Tuesday, July 19, 2011

Farewell to Nakivale : Maniriho (God is with you)

Sadly my stay here is quickly coming to an end. I will miss the refugees, the staff, the clinic, my early misty morning run and my evening walk where the children often greet me and sometimes I try to test their knowledge of geography since they often ask me where I am from. While most may know where US is but Malaysia is another matter.

But I am also an animal lover so I have to say a few words about the creatures that I see here.

The sharp bleating cries of the ibises that wake me up in the morning are part of the scene here in Mbarara but not in Nakivale. Similarly the marabou storks seem to congregate more in the urban areas than the settlement. They are ugly gigantic birds that have long skinny legs and big wing span. Despite their size they land ever so gracefully and effortlessly on the top most branches of tall trees hardly swaying or disturbing them. They have this tendency to perch on the highest points of buildings and trees and sometimes they look like steeples on churches. I feel sorry for them as they scavenge for leftovers in the dumpsters looking kind of forlorn and unloved. Earlier in my stay in Mbarara, I saw a pair of grey crowned cranes on top of the same pine trees that the marabou storks nest but I have not seen them since. Next to the marabou storks these cranes are the epitome of elegance and grace. Such is the unfairness of nature.

On our long journey to Nakivale, from a distance I have spotted more grey crowned cranes in a field and several purple swamp hens.

As it is the season of the matoki (banana), men with heavy loads of sometimes seven bunches of them on their bicycle push their burden for many kilometers of dusty road often times uphill towards the market in Mbarara. A journey that takes us on our 4x4 a little over an hour but will probably take several hours for them.

The most impressive animals of all are the ankole: the long-horned cows. The refugees are too poor to own them but we often encounter several herds of them owned by the Ugandans. Some of the horns are huge and so perfectly symmetrical but they do look rather heavy. They make me wonder what are the evolutionary advantages of these astonishingly and ravishingly beautiful horns.

This week I think I saw my first patient with tetanus (lockjaw). He was hit on the head with a stick a week or so ago and was stitched up and apparently had also recently received tetanus shot. He came in with the inability to open his jaw, sweating, stiff neck, extreme pain in his muscles and bloody diarrhea. Having not eaten for a few days, his blood pressure was not palpable. He showed signs of trismus (inability to open his jaw), risus sardonicus (grimace)and opisthotonus (arching of the back). We gave him fluids and a whole bunch of antibiotics and transferred him to GIZ, a higher level center there they will have tetanus immune globulin and other supports to help him. Joy said a long and fervent prayer before he was transferred. Joshua said tetanus is not very common here but it is more often seen in neonates when the village mid-wives sometimes use cow-dungs for the wounds.

My last day at Nakivale, Joshua and I saw some very interesting patients but these are usually patients with serious conditions. A 40-year-old woman came in complaining of having shortness of breath, palpitations and chest pressure on and off for four months. Our exam showed that she had some heart failure and very likely due to some damaged valve problem likely from a previous bout of rheumatic fever. I started her on some diuretics and Ace-inhibitor and advised her that she should see a cardiologist. There is nothing much else we could do here.

Then an old man walked in with a handkerchief holding a enormous growth dripping with some pus. He had had the growth for four years and had been treated a few times, the last time was probably two years ago. We could not get from him what he was treated with. Joshua sent fluid for TB smear but there was none. The lab could not do any other kinds of culture. I ventured to tell Joshua that this might be actinomycosis (lumpy jaw), a chronic bacterial infection usually in the face and neck with sinus tracts which this patient had. This patient would need long-term antibiotic treatment and perhaps surgery as well given the enormous lump and the number of sinuses present. Joshua had never heard of this condition before so we discussed it for awhile.

Another man crawled into our consultation room with his wife in attendance. The room immediately filled up with a putrid smell. He claimed that his left leg became black just two days ago. The foot was black and from the bottom there was copious muddy drainage. the right leg was only slightly better, quite swollen and he had no painful sensation in either of the legs. We sent him to check blood sugar to look for diabetes but the lab ran out of test strips. We offered him our only pair of crutches. He would need an amputation as soon as possible We shipped these two patients to GIZ for further treatment. I wish them the best of luck.

As I watch the sun sets over Mbarara the refugees will be here even as I leave. UNHCR has been here in south west Uganda since 1954 taking care of these displaced people. The problem has not stopped yet. Worldwide there continues to be conflicts and droughts and as long as there are conflicts and disasters there will be refugees. Drought across the Horn of Africa, now affecting more than 11 million people in Ethiopia, Djibouti, Kenya and Somalia has resulted in waves of refugees to Ethiopia and north Kenya, many will likely die of starvation if humanitarian aid does not reach them in time.

This morning we saw Red Cross trucks coming to the settlement to deliver food to the refugees. A few weeks ago it was World Food Program that came here. We saw fewer patients today because many stayed to receive their food ration. On my way out I happened on a mother and child sitting outside. The baby was severely malnourished and I was sure she was HIV positive. Indeed mother and child went to get tested and both were positive for HIV.

To the staff of Kibengo HC II, a big asante sana (thank you) for welcoming us here.

To the refugees, Maniriho (God is with you).

Monday, July 18, 2011

A Walk into the Village of the Refugee Settlement

Curious about the way the refugee live, I tried to explore the village on my own. The refugees make use of the land by growing a variety of crops and vegetables. As far as I can see, they grow corns, sorghum, sunflowers, beans, cassava, sweet potatoes, ground nuts…Some keep a few goats, chickens and ducks. Many of their activities happen outside the house, I often wonder what it would be like during the rainy season. In the heat of the day, even the animals take shelter in the shade wherever they can find it.

Some refugees have opened small stores selling small items and airtime for cell phones. There is even a hotel just right outside the health center.

Women often work together shucking maize or corn while socializing, pounding sorghum into flour, mashing reeds and then drying them for weaving. Corns, sorghum, cassava, groundnuts are left drying in the sun.

Children often play out in the dirt. I have not seen any toys yet. Some boys have tied layers of plastics together to make them into a ball to kick with or a bicycle tire to roll with. Some kind organization has built a playground right close by the clinic, some place that the children can play in besides dirt.
As I walked into the village, I seldom hear the word “Mzungu” (foreigners or white person) thrown at me except by a few grown-ups. Perhaps it is not a word commonly used in the Congo or Rwanda.

These are pictures I took way past lunch hour. The children share a meal of potatoes and beans in the kitchen while their mothers have their meals under the shade of a tree. One of the children is sitting next to some hot coals left after the cooking.

After passing a row of houses, I saw a structure in a clearing which a man told me is their Catholic church. We tried to converse in a mixture of English and French and I was able to find out that he is from the Congo and has five children while his parents are still in the Congo. The community has no money to build a church and this structure is the best they can come up with. I sat on the bench and tried to imagine sitting on it for the whole service. One needs to be rather alert or risk falling off the bench.

Life goes on despite all the difficulties. The refugees seem to try hard to go on with their lives even if exiled from their homeland.

The Staff of Kibengo Health Center II

Joy my Congolese translator traveled for three days to the border of Uganda to escape the war carrying whatever he could. He was perhaps around 14 years of age. He was separated from his parents who escaped with his younger siblings. In some way it was blessing in disguise. Joy was registered separately and received his own refugee card which entitled him to a plot of his own land, tarp, blankets and cookware. It was also fortuitous that his family was placed close to him. It has been over fifteen years since he came to Uganda. He learned English in Ugandan school besides French that he learned in the Congo. He translates for Joshua and me, but mostly for me since Joshua could often get by using the local language. Despite all the hardship Joy has a temperament that goes along with his name. He always greets me with this wide, white-teeth joyful smile that is quite contagious. It has been a JOY and a PLEASURE working with him.
My first week here I showed him the lyrics to “Joy to the World or Jeremiah was a bullfrog” by Hoyt Axton, just the refrain,

Joy to the world
All the boys and girls
Joy to the fishes in the deep blue sea
Joy to you and me

It brought the biggest grin from him.
He would like to return home but is afraid of the insecurity of the situation in Congo. Two of his siblings have elected to stay in the Congo and are now studying in the university, supporting themselves by selling properties that the family owns in the Congo. Periodically Joy wires money to them when they are in dire need because he is the oldest. He says that he will go back when it is God’s will.
Joy is insistent about being able to tell a Rwanda refugee from a Congolese from the way they dress. But I am convinced that he is aided by their accent, language and their names. Here are two women, one from Rwanda and the other from the Congo and I can’t tell where they are from just by looking at them and for that matter I can’t tell a Ugandan national from the refugees. The women here wear clothing with a whole variety of colors and materials often mixing them in ways that I am not used to. There are no distinct differences that I can discern but evidently there must be.

Moses (Moses 2) who translated for me one day when Joy was not around, has a similar story except that he was around three when he came here. For him he would prefer to stay in Uganda and become a citizen. Uganda is all he knows. He has lived here almost all of his life and knows only English and does not think he will fit well in the Congo. Just like Joy how he ends up will be God’s will.

Mary runs the immunization clinic in one of the open-air buildings. The immunizations offered to the children include polio, measles, DTP (diphtheria, tetanus and pertussis). For the women in reproductive age she ensures that they are immunized against tetanus. There is also a clinic that she provides vitamin A to the children. On Wednesdays she runs a “Growth Monitoring Clinic” when babies are weighed and measured looking for malnourished children and providing education about nutrition and in some circumstances, nutritional supplementation.

Rosette and Amulet are the two midwives in the health center, the prettiest midwives that I have ever met. They run the antenatal clinic on Mondays and Fridays in addition to delivering babies. There is HIV testing and counseling. Roughly 6% of the pregnant women are tested positive for HIV. There is a maternity ward of two beds and one could stretch it to three if one is forced to use the bed in the consultation room. The delivery room is next to the ward. One of the mid-wives is always on call at night and oftentimes they spend the night there with the mother-to-be.

In the Injection room, Moses (Moses 1) and Jocelyn could place IVs expertly even in the tiniest wriggling baby. They are a crucial part of the team in the health center. Harriet and Jeffrey run the laboratory. The injection room and the laboratory are places that the children fear most. Crying often emits from these rooms and they are reluctant dragons when it is their turn to face the music.

Then there are Olivier and Alice who dole out the medications, Patrick who registers the demographics of the patients who have been seen; there are many more personnel that I don’t know who make the day-to-day functioning of the clinic possible. Kibengo Health Center also runs a community out reach service twice a week. I am not familiar with the program since being the only doctor here I was told from the outset that my place is at the center itself.

Joshua is the medical officer with whom I share a consultation room. We saw patients simultaneously on each side of the desk, not much privacy for our patients. If I have to do a gynecological exam, I would take my women to the maternity consultation room. For the men who complain of ailments below the waist, I would empty our consultation room of patients for my exam. Joshua is unlike most African medical people I work with does his physical exam which is quite refreshing indeed. Most African doctors just talk to their patients and prescribe them medications without performing a physical examination.

Speaking of physical examination, I saw a man with insomnia, he told us that he became “crazy” last January and was admitted and then medicated. I decided to do a fairly complete physical examination on him and sent him home on some diazepam (sleep aid). The following week he brought his wife and insisted that she should see me. She also was hospitalized roughly at the same time for psychotic problem and came in for insomnia. He told Joy that he himself has been sleeping well since he had the complete treatment from me. He wanted his wife to get the same physical exam that he received from me. Well if that made him happy, I was glad to comply. Such is the healing power of the laying of the hands.

Joshua is also in charge of the treatment of TB and keeps a record of all the patients who have been sent to get sputum testing. All the patients who are sent for TB testing also receive HIV testing. From my rough calculation, about 5% of the patients tested are positive for TB but 25% of patients suspected of TB are tested positive for HIV.

The clinic sees between 250 to 350 patients a day. Sixteen staff members live in the quarters behind the clinic, two to a room. Many of them have families far away and yet I have not heard any mutterings of dissatisfaction among the staff. They have to use the latrines, no flushed toilets or running water. There is a very thriving vegetable garden in the yard with lots of onions, corn, tomatoes, pumpkins, passion fruits, groundnuts and ododo. There are many more administrators and support staff that I have not mentioned and they also make the place whirl.

Last week Rosette showed me a new-born baby, soft, innocent and vulnerable. He was the mother’s first and she seemed exhausted but grandmother was extremely proud and eager to show off her grandson. Rosette was just as proud.

Tuesday, July 12, 2011

The In-Patient Unit: Malaria and More Malaria

In the Kibengo Health clinic II, there is a make-shift in-patient unit for patients who need short-term hospitalization and who are not sick enough to be referred to other higher level health care centers. There are four beds in the unit but it is not uncommon to have two to three small children sharing the same bed when it becomes overwhelmingly crowded. Most of the patients are being treated for malaria as they have a higher burden of the parasites and are a lot sicker. Intravenous quinine is the treatment of choice here and their fevers are kept down with anti-pyretics and sponging. Parents are responsible for the sponging and making sure that the kids do not pull out their IVs. The caretakers take care of each other’s children and frequently share a meal on the floor of the unit. The meal is often beans, matoki mashed banana), ododo (cooked green vegetables), and occasionally some meat.

We make rounds at the beginning and end of the day. When we leave the clinic the medical officers are on-call at nights to check on them. At the end of the day the patients are usually just starting their treatment and oftentimes are quite cranky especially the children. However rounds in the morning show a complete change in the patients overnight. Most are eating and drinking and raring to go. What a difference a day of intravenous treatment with quinine and IV fluids.

Malaria continues to be rampant; we were told that in the last two months it rivals respiratory infections in incidence. It does not discriminate and affects the young, the elderly, pregnant and non-pregnant women. The symptoms of malaria are so varied that any child with vomiting and abdominal pain especially when there is a fever warrants a malaria test. This week we are low on adult coartem and have to use oral quinine instead. Also we are low on rapid malaria test kits and have to use them with care. The lab was overwhelmed with so many requests for malaria testing that we the clinicians are now doing our own tests in our exam room. The down side is that children waiting outside begin to hear crying coming from our room and they become fearful when they approach us and some of them even start crying before they are being seen. Here is a 3-year-old child who came in vomiting and had a fever. She was so stoic I did not hear a whimper from her when Joshua pricked her or perhaps she was too sick to cry. And this is a elegant woman with malaria in her seven-month of pregnancy and cannot hold down anything for 2 days. She is being admitted in the maternity ward.

At the end of the day last week a youngster had a bout of seizure, he had malaria and was not having a high fever at the time of the seizure. Very likely the malaria parasites had invaded his brain and what we say in medical jargon is he had cerebral malaria. He was transferred to a hospital for treatment.

In my training as an infectious disease specialist, we read about such tropical diseases as malaria and cholera and although I have seen cases of malaria in the US mainly from returning travelers from the third world; I have never seen so many cases of cholera and malaria until I volunteered with MTI in Haiti in its cholera outbreak and now in the Nakivale Refugee Settlement. It has been quite a humbling learning experience for me, indeed.