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.

Grasshopper Night

Today was the day that we really knew the grasshoppers were back. We'd seen flurries of them in the past few days -- and flurries of people filling their sacks with them -- but this morning, when we rounded the bend onto the main road, close to a hundred people were milling around the edge of the road, selling their sacks of collected bugs and buying from the seated sellers who lorded over ENORMOUS, like impossibly enormous, sacks of grasshoppers. The jumpy bugs coated the sides of buildings, flitted through the air like little green fairies, and exploded out of shaken bushes. They were everywhere. Again!

But tonight was the night we fully grasped the plague-like proportions of this visitation. Coming home from dinner we looked ahead down the road, to the same spot we had seen the hordes of bug-buyers and sellers this morning, and saw something impossible. Floodlights illuminated the sky above the cluster of shops but the light was moving -- an undulating upside-down tornado of moving light. It was the grasshoppers, gathered in such jaw-dropping numbers that we had to take a closer look. Nobody else seemed to pay much attention on the otherwise pitch-black road, but our eyes were fixed on the swarm, and all we could say was "Oh. My. God." over and over again.

The pictures won't totally capture it, but trust us when we say that this put the fear of an Old Testament god into us.

Back up Crater Hill

Katrina has been trying to incorporate a little more activity into our lives -- and a little less screen time, which work provides plenty of -- and so around 5:30pm she hustled the two of us out of the hospital and, after dropping our stuff at home, we continued down the road to the path for Crater Hill.

We hadn't been up there since the sunrise hike we posted earlier. We still remembered the way and knew just a little bit more Rufumbira so could greet people we passed on the road. We've become pretty good with greetings and "how are you"s but beyond that we're pretty hopeless. Although Katrina did just learn how to say "where does it hurt" and "point to it" -- pretty useful for a doctor-in-training.

The walk up Crater Hill, once you get to the hill itself, is crazy steep and we were both very out of breath when we finally reached the top, but the view is wonderful. The topography of our corner of Uganda really stands out from this height: hills that rise up out of nowhere, like enormous hands had gathered together piles of earth. We see the patchwork of terraced farming and plots of maize, potatoes, and beans; we see the crowd of people still milling around the market; we see Lake Mutanda just around the bend; and of course there are always the volcanoes.

We walked down in the dusky light. We passed young shepherds with their cows and goats (cowherds? goatherds?) coming in for the night and people streaming out of town having walked in for the day's market or work or maybe a hospital visit. We waded through the still teeming market so Katrina could buy a cabbage -- her new favorite vegetable -- and the stares and solicitous cries of "muzungu!" didn't seem that weird or alienating, just part of the town.

A Ugandan Wedding

Things have been very busy around Kisoro -- hence the paucity of posts. We're still settling into our jobs, with grace I might add, and meanwhile preparing materials and schedules for the next few weeks when we'll be home for a well-deserved Christmas break (yay!). It's amazing how quickly the time has gone.

Last weekend our friend/co-worker Dixon invited us to his sister's wedding. It was a ton of fun. We'll let the pictures speak for us.

See some of you soon for Christmas! Please remove any snow before we arrive; we're very sensitive now.

Follow this link for our web album of the wedding.

https://plus.google.com/photos/112618579612179098204/albums/6093474784992344993?authkey=CKvo7or4hK7t4gE