I remember as a child watching my father play with
campfires. I always loved a good fire—watching the mesmerizing flame lick at
the wood, sometimes playfully, sometimes ferociously, sometimes meekly. I
learned quickly that one of two things can happen when you overload a fire with
wood. Either it engulfs the new fuel which strengthens it and it becomes an
even more formidable force, or, after a brief battle of sparking flames, it
withers and suffocates, leaving only a smouldering memory of smoke where the
bright flames once danced.
I wonder if a heart burning with passion and desire for
justice works in the same way. If obstacles, bureaucracy, opposition,
corruption, and apathy are like logs to the heart’s flame. Just enough, and the
injustice can give fuel to an impassioned heart. But a burden too heavy,
leaving no room for hope to fan the flames can cause burnout and collapse,
leaving only a smouldering heart, bitter at the injustice, but incapable of
mustering the fire to fight it.
This is my foremost impression of Dr Paul, the OB/GYN I am
working with. A fresh graduate, he is full of vim and vigour, passion and
energy. He is the medical director and sole specialist (of any field) at the
hospital. He so strongly desires change for the hospital, yet he comes up
against road block after road block. Even after 3 short months here, despite
the changes he has managed to effect, he is already chafing heavily at the
restraints put on him by a system that is loathe to change. The odds seem stacked
against him. Thus far he’s barged through and made some pretty impressive
changes in the 3 short months he’s been here, saving millions of shillings by
centralizing the pharmacy to prevent drug and supply theft (primarily by
demoralized and severely underpaid staff), streamlining the doctors that work
here so that they are present when they need to be, insisting that the midwives
fill out partographs (charting to ensure that labour is progressing
appropriately and safely for mom and babe). However it has come at a personal
and professional price and unfortunately there are some who are less keen on
changes than he. I am hesitant to get into details on the internet, but please
feel free to ask me and I’m happy to share in person or via email some of the
details of the unfortunate politics that sadly, I’m sure are not unique to this
hospital.
His quote of the day: “you know, maybe if I had everything,
it wouldn’t be as good as it seems. I might be arrogant or something. So yes,
maybe this is better.” Just found out recently the government has told doctors
they won’t be getting paid this month. No one knows when they’ll start getting
paid again. Dr Paul told me the nurses here work 60-70 hours/week and get paid
< 180$ month. That is, when the government is paying its employees. Is that
the reason behind the partograph I saw from a fresh stillbirth last night,
where the woman was laboring for 4 hours here, but the fetal heart rate
auscultated (using a wooden or metal fetoscope, which looks kind of like a
candle holder) only twice, both times in the first hour? Is it any wonder that
Dr Paul is desperate to escape to a better living situation, one where he sees
his young family more than once or twice a month, where he can actually get
paid what he has been promised, where booked cases aren’t cancelled, as they
were today, because they were “out of anesthetic” (or, perhaps the anesthesia
techs weren’t in the mood to work, someone else theorized)? He has committed 3
years here in this rural hospital as a service to his people, how can it be
fair for me to point out that his country is desperately in need of him, that
Ugandans are suffering from the massive brain drain of doctors to wealthier
countries, when I know if I were in his shoes, I would also be looking for escape?
Yet he remains dedicated, spearheading planning for a “surgery camp” for the
new year. Last year a team of UK doctors
came down and did a bunch of surgeries free of charge. The local team here was
pretty excluded, and they don’t even know if they’re coming back. So Dr Paul is
plunging ahead with planning their own 2-week free surgery extravaganza for the
surrounding area, where ORs will start at 4am. They have yet to secure any
funding, but plans continue. Their dedication to forge ahead despite the uncertainty
and passion to provide care for those who need it most but can afford it least is
inspiring.
Dr Paul and the midwives: the maternity team
To change tracks a bit, since I couldn’t fit all of you in
my suitcase and no one (to my knowledge, anyhow!) is coming to visit, I’ll
describe to you the hospital where I’m working. I’m working at a small private
mission hospital, which also has a primary and secondary school on the grounds.
There is nothing else around (literally). The nearest village is about 2km away
and it’s tiny, consisting of only a few small shops and places to resupply
phone credit. The nearest town with internet is almost an hour away by
minibus-taxi. The hospital is typical of those I’ve been to in developing
countries. No A/C, (aside from very occasionally in the OR), but the windows
are perpetually open, which is great for a comfortable ambient temperature, but
less ideal in terms of being infested with flies. Dr Paul always has a can of
Raid in his hand and sprays everything (including patients).
The nursery for sicker babies (there is no neonatal ICU here) consists of a
shelf in the labour room with a lamp that puts out a bit of heat, with swaddled
babies lined up next to each other. One preemie (looks 33ish weeks to me) with
nasal prongs. Another one is so jaundiced and yellow, but there is no special
light, so they tell the mothers to take the baby outside and get morning sun
before 11am. Unlike at home where 24 weeks is considered the limit of
viability, here it is 28 weeks. When I asked Dr Paul if there are ever any
transfers to Kampala for preemies, he laughed.
A sick baby in the "nursery". Sometimes the shelf behind is full of babies.
Labour beds are cots with plastic coated mattresses with a
set of stirrups. Women are seated on a sheet of plastic, and bring their own roll
of cotton (cotton-ball type fluffy cotton) to use as pads and mop up any mess. Breaking
a woman’s water ais done with the back of needle as no amni-hooks are
available. Of course there is nothing for analgesia. Beds are separated by what looks like
dilapidated shower curtains. Minor procedures, like D+Cs, are done in the same
room, separated by a curtain. They get
only some Demerol for sedation and analgesia. The women labour remarkably
quietly. Just a few groans escape them. Often no one is there with them; they
labour alone. I’ve been told in this culture labour is seen as a woman’s
domain, and a man would be seen as weak if he were to participate. Sometimes a
friend or female relative comes, but they can’t always afford the money for
transport, so sometimes patients are alone. A lone midwife or nurse supervises
the floor, but is not there to baby or comfort anyone. I think it must be
terribly frightening and lonely, especially for first-time mothers. Anyone is
uncomfortable in a hospital setting, but to go through hours of labour, alone,
with no one to whisper words of comfort or strength in your ear, or hold your
hand…these women are very courageous. But necessity if not by choice.
Antepartum ward. Patients bring their own sheets and blankets.
Post partum is the typical Florence Nightengale ward, with beds
lined up next to one another, no curtains or anything to separate. There is one
screen on wheels we use if we are examining a patient. The other day we used it
to try to give privacy to a mother we were sure was going to die. (She
survived, miraculously. I’ll post on that later.)
And oh yes. One last image to leave you with. There are also
chickens wandering around the wards. Awesome.
