Tuesday, November 30, 2010

A Belated International Thanksgiving

The following is a joint post from the team:

Throughout the week of Thanksgiving, John and Meredith were on a mission to get us a turkey. Despite being thousands of miles from home, we weren't going to let one of our country's great traditions go uncelebrated. The turkey odyssey began at the chicken coup in the corner of the market. Rumor had it there were some turkeys located in a nearby village, and John got on the phone to inform our would-be holiday bird suppliers, "We want the biggest, baddest gobbler you got." Within 2o minutes, our potential feast arrived, legs tied and strapped to back of a boda boda. The bird was handed to the Sound Man in order to assess quality; he grasped its leathery legs and held the specimen upside-down, pretending to gauge the weight with an up-and-down bobbing motion. "Hmmm..." He tried not to appear overanxious for the purchase, but simultaneously he cringed with the unforeseen pangs of a weighty conscience. Previously, our bearded microphone manager was unaware of the plights of our feather friends. In an act of grace, John pardoned the bird.

After a film crew meeting, the triumvirate determined that Thanksgiving dinner must not be abandoned so easily. But a key question became apparent, "Once we get the bird, who is going to kill it?" Meredith had prepared numerous chickens during her stint in the Dominican Republic, but she thought her counterparts should have to have the experience as well. John was still faint at heart from the turkey encounter the other day... and Michael was a little timid to take up the task, especially after watching the video of Dewan's holiday preparations. It was determined that there was only one way to solve this dilemma - Gin Rummy - a three-night game; loser makes the kill. It was agreed. Meredith took the early lead with Aces galore (15 points each) and never looked back. In the end, it was Michael who had to face the gruesome task. After he returned from Kampala, we ventured deep into the countryside surrounding Gulu town, and picked up the largest turkey we that could find.

Thankfully for Michael, the Italians had agreed to help us host the dinner at Lacor. With in 20 minutes of purchasing our bird, we arrived at the hospital's guesthouse, where Brother Carlo was quick to do the dirty job that we had all tried so hard to avoid. Preparing the bird was an all day affair. While telling stories of how his mother used to do it back in Parma, Carlo and Michael plucked the turkey then covered it in butter, sage, and a collection of local spices. The Italian radiologist had also put together a stuffing made of ingredients that he could rustle up from around the hospital grounds, which included sweet potatoes, pumpkin, and pineapple. It was remarkable, and the staff had a hard time not stealing spoonfuls at any opportune moment.

The fancy chocolate chips sent across the world by Mrs. Otremba were put to use by John, Meredith, and Luca (our Italian pediatrician friend) in order to top off the feast with some delicious cookies. Between the turkey and the cookies, it was hard to say what was the biggest crowd-pleaser for our international guests.

We hope that Luca summarized the sentiments of the guests from Canada, Italy, Australia, Uganda, and the United States with his tongue-in-cheek praise, stating, "This was my best Thanksgiving dinner ever."

Filming with the UHRC in Lira

On Saturday morning we put our new magic letter to use. We first met up with staff from the Uganda Human Rights Commission (UHRC) at their regional office in Gulu. They thought it would be a good idea if we took the Commission's 4x4 as opposed to our Corolla for the long journey to meet right to health complainants in the neighboring districts. We didn't refuse the offer, and we're very glad that we didn't. It took several hours to reach our first interviewee, who lives deep in the bumpy country side of Lira, where the roads are far less forgiving than the ones nearby Gulu town. A decal on the SUV's rear side window is a reminder of the region's recent history of war. It's faded color is also curiously resonant with much of the population's own wish to hold on to their past. Brother Carlo at Lacor keeps telling me that nobody wants to talk about the war anymore; they just want to move on with their lives. While riding the bus back to Gulu on Friday night, I sat next to a college student who was sifting through notes that outlined the different modes of file transferring through the internet. As our bus began pulling out of Kampala, she pulled out a cone made out of newspaper filled with what looked like a bunch of miniature green french fries. She asked me, "Do you know what these are?" I had read that it was grasshopper season in the Central part of the country, and so I guessed. My co-passenger was happy to offer me a taste of the novel insect delight, and to be honest, like most fried foods, it was pretty good. All this to say, via the grasshopper, we struck up a conversation. She was a native of Gulu studying journalism at the local university, and when I mentioned to her how much I enjoyed living in the town, she jabbed, "You like it just because of Kony" (referring to Joseph Kony the head of the Lord Resistance Army). This was not the first time that I came in contact with a local conviction that whites only come to Acholiland to satisfy some curiosity about misery. While our bus was mired at a police checkpoint, I tried to assure her that it was the town's friendliness, like her grasshopper gift, that I greatly appreciated. Even though she didn't resist my explanation too much, I got the feeling that she accepted it with a bit of skepticism as we shifted the conversation to complaining about our insanely long and overheated roadside delay. Having experienced several conversations like this one since being in Gulu, I often find myself having to consider how much of a role the context of this community's recent conflict should play in our documentary film. I'm hopeful, however, that we can share their current stories of using human rights to achieve better medical services without having to drag in the past too much.

Our UHRC 4x4 rests sheltered from the sun while we conducted interviews with the first complainant we met that day. Besides competing with the wind, the roosters provide a constant noise that we are fortunate to overcome with our fancy lapel microphone. Maneuvering in sync with the shade has also become a routine task while filming in the villages, not only for lighting purposes, but also for the sake of keeping ourselves and the interviewees from getting scorched.

This is the home of the first complainant who met that day. Her name is Esther, and her case was picked up by the UHRC after someone from the regional office was notified about her situation by a local radio station. We sat underneath a tree just across from this two-room hut as she shared with us her story. An audience of her relatives and neighbors gathered around us, some requesting to have their pictures be taken with the camera, others just curious to see what the mzgunus were doing in the village.

Esther had no problem telling us her tragic tale, especially since it had already been broadcasted on one of the district radio stations. She required a hysterectomy but was unable to pay for the procedure after it was performed at a private health facility. The surgeon had kept her hostage at the hospital for over 3 months until it was leaked to the media what was happening to her. One of her sons was forced to do manual labor in order to help pay off some of the bills, but at a rate that would take years to achieve. Another son, a soldier in Somalia, was also unable to send back the full amount of money to pay her debt. When her story was released, the surgeon became furious and demanded she leave the premises. The unpaid $70 of her $170 tab was forgiven, but her medical records were withheld from her. Who leaked her account to the local press is still an unsolved mystery, one that we hope to pursue. The UHRC is also intent on retrieving her medical records, which without them she has been unable to receive appropriate followup care. She still suffers a great deal of pain in her abdomen since having the surgery, and responded to most of our questions while lying on her side, finding it too difficult to sit up right for too long.

Here are a couple of videos taken by Meredith that give a short picture of our afternoon in Lira. During the middle of the interview, a parade bicycles passed behind us. When we drove out of the village after our visit with Esther, we came to an intersection where a fleet of bicycles were parked outside of a small home. Our UHRC liaison noted, "There must be a wedding or a funeral." Interestingly, the nearest health center is over an hour way from Esther's home, and the only way she can get medical treatment, while hardly able to move from the pain in her stomach, is by riding on the back of one of these bicycles.

Monday, November 29, 2010


My name is Michael Dewan. I'm a classmate of Michael's, also spending time in Uganda doing research. He's asked me to share some of my thoughts on the topic of the Boda-Bodas:

Etymologically speaking, Boda Boda has an interesting history. This two-word term refers to the motorcycles you can find buzzing around the pothole-ridden streets of Uganda. They were originally bicycles used on the border between Uganda and Kenya as means by which boys and young men would illegally transport goods from one country to another. With the introduction of Asian-imported vehicles, these bikes were replaced by motorcycles which could carry far more goods, further and faster than their engine-less counterparts. For short, the locals began calling these vehicles “border-borders”. Because the English pronunciation of the letter “r” is more-or-less absent from Ugandan languages, this term became further simplified to “boda-boda”, more closely reflecting its phonetics. Bodas have now made their way from the rural border to becoming an integral part of commercial transport within Ugandans urban centers.

Boda-Bodas, and particularly their drivers, have been demonized as reckless, lawless creatures that have no consideration for their fellow roadway users. They are constantly weaving between cars, riding up on sidewalks, and jetting through traffic stops, seemingly immune to the ubiquitous traffic jams that develop in and around Kampala. In a recent meeting with the Sargeant Assistant Commissioner of Traffic, standing in full police uniform, he angrily proclaimed that boda riders were “uneducated, runaway criminals. Simply mad.” He seems to be representing the majority of Ugandan sentiment as a number of voices in the audience could be heard echoing this belief.

And honestly, I felt the same. I’ve ridden bodas countless times and each time I do I notice my arms getting sore from holding on to the metal backing for dear life. But more than anything, something tragic happened about two months ago that found me investing fully into this helmet policy. Moreover, it seemed to confirm my loathing for boda drivers. I found myself going to International Hospital Kampala to donate A positive blood to another mzungu – a 4th year medical student at UMich. While we had never met, he worked within Mulago’s gates at the Joint Center for Clinical Research on his third Ugandan tour. A boda he was riding was struck from behind by a car and he suffered severe brain damage. After an initial scan, he was quickly transferred from Mulago to IHK where he received a hemicraniectomy to reduce his medically refractory increased intracranial pressure. He died 5 days later. And my hatred for bodas was sealed. Perhaps the most disturbing part of the whole story is his last blog post where he describes his excitement after purchasing a helmet for the many boda rides he will be taking. Again, I never met Suj, but from what I’ve heard and what I’ve read, he was golden: http://sujalparikh.blogspot.com/

I felt a lot of things in the wake of what happened: anger, fear, sorrow, to name a few. But without getting much into my emotional reaction, these events combined with my sentiment towards bodas made me realize that something should be done about all this. It’s crazy that every day hundreds of thousands of Ugandans are placing themselves on these machines without helmets. Fortunately, I’m not the only one who felt this way.

Earlier this week I found myself at a conference for the Global Helmet Vaccine Initiative, an initiative with the vision of putting a helmet on every boda driver and passenger in Uganda and the rest of the developing world. The conference brought individuals from all sectors together to discuss the problem of head trauma in boda boda riders and what might be done to curb it. The CDC and WHO are active members of the research efforts, while representatives from the FIA Foundation and Arive Alive – Uganda contribute from a general road safety perspective. Of course the Ugandan government is an active participant sending representatives from the Ministry of Works and Transport, the Ugandan Police Force, and other policy-making officials.

I quickly discovered that from the government and the police’s perspective, these boda riders were pests that needed to be eliminated. And then I met some of them. Thankfully the organizers of the event had the foresight to invite some of these riders – the very people we would be targeting our campaign toward. After sitting patiently listening to their profession be damned by many of the stakeholders present, the boda drivers were given the floor. And they began describing their lives – a side of the story we hadn’t given much thought to.

Yes it was true, they said, we aren’t well educated. Our parents couldn’t afford to send us to the schools that many of you were lucky enough to attend. So we came to Kampala from the villages looking for opportunity. And the prospect of making a couple dollars a day transporting busy travelers on a motorbike seemed ludicrous to pass up. Just like many of you sitting here, we have families to feed and children to send to school, and driving bodas is the best shot we’ve got. And yes, sometimes we don’t follow all the traffic laws, but sometimes we feel we don’t have a choice. Our clients – many whom are businessmen and professors and even doctors – demand more. They are late and they will not accept waiting in a traffic jam so they command us to speed between the rows of cars. So what are we to do? Say no? And risk losing a morning’s wages? And we’re not all opposed to wearing helmets. Yes, they’re hot, and yes sometimes it’s difficult to hear in them, but more than anything, helmets are expensive. When given the opportunity to spend 20,000 Ush on a helmet, or to send two of my children to primary school for a term, I’ll take my chances with a head injury.

And it was true. These people were…people. They were sons and fathers, husbands and breadwinners, just trying to survive.

Boda bodas are not going away anytime soon – nor should they. The Ugandan economy relies too much on their services – and too many people rely on this job to earn a living. But there is work to be done and if anything is going to be accomplished in the way of an effective helmet policy, it will take all parties involved treating each other like human beings.

We’ve already begun some of the work. More on this later…

Friday, November 26, 2010

HEPS, the Mortuary, and the Letter

On Tuesday, I took the bus down to Kampala for meetings with a right to health organization, called HEPS Uganda, as well as to pick up our infamous letter of support from the Ministry of Health. In the Lira District, where we hope to focus our documentary film, HEPS has implemented a novel approach to empower impoverished citizens to voice their needs for better medical services. The organization has introduced anonymous complaint boxes in government health facilities. The boxes are emptied every few months, at which time the NGO reviews the written concerns of patients with each individual health facility. Some of the more common complaints involve medical staff charging for services that are supposed to be free as well as mistreating patients while under their care. For vulnerable communities throughout Uganda, the little wooden repositories have provided a moderately successful forum to hold local health centers accountable for failing to provide adequate and appropriate services. In one district, hospital staff was arbitrarily charging female patients different prices for assistance during labor (often the price would be more for delivering a baby boy). Dozens of patients quietly protested this practice through the boxes, and HEPS then took up the case with the hospital and district health authorities who eventually put an end to the illegal scheme. Sometimes, however, the anonymous complaints only shift a problem to some other unsuspecting community. In another district, a handful of patients and their family members filled up little slips of paper with stories of a surgeon conducting operations while intoxicated. Their silent voices were heard; the district health office ended the doctor’s practice at the community hospital. But, these same hushed grievances also allowed the surgeon to be easily relocated to a health center in the neighboring district, where he is reported to be currently practicing with impunity. Sometimes too, hospitals and healthcare authorities will completely refuse to act on the issues raised by HEPS’s boxes. In these cases, the NGO doesn’t have much teeth other than to lobby for reform at the national level. I asked members of the organization if they encourage communities to file complaints through the human rights commission, and one of them responded, “No, we teach citizens about their rights so they can make demands at the level of the hospital, but we don’t want to raise their hopes and then have them be let down.” The staff had yet to hear of a successful right to health complaint filed through the commission. Hopefully, we’ll capture one on film.

When not in one of my meetings or running on errands around the capital, I tend to make the Yale office at Mulago a base camp for operations. On this visit, I was pleasantly surprised to find Michael Dewan doing the same thing. He happened to be in the capital attending a conference on how to enforce helmet use amongst boda boda drivers in Uganda. How he became interested in the topic, and came to attend the conference, is a long story that he plans to share on this blog. I’ll just say for now, he has discovered a lot of amazing details regarding the boda boda culture, and its curious relationship to Ugandan politics. As a result of his participation in the conference, Dewan has begun helping out with an injury prevention study run by the CDC. One of the study’s first questions is how many deaths secondary to boda boda accidents occur each year? Not a terribly difficult question to answer in theory, but hunting down the numbers from the various institutions responsible for keeping them is an audacious odyssey in and of itself. As part of this quest, Michael had scheduled a visit with the city mortuary, and I decided to tag along while waiting for my next meeting.

To get to the house of the dead, we took a circuitous route through new Mulago and down a back driveway to a nondescript brown building situated just outside the hospital’s side gate. Our guide was a young mortician, happy to help with the data crusade. Though the building bore no visible clues of the treasure that lay hidden within its walls, the harsh odor that greeted visitors 15 feet before its entrance left very little on the differential for what this place could be. With our heads quasi-bowed, in an attempt to minimize the necrotic air directly stimulating our olfactory bulbs, Michael and I followed the city’s plain clothed Charon through the morgue’s doorway. We then entered an atrium painted turquoise and decorated with stainless steal industrial-sized cabinets. Each metallic chest of drawers was 3 high by 3 across, like a tic-tac-toe board. From the front, they were reminiscent of some funky, modern Japanese hotel’s sleeping compartments that I saw once on the travel channel. Across the atrium, we entered a tiny office with a wooden table in the middle, which was bordered on two sides with a single chair each. A middle-aged police officer sat at one end, flipping through some papers, while our guide pointed to a large rectangular book in the center of the table and said, “Here.” At home, death moves from the body to a chart to a computer file. Here, if you’re lucky, it gets saved in a day planner. And even then, the cause often remains ambiguous on paper. Thus, as the mortician flipped through the registry’s pages, he noted to Dewan he would probably have to look through the police reports stored at individual stations around the city if he wanted to patch together an accurate number of annual boda boda related deaths. To give an example of how one of these reports looks, he turned to a faucet, now turned file bin, attached to the office’s back wall and pulled out a few flimsy white sheets of paper attached together. “You see, it says RTA, road traffic accident, but it doesn’t mention what kind. But, maybe they have the numbers at the stations.” The police officer in the room voiced agreement. Leaving the office, we got a brief tour of the rest of the facility, which was basically a large room with a handful of tables. On them, there were a number of RTA victims brought in that morning. We then observed an autopsy of a young woman who had succumbed to injuries received while riding on a bus that had flipped over on its side. The patient had died of a pulmonary embolism, which was facilitated by her multiple broken limbs. While a group of men draped in aprons were carrying out the whole procedure, the doctor was careful to record all the findings.

By the late afternoon on Thanksgiving day, I had a great reason to be thankful, we finally got the letter. The letter. It comes straight from the top of the Ministry of Health and clearly states that there are no objections to our research and film. After weeks of jumping through hoops, I sat outside the director general’s office, describing to his secretaries the various foods we eat on Turkey day, while he made the final edits to our green light papers. By the time I got them packed away safely in my bag, it was getting close to dark, which significantly increases the risk of experiencing a RTA during the 4 hour bus ride to Gulu. So, I decided to take the shorter ride out of town to Jinja for the evening, to celebrate the holiday with Dewan and some of his friends who have been volunteering as teachers there for over the past year. The meal was amazing, a real turkey that Michael purchased down the road. The ride back to Gulu the next day was another long adventure, and the letters have already begun their magic. We started filming in the Lira district with the Human Rights Commission today. But I’ll tell you more about that soon. Hope everyone had a wonderful Thanksgiving.

Sunday, November 21, 2010

Ozuku and The King's African Rifles

As I mentioned earlier on the blog, we've made some new friends in Gulu town, including Ozuku the tailor. Yesterday, he invited us to his village home near Lacor hospital to meet his family and interview him about his life and health concerns. He also arranged a meeting for us with two of his friends who had served in the King's African Rifles (KAR). On our drive through the tall grass fields surrounding the city, Ozuku would point out sites where he was ambushed by the rebels and the Ugandan soldiers. He feared them both equally. We drove over a 15 foot long wooden bridge that had exploded by a rebel landmine 10 years ago. At the time, Ozuku was riding on a lorry overflowing with sugarcane, and the blast had thrown him onto the shore of a small creek. He joked, "If there wasn't so much sugarcane, it could have been much worse" (referring to the fact that he now only has a permanent limp on his right side). As our Corolla struggled through the massive craters in the dirt road, the tailor would gesture with his hand outside the window, pawing at the hills stretching green towards the south, while describing how he could spend days fleeing the unflinching soldiers from both sides of the war. He then would let out a loud chuckle, "They were such terrible times."

Despite it all, Ozuku still finds a way to make light of a very dark period. The first time he shared this story with us, he was busy hemming the puffy shoulders of a bright pink traditional dress under the awning of his shop in town. Like most store fronts throughout Uganda, his is painted with the colors and logo of a local cellphone company (red, black, and white in his case). Ozuku began with his classic laugh and shaking of the head, "One day, I acquired some beans and put them on a fire with only piece of wood burning. The bullets started, and we dodged the bullets until we ran into the bush. Now after returning home later that day, around 6, we found the beans were cooked just proper. I had put on just the right amount of wood. That was just another sign of God's support there." And again, he let out a booming chuckle, while we joined in this time.

The KAR were a special unit of soldiers created by the British from their East African colonies between the early and mid 20th century. The soldiers helped on military campaigns in Africa and abroad during both World Wars. Probably the most notable member of the KAR was Idi Amin. When Ozuku proposed to organize a meeting with two of his friends who had served in the KAR, we jumped at the opportunity to hear their stories. Before giving a little background about the video above, I will just touch on some of the highlights from our interviews with them. The men were both around 90 years old, a rarity of rarities in this part of the world. Having lived through WWII as soldiers serving in Burma, where they fought a relentless Japanese advancement, these men both noted that life in Northern Uganda was much more difficult than their military service. One of them noted, "WWII was a clean war, while war here is dirty." One of the men had lost 3 sons to the rebels. Both men also had numerous complaints regarding the lack of compensation for veterans, and one requested that we ask the Queen of England to provide money owed to them for their services protecting the empire over 50 years ago. They also were promised money from the current ruling government in Uganda, which they believe was "eaten" (a term commonly used to mean "taken" or "stolen") by the politicians. They provided us with their military credentials in hope that we could report their plight to anyone in power, and help secure some of the money that they've been promised. We brought them sugar, salt, soap, and tea for welcoming us into their homes.

Regarding the Flip video above (courtesy of Meredith): Just as in a medical interview, sometimes the most significant information comes out at the very end of it by simply asking, "Is there anything else you want to tell us?" This gentleman, in classic Ozuku fashion, began his response with a chuckle. What you see above is the start of a story where this elderly KAR vet describes taking 4 Japanese soldiers prisoner while fighting in Burma (Ozuku is the translator with a white beard and neon colored baseball cap). As the story continues, he reveals to us that his regiment of Ugandan soldiers were desperate to keep the Japanese at bay. So they decided to exploit the old rumor that Africans were cannibals. They killed one of the 4 prisoners, chopped them into pieces, and put the body parts into a pot. They showed this to the remaining 3 Japanese captives, who were subsequently released to tell their friends of the "madness" of the African troops. When we asked, "how did you choose which prisoner to kill?" He answered, "His own bad luck."

A Whirlwind Week

We headed back down to Kampala on Tuesday morning to pick up the newest member of our team, Meredith Camp, and to continue on our quest for the Excalibur of letters that will finally cut through all the red tape in one fell swoop. On the way back to the capital, Akra successfully navigated our Corolla through all the dusty traffic, trading centers, and potholes in record time. While our ride wasn't the most spacious, especially since we were joined by Luca, the Italian pediatrician from Lacor, our discomfort was probably nothing compared to what these soldiers felt bursting out of the back of a lorry.

After spending the past 2 1/2 years in the Dominican Republic, Meredith just finished the Peace Corps. in October. Before she could make New Haven her new home, however, she has decided to bring her skills of thriving on limitations to this side of the world for the next month. Despite her long travels, the only rest she got that day was in the backseat of the car as we raced around town for meetings and gathering paperwork. The big meeting of the day was with the Secretary of the Uganda Human Rights Commission (UHRC), who granted us permission to now interview all the potential characters for our film but still wants us to hold off on actually using the camera until somebody high up in the Ministry of Health (MOH)gives consent to the project. He explained that he's a bureaucrat, and though he thinks our project is "benign," he doesn't want to be held responsible if our film "paints the current government in a bad light." With the help of some of my friends, we were able to schedule a meeting at the MOH two days later, and the ultimate letter we've been hoping for seems to be within our grasp. We are hopeful to get it by early next week, which means I have another 4 hour trip to the capital coming up soon.

While we had a some time off in between meetings, we ventured to Jinja and enjoyed a day on the Nile river. Only an hour and a half drive from the capital, it's the perfect oasis from the nonstop hustle and bustle of Kampala.

We made record time on the way down from Gulu, and we also made record time on the way back. This trip, however, was the longest it's ever been. 2 hours into the ride, I noticed a little orange glow coming from behind the steering wheel. I turned to John, who was sitting next to me in the backseat, and asked "Do you think that is the check-engine light, or is something wrong with the battery?" To which John then asked Akra if he was worried about the illuminated warning sign shining underneath the broken speedometer. Akra simply replied, "No problem." So we thought to ourselves, if he's not worried, we're not worried. Well... even if worrying wouldn't have done us any good, our initial intuitions, that the car was indeed trying to scream for help, were correct. About 15 minutes after I noticed the new glow in the car, the car puttered to a stop on the side of the road. After we tried all kinds of creative pushing and pulling methods, and hypothesizing the significance of some fluid spots under the car, Akra hitched a ride to the nearest petrol station 3 km away to look for a mechanic.

When we left Kampala, it was close to 5pm and I was a little nervous about starting the journey so close to dark. Now, I was really regretting it. While our driver was gone, the rest of us tried to keep ourselves entertained by engaging the local livestock (until a bull became made some aggressive steps towards us, then we kept a safe distance across the road) and by trying to predict the eventual outcome for our evening. To make a long story short, Akra showed up 30 minutes later with several mechanics who disassembled the engine by flashlight and diagnosed a problem with the belt. We spent 3 hours in some small town while the car was being fixed, and $40 later we were back on the road. We reached Gulu by around 1 AM. As our hotel's doors were closed, we knocked numerous times and called the main desk phone, which we could hear blaring some loud obnoxious ring tone. I felt bad thinking that I was going to wake up the other guests. But, despite all these efforts, nobody came. Then a guard patrolling the outside noticed our fatigued groans, and came to our aid. He merely walked to an open window, and said in a modestly forceful voice, "Boy." Less than a minute later, a semi-conscious young man unlocked the glass doors and guided us to our room keys.

Sunday, November 14, 2010

More Scenes from Gulu

Road construction began on market street this past week. While little shops close early in the evening, smoke collects over the road and kids return from school along lines carved into the dirt by a giant tractor.

After making strong progress at the beginning of the week, we ran into a bit of a snag by the end of it. To meet our possible film subjects, we need another letter from a desk higher up in the human rights commission, which we are now in the process of acquiring. So while we wait for yet another document of approval, we decided to spend our down time meeting other members of our new community. First, there is Leonard (or Ozuku, a nickname he received because of his well-groomed beard reminiscent of a Nigerian rebel of that name), the elderly tailor who has survived every war in Uganda since its birth. He has been teaching Acholi to John and me, and requested that we film him telling stories of his medical struggles, including a hip injury he received secondary to a landmine explosion 10 year ago. This weekend we are going to his village where he is also introducing us to a few surviving members of the King's African Rifles who fought in WWII. Next, there is Florence, a woman in her 30s who runs a crafts store next to Leonard's business. She is also happy to help us learn the local language, and sold John an adungu (a string instrument shaped like a miniature boat). Wile trying to find someone to help John tune his new instrument, we met Charles on the street, a boda driver by profession, who plays the adungu in the local catholic church. After treating him to a soda for his help, we now hope to recruit his musical talent for the film (a possible lead for you Savant).

Behind our hotel, the city clumps into small clusters of administrative buildings, NGO offices, and local businesses. On the left hand side in the far back of this photo is the Gulu regional hospital. Sadly it looks as if the building has suffered from the war as the much as any place or person. Echoing the hospital's broken windows and fractured walls, 12 health centers in the district closed this month because of a lack of medicines.

Across the street from our hotel is a school yard. Throughout the morning, its floods with children dressed in bright blue and yellow uniforms. Like any other piece of valuable property in the developing world, the grounds are walled off by brick and cement coated with shards of glittering glass.

Because we had no map of all the affordable hotels in Gulu when we first arrived, John and I had to be strategic in finding our accommodation. We would visit a guest house, request to see one of its top floor rooms with a balcony, then negotiate a price for the room. While conducting our negotiations, we would look out over the town for another nearby hotel that had the architecture for our price range, as well as a decent looking balcony. That's how we found the Acholi Ber, and I have to say we got pretty lucky with this one.

While I was busy one afternoon jumping through hoops for our letters of approval, John and Akra went for a little reconnaissance drive in the surrounding area. Though these puddles looked fairly innocent, they almost swallowed our Corolla. A crowd of local spectators gathered outside their grass roof huts as the soundman and the car's captain navigated the waters at a 45 degree angle. In celebration of their successful traverse, John got out of the car and juggled a soccer ball with some of the local boys. With high fives and the sound of laughter from the audience, they drove on.

Akra, busy at what he does best... From the rear view mirror dangles a large picture of the Kabaka (Bugandan King) and his wife. At the bottom of their photo is laminated a brightly colored map of the world cut out from some report that looks like it could be from the WHO, UN or some global NGO. Of the many colors representing the different states of states, in the middle of a sea of yellow that is sub-Saharan Africa, Uganda shines red, a color listed critical on the legend. I've spent hours in the front seat speculating what could be so lacking in this country compared to all its neighbors. Akra isn't sure where his dad acquired the map, and while driving in the villages, he often wedges the large photo-map ornament behind a sun visor so it doesn't obscure his view of all potholes.

The Germans, Marcus and Thomas, legends from the casualty ward. They spent the weekend with us in Gulu. We visited Lacor together on Saturday, and they shared stories on camera of their work in Mulago. They experienced a lot in their three months at the national referral hospital, and witnessed the extremes of its limited resources. They were the essential medical care that P. received, and lots of others.

Wednesday, November 10, 2010

Views from the Acholi Ber

Due to some scheduling conflicts, Binford and I were forced to look outside of Lacor for a place to stay while in Gulu. After checking out 4 different hotels, and their various balcony views, we negotiated a great price at the Acholi Ber. Our room is on the top (5th) floor of the hotel, and has pretty amazing views all around. This view is while looking west down market street.

Looking to the East, there is a collection of traditional homes at the dead end of our street.

In Gulu town, old and new live in a dense network of cement, brick, metal, mud, and grass .

While we're not enjoying the wonderful scenery from our hotel balcony, John and I have got two strong leads on stories for our documentary. One involves a woman who was imprisoned for 3 months in a hospital because she was unable pay for a necessary hysterectomy, and the other involves a woman denied access to anti-retroviral therapy while being jailed. The Human Rights Commission is organizing a time for us to meet with the complainants soon.

Tuesday, November 9, 2010

Headed North

Akra with our ride on the highway north. We traded his car for his dad's for the month. We lost a pretty nice radio, but gained a lot more reliability and security in the rest of the car's functions. It's about a 4 hour drive from Kampala to Gulu, but ours had few delays...

Road accidents are a pretty common site in Uganda. We came across this accident an hour and a half into our drive. A matatu collided with a lorry carrying timber. We stopped to offer help.

Binford put his emergency medicine skills to good use for this American on board the matatu, heading towards Murchison Falls for a safari. The collision caused his shoulder to hit the seat in front of him with considerable force. Luckily, he broke no bones and John made sure the pulses, sensation, and motor functions were intact in his arm. His shoulder, though, caused him immense pain with any movement, so Binford fashioned a little sling with a T-shirt, a skill he picked up recently with some Wilderness Medicine folks in Connecticut. I, on the other hand, relied on my pre-med training to be of assistance. A mzungu came over to our car and typed into a little hand-held device, which then produced short English phrases on its screen. "Can you call my friend?" "Tell him I'm okay." "I have no minutes." While we tried to communicate in English, it became clear he couldn't understand us very well, nor produce much of any language from his mouth. I asked, "Where are you from?" That one he understood. A strained "France" came out of his tightly pursed lips. So I put my French to use, he would respond on his machine, and in the end, we got him a ride on another matatu taking him back to the French Embassy in Kampala.

After our work was done there, we continued on our way, crossing the Nile while baboons chased along side our car for food, and reached a small town just north of the river where the election fervor was taking hold. Yellow is the color of the ruling party, the National Resistance Movement (NRM). And dried banana leaves are another symbol they commonly employ. Note on the back of the matatu, it says "School Fees." Not sure what to make of this phrase, but big decals saying all kinds of phrases like "God Will" or "Jesus is Lord" are routinely pasted on the rear windows of buses and taxi vans.

Museveni on a T-shirt. Elections will be held this February. With so many candidates running for president and the opposition parties fragmented, public opinion is that there won't be much trouble for the ruling party.

The Eritreans

While visiting Kampala in 2007, I ventured across the street from the Human Rights Commission to do some shopping for souvenirs at a crafts market that benefited local organizations supporting women in need. While visiting one of the stalls, a female vendor, who looked East African but not Ugandan, asked me where I was from. I said the USA, and she followed up with, "Which state?" I replied, "you've probably never heard of it, but it's the greatest of them all, Minnesota." To which, she said, "My sister lives there." This is how I met Yordanos. She is an Eritrean refugee who has been living in Kampala since 2003. At the time that I met her, she had two sisters living in the US (Hizbawit in Minnesota, another in Colorado), two sisters left in Eritrea, and one sister with her in Kampala, Sehin. During my previous stays in Uganda, Yordanos has invited me and fellow travelers to her apartment in Old Kampala for amazing Ethiopian/Eritrean lunches on Sunday afternoons when she is not working in her shop. This year, I found her again in the same craft market, and once more she invited me and my friends to her place to enjoy her native cuisine and hospitality. On the way to her place, Binford was captivated by the scene of a man carrying the back door of a matatu while riding a boda boda.

A lot has changed for Yordanos since I last saw her in 2008. First, she spent most of last year working odd end jobs in Juba, Southern Sudan, where she raised enough money to now be able to rent half of a stall in the craft market where she can sell goods she directly buys from suppliers. This still doesn't provide her with enough income, she works at another stall selling crafts for her landlord. Secondly, Yordanos's mother was granted permission last week to come to the US and live with her sister in Colorado. Her mother had been a refugee in Nairobi for most of the past year with Yordanos's younger sister, Emuna (which means Hope), who is 20. Both have recently relocated to Kampala, Emuna now works in Yordanos's craft shop and the mother will be leaving for the US in two weeks. The last big change for Yordanos, however, has to do with her sister, Sehin.

When I found Yordanos sitting in her shop two weeks ago, I immediately asked about her sister Sehin, to me they were inseparable. Sehin is younger than Yordanos by a couple years, and speaks nearly fluent English, which always came in handy during our lunches. While sitting on tiny, wooden tripod stools on her half of the craft shop, Yordanos pulled out a large blue annual planner from a low lying shelf, and told me that she has concerning news about her sister. She opened the planner, and on the inside cover was a world map, with black pen lines drawn from Kampala to Dubai, Dubai to Ecuador (a shaky tracing across Europe with some scratch marks over Turkey), Ecuador to Columbia, Columbia to Honduras, Honduras to some where in the middle of Mexico. After 7 years, Sehin had grown tired of being a refugee in Kampala and set out to make some money in Dubai. While there, she met a handful of other Eritreans intent on reaching the US and applying for asylum. Their journey began two months ago, and Yordanos only receives a phone call from her sister when she arrives at an immigration office kind enough to let her call her family. Yordanos last spoke to Sehin when she had arrived in Honduras two weeks ago. The conversation lasted for only a few minutes, but Yordanos learned that Sehin had to walk 5 days straight in Columbia without rest and with little food, had to cross by paddle boat to Panama, and was now on her way to Mexico. No one in the family has communicated with Sehin since Honduras, but we recorded video messages from her sisters and her mother on my flip camera that will be posted online for her to see for whenever she gets access to the internet again.

The story of Yordanos and her family is closely tied to the land they come from. The mother is Ethiopian and the father is Eritrean. After over 30 years of conflict and a mutual disdain for people born on the other side of the border, the family has been torn apart. The youngest sister, Aday (which is the name of a yellow flower that only blooms in September) had been living with her father in Eritrea until this past September when she secretly crossed the border with some friends to defect to a refugee camp in Ethiopia. Aday is 16. Above: Yordanos and her mother relax while roasting coffee beans after our meal.

The hospitality of this family cannot be praised enough. In this video, Michael, John, and I are wowed by their traditional technique of making coffee.

John, Emuna, Mother, Michael, Me, and Yordanos

Binford's Arrival

After launching his pedicab project (http://www.yaledailynews.com/news/2010/nov/08/yalies-start-pedicab-business-to-support/), Binford made the great journey east to Entebbe via Istanbul. I picked him up from the airport last Monday, and the way there negotiated with the driver, Akra, to be our driver for next month in Gulu. Akra had been my go-to taxi driver in Kampala, and coincidentally the driver Mr. and Mrs. M use for their children when they can't pick them up in school. Knowing how reliable he was, I was certain he would make a great addition to our team, even if he's a little unfamiliar with The North (or as he put it, "Being here is like when you travel from the US to Uganda). Akra has only visited a few other cities outside of Kampala, a for a few hours each.

Since John arrived, we have been acting as primary care doctors for Mr. M's brother, working hard to get an expedited review of our film and research proposal from the Makerere School of Public Health, and making arrangements for our projects in Gulu. Lots of success stories, will tell in the coming posts...

The CT Scan Part 2

In the waiting area, I told Mrs. M the news. P. would need a CT but we would need to venture outside the hospital to find a machine that could work. It would also cost 180,000 Schillings (about $90, and insane amount of money for a population that mostly lives on less than $1 a day). Mrs. M immediately responded that there would be no problem getting the money or transportation necessary for a CT, she just needed advise on the nearest place to go. I hurried back into the casualty room, where P. was still lying on the exam table knocked out from the Diazepam, and the Germans were attending to another patient. They advised me to talk to the senior house officer (SHO), a second year resident, working in the neighboring cell for suggestions on where to get a scan.

On the other side of a cement wall, I found the young SHO talking with a frail elderly man who had collapsed on the street. He stopped his conversation with the patient to field my questions about finding a CT for P. He initially dismissed my inquiry as the result of a classic mzungu mistake; “Don’t worry about it, he can’t afford a scan.” Trying to be sympathetic to his intuition, I kindly explained that despite the patient’s appearance, money would not be a problem for this one. He gave a few names for diagnostic imaging centers in the area, but didn’t know where they were located. Beseeching the nursing staff seated in the corner, they recalled some of the roads and neighborhoods where I could find them. And just as I thought we had a green light, the SHO informed me that the patient still needed a CT request form filled out before he could leave. The hitch, the ward doesn’t have any forms, and the SHO doesn’t have any idea of where to find one. After apologizing that he was new to the ward, the young doctor returned to his interview with the elderly patient, now hunched over the side of the exam table.

Realizing there were no more teeth to pull on this side of the wall, I crossed back over to P.’s cell. I again turned to my new German friends for help. Maybe it was the rare chance to see their triage efforts carryover into definitive care, or the thrill of possibly uncovering a neurosurgical emergency that could save a man’s life, either way the medical students were excited to help P. a scan scan. Thomas went off on a mission throughout the hospital to find a CT request form, and Marcus and I began orchestrating how to transport P. to Mrs. M’s minivan waiting under the main entrance of the hospital.

After about 20 minutes, we acquired one of the few gurneys on the ward, and Thomas returned empty handed. The radiology department had informed him that the hospital was out of forms, but helped dictate one that he could handwrite on a blank piece of paper. With our quasi-document in hand, we started a mannitol drip (a medication that helps reduce pressure around the brain while increasing a patient’s need to urinate, which can be quite an inconvenience when no catheter kits are available), and then transferred P. to a gurney. As we struggled to steer through the throng of urgent care seekers, the stretcher’s wheels squealed incessantly, giving the patients an advanced notice to totter out of the way. When we reached the van, the mannitol had already begun to work its inconvenient magic; we gathered him up in our arms, his jeans sopping wet. We laid him across the two rows of seats folded down in Mrs. M’s minivan, and informed P.’s wife to keep his head elevated in her lap, as her feet dangled into the trunk space. After closing the back door, I turned around to see a large gathering of spectators made up of both staff and patients.

Inside the van, I scrunched up with my back pressed against the rear side of the front passenger seat where Thomas was sitting. With my right arm raised and elbow dangling outside the open car window, I held the mannitol bottle above my head. Our first stop was an imaging center in the neighborhood around Makerere University, which was only a 5 minute drive despite heavy traffic. The center’s machine was down too, so we hopped back into the van drove into the city center. After 30 minutes of getting mixed directions from pedestrians on the street, we arrived at a polished, modern multi-story building near the police headquarters. But again, luck wasn’t with us yet. This center didn’t do CT, their sister branch on the other side of the city had the scanner. So once more, we got back in the van and made our way across Kampala.

As a result of the morning’s non-stop hustle and bustle, I had almost completely forgotten about my inflamed esophagus. But as our make-shift ambulance trotted through the bumper-to-bumper traffic, speckling each other in red dust, I became very aware that my throat was still pissed off at me for the poor choice of taking my Doxy without water. I strangely began craving lidocaine, but found white coat pocket empty, having left the bottle behind for the casualty ward. With some effort, I ingested a handful of antacids and a few painkillers, and then tried to distract myself by naming all the neighborhoods we passed through. Thomas would periodically check-in to see if P. was waking up too much or required any more of the Diazepam that he had packed for the journey. But after an hour from when we had set out from the hospital, we finally found a functioning CT scanner without having to tackle too much restlessness from P.

The imaging center was located in the Beverly Hills of Kampala, known as Kololo. The center kept itself as polished as the homes around it. We were forced to take off our shoes when we entered the scanning room, and the staff was resistant to having P.’s gurney wheeled too close to the machine’s bed. So we again had to get creative transferring P., this time with a bed sheet sopping from Mannitol’s charm. The staff was just as guarded about their work as they were of their scanner. The technician was uneasy about letting us take a copy of the scan to the hospital until after the center’s radiologist gave her reading of it first. In the end, it took another hour and a half for the CT results to arrive at Mulago.

P. had two small isolated bleeds in the front of his brain (right and left frontal lobes) and one in the back (right parietal lobe), as well as a small fracture in his skull and a clear increase in pressure around his brain. He didn’t require emergent surgery, but it took us 7 hours from the time he first arrived in the hospital to figure this out. Compared to the rest of the patients coming into the casualty ward, P.’s is a success story. Back on the wards, he received a protocol of medications that would help prevent seizures, decrease the swelling around his brain, and prophylactically treat a possible infection.

That evening, I learned the fully story of what happened to P. Mr. M, who was needed out of town that day for his work, received a phone call from a relative just before breakfast. The relative had learned by word of mouth that a pedestrian had witnessed P. get hit in the head by the side-view mirror of a taxi van while he was walking on the side of a road on the east end of Kampala. The pedestrian had found P. struggling to standup after being struck to the ground, and then wandering into traffic. The good samaritan had lead him to a nearby health center, but the relative was unable to determine which one. So while I was chewing around the crusts of my margarine sandwich that morning, Mr. M was taking in the news that a relative had heard in rumor fashion that his brother was seriously injured and lost somewhere in the outskirts of the city.

A few days later, Mr. M cited the events of that morning to me as an example of the power of word-of-mouth news in Uganda. I had become frustrated with P.’s wife for repeatedly trying to feed him orally while he was still unconscious (before we could place an NG tube, a story that could take pages to write on its own). Every time I stopped by to see P., I would ask his wife if she tried feeding him again, and she would say yes, prompting me to warn her again of the dangers of aspiration. After days of this happening, I asked Mr. M why she keeps doing this when all the staff, not just me, tells her not to do it. “Doesn’t she get that she could seriously hurt him, if not kill him?” To which Mr. M simply replied, “she’s only doing what her mother tells her, which she learned from her mother, and so-on.”

Lots of stories about P.’s stay in the hospital could be written, but so much is happening so quickly here that I don’t have the time to write it all down at the moment, so will try to stay on top of the highlights of current events.

-P is recovering well now, discharged from the hospital yesterday, walking, still some confusion, but very impressive for how he started.
-He did require another CT outside the hospital during his stay, with which John Binford helped me orchestrate
-Hit and run accidents are common practice in Kampala, so strangely, it’s not strange that the driver didn’t stop to help P. after hitting him
-The esophageal ulcer stopped ruining my life after 10 days
-Now in Gulu, stories from the final days in Kampala and travels North will come shortly

Wednesday, November 3, 2010

The CT Scan Part 1

Thursday morning, I woke up with an excruciating pain in the back of my throat. I had developed an esophageal ulcer from a freak accident where my doxycycline pill (antimalarial prophylaxis) got stuck in my throat during the prior weekend in Fort Portal. While I was busy trying to find a good position to swallow my breakfast without the feeling of a knife running down my esophagus, I noticed that Mr. and Mrs. M were not in their usual state of chatting with me about our mutual plans for the day. I thought they might be discontent with me eating only the insides of my morning margarine sandwich and neglecting to finish my African milk tea. While gathering the bread crusts on the edge of my plate, I apologized to Mr. M that my throat hurt and could only tolerate the soft sandwich innards. With a blank stare on his face, as if preoccupied with thoughts far from the breakfast table, he assured me that my new dietary requirements were not a problem.

On the ride to Mulago, the only thing that I could think about was finding some sort of painkiller or antacid to fight off the burning in my throat. Like Mr. M, Mrs. M also seemed much quieter than usual. But unable to deviate from my one track mind, I let the morning drive pass in silence, broken occasionally by the brakes shrieking as we bounced over decrepit speed bumps and weaved our way through pedestrians and livestock congregating in roundabouts. At the hospital, I found the ultimate cure, 2% lidocaine, a recommendation by one of the residents in the MUYU office. A little timid at first of putting a little PPD syringe full of lidocaine in my mouth, and aiming it in the mirror like a squirt gun around my uvula, I was euphoric to find my pain vanish in a matter of minutes (no viscous lidocaine or anesthetic sprays could be found). The freedom from torment, however, only lasted a half hour before I’d sneak away to the bathroom again for another fix.

With my pain under control, and my syringe and vial of lidocaine in my white coat, I made my way to the cancer institute at the top of the Old Mulago hill. I spent the last two weeks rotating there with Dr. Fred, an old friend and former visitor to Yale through the MUYU exchange. While waiting in his office for clinic to start, I got a phone call from Mrs. M. She was down in casualty (the emergency department). There had been an accident and Mr. M’s brother, P., was badly injured. She reported that there was a long line to see a doctor, and asked if I knew anyone that could help. I reported the situation to Dr. Fred and he gave me a letter for a friend down in casualty who he thought could help. I ran down the winding walk way of Old Mulago, skipping over sets of broken stairs, and taking the red dirt path shortcut snaked in between the TB and prenatal care wards.

Once inside the Eastern bloc edifice known as New Mulago, I scurried through semi-lit hallways lined with patients and their family members and down a flight of stairs to the casualty ward. There I found Mrs. M standing on the edge of a row of benches in front of a caged-in reception desk. She told me that P. had just been taken into a room and being seen by doctors. The casualty ward corridor is a series of concrete cells cut off to the outside world by wooden doors, whose opacity is enhanced by the white paint pealing at their edges. Mrs. M guided me to one of them, and unsure of what I would find behind the veneer, I pressed down on the handle and swung it open.

Inside the room I immediately noticed two young muzungu men in white coats and two plain clothed Ugandans struggling to hold down a man squirming on an exam table. They were trying to place an IV, and though P. looked half-sedated with his eyes closed and a swollen contusion across his forehead, he was doing everything he could to throw these guys off him. I shut the door behind me, and moved in closer to the action. The young munzugus were rapidly calling out in German to another young blonde woman in scrubs around the corner. She handed one of them a new IV needle and cannula, as P. began flexing his arm away again, I spoke up, “you want some lidocaine?” One of the German’s jokingly responded, “why, you know where to get some?” I pulled it out of my pocket and handed it to him. With a little bit of the numbing medication, and a big help from some Diazepam, an IV finally got situated in his right arm and P. rested easy on the table.

After the room settled down a bit, I asked who was in charge because I had a letter requesting a certain physician’s involvement. The Germans laughed again and said they weren’t sure who was supposed to be managing the ward. They introduced themselves, Thomas and Marcus, and told me they were senior medical students doing a rotation abroad as well. They advised me to check in the neighboring cell for a doctor who might be able to help me, but I was unsuccessful at finding any physician who could help. I abandoned my plans to find Fred’s friend, and realized these German medical students might actually be P.’s best shot. I returned to his bedside and asked their assessment and plan. Thomas told me P. had been hit by a matatu (minivan taxi) while walking on the street a few hours earlier and came into the ward with a GCS of 7 (severe head trauma, not making any verbal communication or opening his eyes, but localizing pain). He absolutely needed a CT scan, which everyone had written off as impossible because he came in with tattered clothes half hanging off his torso and dirt crusted to his skin. Even if he could afford it, they noted Mulago’s machine is down for at least another week. Next step would then be a neurosurgery consult, but the Germans added that they’re not going to do anything without a CT. I told them that I was a friend of his family’s and we would figure something out.

More to come soon...