Farwell to the Balkans!

 After just under a month we have decided to bring our Kosovan adventure to a premature conclusion. We have thoroughly enjoyed our time in Prishtina but it has become increasingly clear that we aren’t achieving very much and maybe we could be better spending our time elsewhere.

Our main problem has been the language barrier. The hospital staff and medical students had basic conversational English, but very few of the patients did. German was much more widely spoken and despite my linguistic pedigree (GCSE Grade B – 1997), it was insufficient to really talk to patients or staff at more than a superficial level.

The other main problem was the notable present of many doctors. In contrast to Gulu, the hospital often had more qualified doctors than patients and a significant part of the doctors’ working day was spent drinking coffee and smoking. The care given was of a reasonable/good standard, but there was a lack of ambition to improve things further.

When the  proposed ‘tooth fairy’ research project failed to materialise, we realised that there wasn’t much benefit from us staying in Pristina and we have travelled home. We took the opportunity to spend a weekend exploring rural Kosovo. Away from the bright lights of the big city, rural Kosovo is pretty grim. The majority is flat, land-mine ridden terrain that is used mainly for growing cabbages. The mountains in the Rugova valley were beautiful and we enjoyed exploring the old towns in Prizen and Peja, but the scars of the Serb-Albanian conflicts are still pretty fresh.

We have now returned to the UK and are hoping to find some paid employment over the Christmas period and then to get involved with a new project in the new year before we fly off the Zambia in February.  We’re not quite sure where or what – but we hope to know soon!

Dave

Welcome to the Balkans!

Out of the frying pan into the deep freeze – and the locals haven’t even started wearing coats yet!

Google ‘Prishtina’ and you get mixed messages One website suggested:

Pristina is the city many of us love to hate... it's grey, dusty and traffic-clogged

Whilst another said this

Prishtina is a bustling capital inflated with the activity and personnel of foreign agencies, plus all the bars, restaurants and internet cafés to service them.

We have found them both to have elements of truth but have warmed very quickly to this war ravaged country. Whilst it is undoubtedly a post-communist, bomb-damaged eastern-block concrete jungle – it is very like-able. It might be the Coventrian in me – but the limited architecture doesn’t detract from the multitude of cosy coffee shops and restaurants that cover the city – and it certainly has earnt its reputation for having the best coffee outside of Italy. Crossing the road is mildly terrifying and everybody smokes like a chimney – but it all adds to its charm.

Prishtina is the youngest capital city in the world. 70% are aged under 28. We have rented a room in a student hall of residence (cheap – but better than you’d imagine) – and I’m pretty sure I’m the only person on campus with grey hair! It could be that that makes us stand out – or it could be the fact that we are wearing coats, hats, scarves, gloves, another coat, two pairs of socks and shivering in the biting wind, whilst everyone else potters around likes it's early spring. Our other distinguishing feature is our lack of Albanian. Whilst the locals are overtly friendly and will happily interrupt an entire restaurant to find an English speaker to translate our order – our lack of language skills is much more of a problem than in Uganda.

The hospital is large and imposing – but significantly better than Gulu. Power and water and free flowing, and there are plenty of doctors and nurses. Indeed, many doctors struggle to find paid employment and the emergency department seems slightly over-staffed. Whilst this is good for patients – it does make our tasks slightly less well defined. Fortunately (for us!), there are still obvious gaps in medical training and some of the care is very different from what we are used to at home. How we are going to be of use, with little language skills and plenty of staff – is less obvious – so we are exploring other activities including education and research.

Two views of the city:

We’ve arrived home after a 3 months in Gulu, Uganda. Despite a challenges, frustrations, culture differences and the odd illness, we had an absolutely fantastic time!

Shortly before leaving the hospital, we organised a ‘clinicians meeting’ with the other guys from the Manchester group so that we could present some of the work we had done during our stay and hopefully stimulate some discussion of the issues amongst hospital staff. After a nerve-wracking first half-hour sitting alone, people finally began turning up and we eventually got going, 50 minutes late but with a good turn-out. The presentations were well received and definitely stimulated discussion. One of the problems in Gulu is that the staff in different specialties had stopped talking to each other and it was so encouraging to see how keen the hospital staff were to talk and think about the issues and come up with ways of improving patient care. After all, they’re the ones who will be making all the changes after we’re gone. The plan is for the clinicians meeting to be a monthly occurrence from now on. 

Looking back over our time in Gulu, we’re hopeful that things are and will continue to improve, despite all the challenges the hospital faces. And although a culture of acceptance has certainly developed amongst some staff, following years of poor funding and lack of government support, this is changeable. As new young people begin working at the hospital, they will help to raise expectations and encourage and motivate others to work towards a better level of care. And also, the work of the Manchester-Gulu link is set to continue, at least for the next 10 years. Who knows, maybe we’ll be back in Gulu in the next few years on one of the short-term projects – we’d like to think we will be.

Despite our pleading for a small affair, we were thrown a big going away party by the hospital. We had some concerns over the money spent buying an entire goat for the event, but it was a lovely evening and a great excuse for all the staff to have a good meal and socialise. We realised how many friends we’d made during our short time and were really sad when it came to saying goodbye.

We left Gulu on the Saturday morning, with flights home booked for the following Friday. This gave us a full week to explore some of Uganda and enjoy the last of the sunshine before heading back to English autumn. The highlight was definitely going to see the mountain gorillas in Bwindi National Park, an incredible experience that we will never forget.

We arrived home to a large family gathering at my parent’s house in Salisbury and had a lovely weekend wrapped up in jumpers by the fire. We’re now in Coventry with Dave’s parents for a couple of days before flying out to Kosovo on Wednesday (9^th).

So, until next time…..

The hostpial in Gulu

A visit to the hospital

Gulu Hospital

Frustrations

As you may know, I (Mattea) didn’t really enjoy working as a doctor in the UK (hence my future career choice for non-clinical medicine). A big part of that is a fear of getting it wrong, of not meeting expectations, and what the result of that could be. I often came home feeling like I’d been chasing some impossibly high standard of care, never quite reaching it. I never thought I’d miss that.

We’re now into our 6^th week working at the hospital and are definitely starting to feel like we belong, almost too much, since in a month’s time we’ll be gone. We’ve taken the doctor count from two 1^st year interns who are on the ward three days a week (the other two days they run outpatient clinics, usually with no senior support what-so-ever); to two interns plus four full-time doctors with impractically-high expectations.  Patients now get reviewed at least every other day, mostly every day, instead of once or twice a week.  While this means a better level of service for the patients, it places that same impossibly-high expectation on the hospital staff.  And actually, raising expectations is part of what we’re here to do. But getting the balance right can be hard. We’ve done a few audits since being here to look at where the biggest needs for change are. For example, drug charts exist, but are barely used. Depending on the ward, the doctor, and the mood of the doctor, drugs may or may not be prescribed. If they’re not prescribed, they are written in the notes and there is an assumption that somehow, they will be given. If they are prescribed, they are almost never prescribed legibly or correctly. And if they are prescribed, they may or may not be given, depending on whether the drugs are available, whether the patient has an iv line, whether the patient is present on the ward during the drug round, whether the nurse can find the notes/prescription chart before doing the ward round, whether the nurse thinks the patient needs the medication, and definitely not if the night nurse calls in sick – as we found out today. Yesterday, we heard that one of the best nurses on the ward, who is new to the hospital and in fact new to Gulu, was found crying after a night shift. It turns out that since starting work at the hospital (3 months ago), she’s not been paid, some mix up at payroll. She doesn’t have enough money to buy food, and however quickly payroll sort it out, she will almost certainly never get the money for the past 3 months! It’s no wonder she didn’t turn up for her shift, I certainly wouldn’t have.

For the past 2 weeks, a short-term team of doctors and nurses from Wythensahwe have been out here running some training courses for some of the students and staff at the hospital. A few of them have been out here before, one was here almost exactly 2 years ago, for an 8-month stint. After lots of discussions about ‘our ideas for improving the hostpital’, it’s become clear that they are the same ideas that others have had and tried to implement many times before. There are so many reasons for the lack of change, half of which we will probably never know. Money and gross staff shortages are certainly two of them, but there’s a huge cultural influence too.

Maybe it’s because death is so common, and because we can offer patients so little. Whatever the reason, there doesn’t seem to be the same feeling of responsibility for patients that we have back home. And that’s probably the biggest barrier we face when trying to impose our standards and ideas for changes in the hospital.

As a little break, we took a long weekend last weekend and went down to Murchinson Falls National Park. We ran over a python in our car, watched a lioness and meet up with her three cubs and wander off for a cat nap, got absolutely savaged by tsetse flies when stopping to look at the rotting python on our way home, and got our car completely stuck in the mud, and thankfully were rescued by a 4x4 and a tow rope.

Life in Gulu is an adventure.

Medical equipment graveyard

Gulu high street.

Our favourite takeaway - Geoffrey and his Rolex

Chicken

Hordes of Medical students

Medical ward II

Emergency transportation vehicle

Our local shops

Catching the Bus.

Before we left sunny Manchester, we were asked to sign a form saying that (amongst other things) we wouldn’t use public transport in Uganda. It was a mixture of curiosity, cost and basically not having any other option that led us to Kampala bus station last Sunday morning.

When we arrived; it wasn’t the perceived poor safety record that was worrying me. My bowels hadn’t produced anything solid in several days and I knew for a fact that the bus would not have any emergency lavatory facilities. The thought of a public transport gastro-intestinal catastrophe played heavily on my mind. We’d been warned that the bus would be busy/full so we arrived in plenty of time. The bus was due to leave at 11am – so we arrived at 10.15. We were pleased to be shown directly on to the bus and found two seats near the back. We paid our 20,000 Ugandan Shillings (about a fiver) each and made ourselves comfortable.

The grandly named ‘Gulu Express’ is a battered blue coach from the early nineteen eighties. Covered in scrapes and rust, it does not inspire confidence. The window adjacent to us had been broken and expertly put back together with selotape. It is the size of a regular coach but instead of the regular 4-per aisle, they have crammed in an extra 5^th seat. We had seven people in our row, including two children and no seatbelts. At 11am the bus was full and ready to go. At 11.30am, the bus was even fuller and pulling out of Kampala bus station.

As we pulled away the most noticeable thing was the lean. We knew the road was uneven, but it genuinely appeared as if they’d put a load of massive tyres on one side and tiny tyres on the other. From my vantage point, I could see nothing. No view forwards, backwards and only a slight view of the passing city through the broken window to the side. I spent the first few minutes trying not to slide off my seat. Every bump came as a surprise and my bowels felt heavy

At 11.45am we stopped at a roundabout. At 12.45 we had circum-navigated said roundabout and were able to start making some progress. The roundabout wasn’t especially large but it was complete chaos. Thousands of mopeds and bicycles, often carrying impossibly large cargo (wardrobes, car bonnets, 12ft pipes) dodge around each other, making it almost impossible to move a larger vehicle. Traffic policemen sleep idly close by on the grass. They carry large machine guns which is probably why no one attempts to wake them up.

At about 13.30 we arrived at the edge of Kampala, and I was actually quite enjoying our adventure. At the first police stop, a man had asked to hide behind my seat. I’m not sure if he wasn’t supposed to be on the bus or if he wasn’t supposed to be out of jail, but no-one else seemed to mind, so neither did I. I’d plugged Mattea into Glee on the ipod, and I don’t think she noticed

I glanced around the bus trying to figure what infectious diseases I might catch. Whilst I can’t deny that the bus was a sweaty mass of humanity, it struck me how normal this was for everyone else. These people were normal Ugandan folk (rich enough to afford a bus fare) who were travelling for work or to visit family. None of them seem worried about the rattling noises from the engine or the occasional grinding noise as we slipped off the tarmac to allow another vehicle to pass.

Similarly, no-one else was gazing out of the window and the passing villages, wandering about the tiny huts and the cramped living conditions. They didn’t seem too bothered about the crumbling market stalls selling almost nothing, or the wandering goats/children/cattle who hang out the edge of the road. It looks awful, but actually it’s not poverty or that sad, it’s just life in Uganda. The tiny hut is home and the ramshackle shack is work, and that’s ok. It’s different from Manchester, but it’s ok.

My favourite part of the bus ride were the food stops. About every three quarters of hour, we’d pull off the road and stop. Within seconds we’d be swamped by people trying to flog us stuff through the window. Corn on the cob, bottles of Fanta, pineapples, even live chickens! My favourite is the ubiquitous ‘meat on a stick’. A couple of bits of unidentified flesh burnt onto a random sharp stick, poked through the window whilst someone shouts ‘Mzungo’ at me. I’m not sure what it is (probably goat roadkill), but at 10p a stick, I’m not convinced that my bowels would have thanked me.

After 6 hours and 270km, we arrived safely into Gulu bus station at about 5pm. I stank, but my underwear was intact and so was the bus. I probably won’t get on it again, but I had developed a fondness of the ‘Gulu express’. Like so many things in Africa, and in particular in the hospital, it’s a bit rubbish, but it’s what they’ve got – and it sort of works.

The hospital continues to frustrate. We have settled well and are working hard, but the inability to do even the most basic things is baffling. The lack of awareness or acknowledgement of the death or suffering is difficult to watch, but life is definitely cheaper here. We’re having to learn that. We hope that the locals have noticed that we have higher ambitions and expectations and hope that they want to join us in making it a bit less rubbish.

Many thanks to those that have e-mailed. Apologise for the lack of writing recently. Mattea was briefly ill with an unspecified vomiting/fever but gladly she has fully recovered. We have also spent an amazing week in Zanzibar celebrating John & Angela’s wedding. Add into that the lack of reliable electricity and/or internet and blogging/e-mailing has proven more difficult than we hoped. We hope to do better.

Please do keep in touch

Dave & Mattea xx

Impressions

The People – Incredibly welcoming, generous and friendly. When we walk down the street, we’re struck by how cheerful people are. It’s clearly a very close knit community, lots of people bumping into old friends, shaking hands, always with a smile. On our way from Kampala, our driver thought he’d splashed a pedestrian when he drove through a pot hole. So he pulled over to check he was ok and apologise, turns out the man hadn’t even gotten wet!

The Pace – Slow! But then, when a nurse only earns £75month, £50 of which goes on rent and most of the remainder on food, what’s the rush. There’s not much else to do except make things last. And to add to the above point, one of the nurses from Manchester who has been working in Gulu for the past 6 months had a leaving party last night. Despite the relative poverty with which people live here, she got generous gifts from a number of the nurses on her ward, all beautifully wrapped.

The Food – Well, it depends if you like boiled goat, dried fish and LOTS of carbs. No, I’m being unfair. It’s ok, perhaps a little less interesting than the choice we have back home, but when the electricity goes off every other day for between an hour and 2 days, anything that needs to be refrigerated is kind of out of the question.

Meal Times – Amusing. Dave and I have been to a couple of people’s houses for lunch. On both occasions, this began with a prayer, followed by a hand washing ceremony, and then the TV was switched onto soap! The first time this was a Philippino soap, the second time it was a Spanish soap – both horrendously dubbed with American voices, and even one random very British voice. Although it seemed a little strange to us that you would have guests for a meal and insist on watching the equivalent of neighbours, we actually really enjoyed it and so thought not much more about it. Until, when we were out for dinner last night at the leaving party (comprising all the staff from the surgical ward, including the chief exec of the hospital), we spotted a TV in the corner of the wooden hut at the restaurant. I actually joked with Dave before the meal that it must be for watching soaps whilst eating. I spoke too soon. No sooner had grace been said, the dubbed Spanish soap crackled onto the TV. Unfortunately, the reception wasn’t very good because there was a tropical storm raging and so after 5 minutes of moving the aerial around, the TV was switched off and scanty conversation ensued.

The Hospital – A HUGE challenge. From talking to the nurse from Manchester, it sounds like the surgical ward is significantly better organised than the medical ward, which is so far from what we know as a hospital in the UK. For those of you who don’t know, in the UK, the nurses do regular observations on all patients such as blood pressure, heart rate, respiratory rate etc. This enables them to identify patients who are unwell or deteriorating. They can then either implement a treatment themselves or request a review by a doctor. This is not done on the medical ward. So, other than walking up and down the ward trying to identify any sick-looking patients by eye, which encompasses most of the patients, there’s no way to prioritise who you see first when you arrive on the ward. It also means that our review of patients always begins with doing the routine observations ourselves. This is particularly frustrating when you can’t get an accurate blood pressure reading because the cuff is too big for almost every patient’s arm (we have the opposite problem in the UK as you might imagine). We had our first death this week, a girl in her 20s with HIV. We don’t know the exact cause of her death but we do know she had a haemoglobin level of a quarter of what it should have been (and in fact, it was a nurse who took the blood and asked for an urgent haemoglobin check once she spotted that the girl looked unwell). She died whilst she was having a blood transfusion. It’s really sad to think that maybe her life could have been saved on that occasion if she’d been identified as being the most unwell patient and therefore the priority to be reviewed that day.  There are many other frustrations and difficulties, including the lack of investigations, drugs, and doctors (apparently there are no doctors on Thursdays and Fridays because the ward doctors are at clinic and thus the ward is run by well-meaning medical students).

Anyway, lots to think about. And things are no doubt on the up. In fact, US Aid are currently building a brand new laboratory for the hospital – a much needed commodity that will no doubt save many lives.

Our first day.

Background: We were both slightly anxious. Despite a decent UK education and a good amount of NHS service between us, we’ve never really seen much tropical medicine, and we are both quite use to senior supervision and back up from nurses and other parts of the hospital. We were also unsure about cultural differences, the ability to offend, the inability to help and the risk of picking up diseases. We’d had lots of reassurance and we’d been told that as long as we were sensible, we could always ask for help and stick together

We arrived on the medical unit and found two doctors struggling around two wards and introduced ourselves. They seem bemused but pleased to see us. Mattea immediately abandoned me and suggested we take one Ugandan doctor each and split the wards. Off I went with a Ugandan intern called George.

We enquired as to whether or not others would be joining – but apparently, someone had decided that today should be a bank holiday and announced it on the radio THIS morning! Consequently, most of the staff were not coming to work today (including the senior surgeon with an expectant list of patients!)

I thought I’d start as I meant to go on, and as we reached the first patient, I asked if there were any gloves. Sorry – we’ve run out. Never mind, I’ll wash my hands, Sorry we’ve no water. Ok.

Things we don’t have:

Ø  Gloves

Ø  Water (intermittent)

Ø  Electricity (intermittent – and rarely on a night shift!)

Ø  Blood sugar machines

Ø  X-ray (‘its broken’)

Ø  U&e machine (its broken)

Ø  ECG machine

Ø  Thermometer (the intern had bought his own)

Ø  Sheets

Ø  Curtains

Ø  Any drugs I’d heard of

Things we had plenty of:

ü  Patients

ü  Insects

ü  Chickens

ü  Human Immuno-deficiency Virus

We do have access to a full blood count and a malaria screen – but the doctors don’t trust the results so generally don’t bother ordering them.

Despite our somewhat limited resources, we ploughed on with the ward round. Gradually I realised that I wasn’t the only one that didn’t know what was going on. The poor interns (first year doctors, equivalent of FY1s/house officers) were doing their first medical job and were only slightly less clueless than we were. Mattea and I bumbled our way around the expectant queue of patients and then re-convened for lunch.

Quite weary by our mornings efforts, we were invited to lunch by one of the nurses. She lives on site in a small but lovely house and cooked us some traditional Ugandan food. We spent a good hour sat on her sofa eating Ugandan cuisine and watching a ludicrously bad dubbed Spanish version of coronation street! The NHS could learn a thing or two about how to do lunch breaks.

Post-lunch, we weren’t sure what to do. The medical ward was deserted of staff but a helpful medical student told us that the intern might be in A&E. We set off to find him. He wasn’t there but they did have a smallish room with 7 beds packed together. Six of them had patients on, All of them looked half-dead.

Shortly after, another patient arrived. We did our best to ignore her screaming and pretended we were busy with important ‘English doctor work’. Now that the seventh bed was occupied, the senior nurse closed the barred doors and proceeded to bolt them together. Brilliant – no more patients (Andrew Lansley watch and learn!) But I’m not sure how we get out…

Eventually, our in-activity became embarrassing and we offered to see a patient. The nurses, looked bemused but suggested we see the new patient. We strode over to bed one and introduced ourselves to the young naked girl and a lady we assume was her mother and another who was probably her grand-mother. We were met with a stony silence.

What is her name? I asked politely

‘Allo’ she replied

Hello. What is her name? I replied again in slightly louder and slower voice

‘Allo’ her grandmother said.

Hmm – without a translator  - this was going to be difficult. The nurses had all disappeared and I glanced around the room of half-dead people unsure how to proceed. Luckily, a family member of another patient interjected and offered to translate.

‘Please can you ask her what her name is’ I asked the kindly translator

(In Ugandan) ‘What is her name’

‘Allo’ her mother replied…

Allo was a 12 year old girl with an ear infection. The initial antibiotics had not worked and now she had an invasive meningitis (infection of her brain). In the UK, we’d sedate her, give her intra-venous antibiotics, CT her brain, send off all the investigations we can think of and send her off to a specialist paediatric intensive care unit. In Gulu, I enquired if they had cannula.

After our first day, we felt quietly pleased with ourselves. We had sort of integrated ourselves into the system and feel more confident about what we might be doing tomorrow and for the next few weeks. We are still very doubtful about our ability to make much difference. We don’t really know what diseases anyone has, because we have never seen them before. We have nearly no tests to help and the limited drugs we have at our disposal don’t seem to be distributed anyway. However, all hospitals must start somewhere and I’m sure the UK hospital wards used to be filled with chickens, insects and bereft of any useful equipment – so the only way is forward and I doubt we can do much harm.

Our first few days....

We arrived in Gulu on Friday afternoon after spending a night in Kampala (it was too late to travel all the way to Gulu on Thursday; apparently the roads don’t have the best track record at night).

We were greeted by Paxi, a nurse from Manchester who is currently working at the hospital in Gulu.  She introduced us to a few people and we were shown round the hospital.  It was really nice to have a chance to see where we will be working but has also added some reality, we’re starting to get slightly nervous about starting tomorrow.

Our house is less than five minutes walk to the hospital (unless you’re walking at the chilled-out Ugandan pace, then it might take ten).  The house is a three bedroom bungalow in a gated complex with an armed guard.  The level of security doesn’t really seem necessary and we’ve certainly not felt at all unsafe so far, but we can’t complain, it means it’s totally safe to leave valuables in the house. We have a small garden with a mango tree – but unfortunately no mangos at the moment!

Paxi showed us around Gulu town yesterday.  We found a lovely bakery which also sells homemade peanut butter – I think peanut butter and bananas on toast might become our new favourite food.  We got home just before the thunderstorm began, not realising how lucky we were.  The heavens opened and the loudest thunder we’ve ever heard started.  We lost electricity just after starting to cook dinner, luckily it hadn’t quite got dark.  Dave insisted on keeping me company in the kitchen ‘in case I got scared of the storm’.

This morning we went to church and then for lunch at the house of one of the nurses from the hospital who’s a friend of Paxi’s.

All in all it’s been really fun so far. Everyone is very friendly and we’ve not been hassled at all when walking through Gulu city centre.

First day of work tomorrow, we’ll write again soon.  Below are a few pictures of the house.  We weren’t sure how good the internet would be but it seems to have uploaded them ok, so we might try a video next time.

The adventure begins

After a lovely few weeks of seeing friends and family, the time has finally come to get on a plane and wave goodbye to home. We fly from Heathrow this evening, stopping in Addis Ababa (Ethiopia) for a few hours tomorrow morning, and then onto Entebbe (near Kampala in Uganda). From there we'll travel by road up to Gulu.

Bags are packed, just time for a last roast dinner and wander in the New Forest before heading to the airport.

Our next post should be a bit more exciting.....

2 weeks to go!

Welcome to Dave & Mattea abroad!

Lots of people have been asking how best to keep up to date with our travels - so we have decided to open a blog! We're not quite sure what that'll mean - but we'll aim to keep you all uptodate with where we are, what we are up to and and hopefully lots of photos and videos of our adventures!

Its now only 2 weeks until we jump on a plane and head off into the unknown. Some days are a buzz of excitement at the adventures ahead, others a spent worrying about all the practical bits and other quite moments are spent anxious about crime, disease and not knowing what we are doing or why we are there!

For those of you that don't know, we have a basic plan for the year. The first 10 weeks are being spent in Uganda, in a northern town called Gulu. The state hosptial has links with a Manchester hospital and we have been placed in the hospital to work on the medical wards. After Uganda, we are heading to Kosovo. We have been offered a WHO (world health organisation) research project and also some clinical and educational work and the University of Pristina Hospital. The last 6 months will be spent working in conjunction with On-call Africa. OCA is a small but exciting charity that is working to improve healthcare to those in rural Zambia (http://www.oncallafrica.org.uk/). People keep asking us, exactly what we'll be doing when we get there - I guess you'll just have to watch this space...!