Happy Birthday Tri-tri!

Katrina turned 29 today!

The morning started with some hot-off-the-griddle Robie's Pancakes which, if you don't already know, are the finest pancakes that flour, eggs, and milk have ever had the honor of producing. I knew we had just enough ingredients to whip up a batch and I used a trick Katrina taught me to improvise on the buttermilk (add freshly-squeezed lemon juice to whole milk). The results were divine. We sat together in the early morning sun, sipped our french-press coffee and enjoyed hot, crispy pancakes slathered in real Kisoroan honey.

To further celebrate, she and Andrea and I all went to Lake Mutanda to bask on a certain porch that we've come to love. The Lake Mutanda Resort boasts an amazing view of the lake, its islands, and the misty rolling hillsides. We arrived in time for lunch and then read, listened to music, chatted and ducked in, and out of the two or three sun showers that blew through. Nothing could diminish the spirits of pure relaxation and celebration that we brought with us.

On the way there, we had an interesting run in with the Ugandan Public Works sector. Not once, not twice, but thrice did we come across enormous ditches being dug straight across the road. Straight across, I should mention, the only road to our destination. Each time we came to one of these ditches, our driver and friend Robert (Uganda's friendliest, most knowledge, bird-loving guide) exited the car and conversed with the two to three workmen to reach a compromise between our desire to reach the lake and their obvious desire to remove large pieces of the road.

Some money changed hands, some rocks and large amounts of dirt were shoved back into the ditches and in all three cases we bumpily made it over. At one impasse we even ran into the "engineer" of the project who was zipping back to town on the back of a motorcycle. He laughed off Robert's line of questioning, claiming he had never expected cars to actually use the road during his project. Leave it to an engineer to think of all the contingencies. 

But our time at the lake was divine. Blessed open time with no commitments. We were joined for dinner by Nori and another resident Sofia who had ridden over on a motorcycle. We were all happy to have this little slice of quiet paradise amidst an already beautiful landscape. It was a gorgeous place to celebrate the anniversary of the birth of a gorgeous lady!

Homemade Gardening

The girls decided to plant a garden. They borrowed a hoe from our neighbor (who probably looked upon the request with some amusement) and picked out a sunny patch of grass to hack to pieces. We now have a 2' x 5' rectangle of exposed earth in our yard with lettuce, spinach, and basil seeds ready to pop up and deliver salads unto us!

This is very much Andrea's and Katrina's baby. In fact, I've been asked not to help after I took a turn at the hoe and snapped the handle in half with a few hearty swings. Not my intention, I promise. Now I'll get to watch them plant and weed and tend to their field. Farmers Jacky and Jill.

To compensate for the violence I perpetrated against the hoe, I had the errand of finding a new one. I showed the wreckage to a hardware store owner in town and he pointed toward a carpentry shop around the corner that would craft a new handle. Woodworking is a pretty booming business in Kisoro. There's probably close to a dozen workshops in town that are advertised as such by the stacks of freshly made wooden furniture out front and the young men hard at work cutting and nailing and staining and scraping.

The owner of the carpentry shop that I found took one look at the broken hoe and handed it to a boy at a nearby worktable. The young woodworker promptly popped the head off the tool, grabbed a suitable piece of wood and a machete and got to work.

While I waited, I had time to admire the woodwork being done around me by other craftsmen. A family waited on a bench for a large door to be finished. A young man in coveralls was tracing a gentle curve on the corners of the door with a flexible saw blade and pencil. With his guidelines drawn, he used a machete to hack off big pieces first and then, swinging closer and closer to his line but never over it, cleaved away thin slices of excess door. In just a few minutes, he'd sculpted a very smooth and precise curve with a tool that we associate with slashing through a forest.

Meanwhile, the boy at the worktable had used his machete to whittle a thick dowel from a very square-shaped plank. He then ran a small hand plane over the surface, shaving off the bumps and leaving a rod as neat and even as if it had been passed through a machine. Finally, the iron tool head was fixed on and held in place with scraps of wood wedged tightly between the head and handle. The work was done and I owed 2,000 shillings, but all I had was a 5,000 shilling bill so we called it a tip and I walked home the proud owner of a handsomely restored farming implement.

Watching the process got me thinking about how little I know about the way things are made in my country. The origin of most of the things we use is hidden behind distant factory walls. We’re able to buy furniture, computers, even food without needing to know much about where these things came from or what they’re made of.

In a town like Kisoro there are plenty of examples of goods shipped in from far away, made from unfamiliar materials: mountains of used clothing from America, electronics from China and Korea, cars from Japan, packaged food from the Middle East. But there are also many prolific makers here, not just sellers. From furniture to food, you can find hundreds of examples of ingeniously used local resources here. I wonder about how this changes your relationship with the things you have. Knowing where they came from, how they were made… 

A Fine Balance

Two Towers Mountain

Nori, the attending doctor/adventurer, showed us an amazing hike today. We walked to the other end of town and then down a road that led straight out of it, past a church and girls school and orphanage and fields. The road starts to slope up and the eucalyptus trees grow thicker on either side. We slowly made our way up past houses tucked behind handmade fences, past baby goats and past groups of kids who would pause their playing to scream "Muzungu!" and "How are you!", excited for the chance to try this out.

We could soon see that we were walking up the spine of a ridge that rose to a peak and left the county far below on either side. At the top are two tall radio towers that give this mountain its name. Nori called this the "two towers hike" and we added "mountain" because we were breathing way too hard by the end for it to just be a hill.

The top opens up to one of the greatest views I've ever stood in front of. Immense scale, and the dappled water of Lake Mutanda which made me think of the ocean, sheer drops and wide open spaces. Even from that incredible height, we could hear the chatter of the town, lively drums, braying goats. It was like the highest point in a quiet neighborhood --no cars, no planes, no collected drone of a city, just the sound of people and animals, lives you could almost listen in on if you sat still enough.

We got back down just before dusk and ate a very generous and well-deserved dinner at a local buffet: mashed plantains, potatoes, goat meat (so good!), beans, and peanut sauce. Another of Nori's solid recommendations. We may not be quite ready to conquer a volcano, but we're a little closer.

Settling back in Kisoro

One of the views from our porch: 3 tall eucalyptus and a grandma

It's good to be back! The weather is still enchanting. The breeze is as cool as if an ocean is nearby and the sun is warm but never harsh like you might expect on the Equator. The mountains have been entirely invisible since we arrived, hidden by a wide band of haze and clouds that hangs above the horizon. It hasn't really rained since we got back on January 8th but these formless, encircling clouds are always there -- often leaving the sky above you blue but always keeping the edges misty gray and green and white.

Walking to the market

President Museveni is rumored to be visiting town today. In fact, we're pushing our village health worker training back a week to accommodate what is expected to be a bustling and excited day, all swarming around wherever the president will happen to visit -- no word on where that will be yet.

We woke up in 6 am darkness to walk up Crater Hill with Nori, the new attending doctor. We're still entertaining the possibility of climbing one of the big volcanoes, eventually. But before we can do that, we need to prove to ourselves that we can climb hills without any trouble.

Waiting for fares

I can hear the birds starting to wake up as I type this on our porch, steaming earl grey at my side and a brilliant, razor-thin crescent moon up above. Lights are starting to turn on. I think we'll set out soon.

They both look like they're having a pretty good day

Primary care in the community: We come to you!

Andrew and I arrived back on Thursday and are right back into the swing of things – even after just 3 months, it feels like we came back home. On Saturday I went into the community to do CDCom, and I wanted to share more about it.

CDCom [“Chronic Disease in the Community”] is a program that DGH has been running for several years through which we bring a month of medicine to patients with known chronic diseases in their communities. Patients from two or three villages are mobilized by their village health workers (VHWs) to the meet-up point, usually a VHW’s home compound or local landmark like a grassy knoll or a water tank. We check “disease measures” like blood pressure, urine glucose, listening for wheeze, and gather basic history about symptoms, medication adherence, and possible side effects. If the patient’s complaints seem more complicated than just a refill and he or she would benefit from further work-up, we refer them to our chronic care clinic on Wednesdays or Thursdays. If they need medication titration, we work with the chronic care nurse and the attending on the wards to adjust the regimen.

We believe this service to be pretty unique and an valuable service – delivering anti-hypertensive, anti-diabetic, anti-epileptic, and anti-asthmatic medicines from a government hospital directly to patients who are miles and miles away over bumpy, rocky roads. This saves the patients or their caretakers a significant amount of time, as they don’t need to take the day off from working in the fields or taking care of work around the house.

The program was free for all participants for the first two years of its existence, but within the last two years, DGH has established a small transportation insurance program that has unfortunately introduced a fee for this service. “Tehaz”, as it is called, is modeled on various private community transportation funds that pool villagers’ money to be available to contributors to pay for transport to the hospital in emergencies. DGH figured that it could operate such a fund that heavily subsizes and discounts transport and allows proceeds to fund community health programs. 

We are in the midst of evaluating whether the added revenue is sufficient to warrant the time and money we invest in selling Tehaz (which is short for Tegurira Ejo Hazaza, which means “Planning for Tomorrow” in Rufumbira). It does make me uncomfortable as a healthcare provider in training that we are excluding people who don’t pay. We do have a stipulation that the poorest 10% of people in a village can join for free – but is difficult to determine. There are only a handful of people on our roster of ~300 patients who are “exempt” and I am sure there are many others who could benefit. My conscience is slightly eased when I remember that all patients are welcome to come to KDH for free chronic disease care any Wednesday or Thursday. But still, transportation for these patients, mostly on foot, takes hours and means lost wages or valuable time working in their “gardens”.

My colleagues over the years have integrated certain other programs into our mobile chronic disease clinic, most notably malnutrition services. VHWs screen for malnutrition in the community and invite newly identified cases to join us at CDCom. They actually can refer the mothers directly to the health centre, but many come to be enrolled in our community nutrition program either before or after visiting the health centre. We were once able to deliver RUTF (see: plumpy nut) straight to the communities, but a process of centralization took away that perk –something to do with USAID centralizing procurement of RUTF and not wanting us to be distributing it in the field. As I understand it, the USAID program is attempting to ensure that RUTF (called Rutafa here) is available at all or most government health centre IIs, a small health centre usually staffed by one or two nurses with only outpatient services.

To evaluate each child, we take their weight and measure their mid-upper arm circumference (MUAC). We compare this to measurements we recorded the previous month(s) and ensure they are growing. We refer patients with severe malnutrition to the hospital to ensure they are receiving RUTF and that they’ve received an HIV test and a medical evaluation. We also do very abbreviated counseling about what foods to eat more of. We follow kids for several months and make sure they are growing. If not, we refer them back to the hospital for a medical and nutrition work-up. 

In my first month of working on CDComs I met a grandmother with a severely malnourished 6-year-old granddaughter. The child had recently been sent from Kampala to Kisoro after one of her parents endured a long hospital stay and ultimately passed away. The child was so thin and had a full body rash. I suspected HIV and urged the grandmother to take her to the hospital on the same day. The grandmother said, “Maybe tomorrow.” I didn’t know what to do except to give her the money she would need to get there and back by motorcycle “boda” – about $4. I figured this could help her get to the hospital with less concern that she’d spend hours walking each way. We don’t have a good way to evaluate whether patients “need” this money for transport, but I think it’s a small price to pay to increase significantly the chances that these patients get to care ASAP. Plus, any money they do have could be better spent on school fees or food to feed the kids. We’ve been trying to establish a more regular “emergency referral fund” for patients like this one, but we also need criteria for who gets money, if it's not everyone.

We have recently started having VHWs measure vital signs for all of the children at these gatherings– especially respiratory rate and temperature. They take a history of any recent illnesses, like fever, cough, or diarrhea and feel for the fontanelle if the child is young enough. This is an important opportunity for continuing education with our VHWs and also a chance to identify sick kids. Children with malnutrition are much more likely to become sick and die from pneumonia, diarrhea, or even malaria, than children who are healthy.

In the coming months, we are looking to integrate mental health as well as family planning patients into our CDCom practice. We will keep you posted on how that goes! 

Please share your thoughts, questions, comments with us on this or other posts.