where I am now, a dormitory in Entebbe only a maybe a quarter mile to Lake Victoria. When we pulled in, Jessica my project leader said, “Here we are, at the zoo.” Based on the buses full of school children running around (and throwing things at me, another story), and the small monkeys running around in the dirt, I thought it was a figure of speech. It was not. It really is a zoo. With animals. Last night, we walked into “downtown” Entebbe and had dinner, and then I passed out under the protection of my bed net, but this morning I woke up to the sounds of birds and snuck out for a walk in the sunrise. I noticed that I was fenced into this little compound, and then found a security guard who directed me towards the animals. It was surreal walking around an empty zoo in the morning sun. It was entirely sensual: the sounds of the birds and monkeys here are unlike anything I’ve ever heard before, and the colors and shapes and sizes of the birds are just as stimulating. I found a path down to the beach of Lake Victoria and sat and journaled – an incredible first morning here. Now, I found a computer and am trying to send out my first thoughts from Uganda – we’ll see how well it works. We’re having power outages in Uganda right now, and the internet collection is notoriously terrible, so hopefully this will get to you.

In the big picture, my less than 24 hours have given me a good taste of Uganda. The people here are generally friendly, though most of course see me as the “mzungo” who has money to throw about to anyone for anything. I heard that converting my medical school debt into Ugandan shillings (somewhere around 4 billion) typically impresses them, so I’ll give that a try. But that is not everyone, and in just walking around I have made plenty of five-minute-friends – people who will walk with you for a while to find out who you are and where you’re from, then go their separate way. It’s been nice.

We are here in Entebbe until Monday morning, when we set out for our journey to Ibulanku, the village where we’ll be for the majority of my time here. The last few members of our team of seven will be straggling in over these few days, so I pretty much have the time to do as I please. In walking through town yesterday I spotted both an AIDS support organization and a hospital, so I’m hoping to stop by each and see if there’s anything I can do to help or what I can learn from them. I’m excited.

It’s hot, buggy, and smelly here. It’s what I expect. This experience will be an interesting one...

Until next time,
Jonah

Wednesday, May 31, 2006

Here are the pics of the voyage into the village, and of the trading center that makes up the community area of the village...



Monday, May 29, 2006

Hey all! Keep watching this site for updates...

I have pics of the area of Uganda I'll be in, and will post them after my test on Wednesday. Check back!