Day 7 – Vaccination Clinic

This marks a full week of living in central Africa.  It feels like it’s been a month or more, and I’m saying that in a positive way.  I sleep a little longer yet again but I’m surprised to find the lights on and low singing to be heard when I leave my room.  Esther (big Esther as opposed to the little one) is a girl of perhaps 16 who was taken in by Victoria because she couldn’t manage school, and the parents’ couldn’t seem to control her behaviour or teach her anything.  She stays in the big house, sleeps in a room with Don, the BKU baby, and takes care of Don, Arnold & sometimes little Esther during the day & evening.  She is also responsible for cleaning the floors and sweeping the courtyard area.  Her parents have remarked at the great progress she has made when she returns for visits.  Victoria wonders if she may be suffering from a mental health problem and has been told by a friend she will arrange a psychiatric consultation at the hospital where she works.

Victoria finds she needs to be very concrete in giving direction to Esther, and that the child decompensates if pressured or hurried.  She also becomes extremely excitable if overstimulated with activity or even music.  Esther tends to speak in a low voice to adults and avoid eye contact, in the manner of some individuals with low intelligence.  I would be interested to learn if she is strictly struggling with low IQ or whether something like ADD or an anxiety disorder is a major contributing factor.  Esther’s English mastery is rather poor, so I’m unable to do much of an assessment myself.

Big Esther

After half an hour of my working on the computer while she cleans, hums and prays intermittently, Esther approaches me and asks in a very low voice, “Doctor, I want to go to school but I cannot afford the fees”.  My heart goes out to her, and I promise I will speak with Victoria.  When I do, she provides some of the information recited above, and goes on to say Esther was good at attending school, but would become extremely agitated and decompensate when presented with quizzes or exams, so her being unable to attend school is a problem of low performance and generally very difficult access to testing and special needs programming.

Another very hot day, but the two public health nurses arrive on time with the vaccine supplies, and we are underway.  The clinic is considered a success, with about 15 clients from the community accessing care and almost twice as many BKU kids being vaccinated.  There are some distinct differences from Ontario.  The immunization schedule is a little different, polio vaccine is given as the oral version, which is superior to the injectable variety we use in Ontario, and all children are given BCG (tuberculosis vaccine, because of the high incidence of that disease in Uganda).  Alicia is very helpful in restraining and consoling the kids undergoing treatment.  The kids are each given a dose of Abendazole (deworming agent) and Vitamin A (to prevent ocular disease).  Parents are educated about vaccinations and general health advice.

Rose weighs a very anxious little Esther while I encourage in the background

Kids clown around while waiting their turn

Some clients from the community await vaccination

The public health nurse reviews the immunization record, while Alicia prepares to help hold or comfort another needle victim

I had assessed Olivia, a child of about 8 years old, for mild sore throat yesterday evening, and gave her some Advil, finding nothing too remarkable on physical exam.  Similarly Rona, one of the babies, was seen for a slight temperature and a couple of loose stools reported.  The matrons were asked to bring them back today.  What an education for me!  Both children today have high fevers and are quite lethargic.  We make use of the newly purchased malaria quick kits and both test positive for malaria parasite.  We treat their fevers (Rona gets IM diclofenac, which works very quickly), and they are started on Quinine.  Olivia has a history of being non-compliant with oral medications, so we set up an IV, and she will get her first couple of doses by that route.  I never expected to see or treat acute malaria in my medical career, and I’m very thankful for the experience and expertise of these competent nurses.  I am reminded that the differential diagnosis of fever in a child is not that similar in equatorial Africa compared to southern Ontario.  Rest assured that we fully expect these two tots will be functioning normally within 24 hours.  In fact, one of the pitfalls of treatment is that victims improve so quickly, they very often don’t complete their 5-7 day course of treatment, and the parasite stays in their system, ready to flare again in weeks or months.  I realize I am learning at least as much from these nurses as they are from me.

Rose assesses Rona, our littlest malaria sufferer

Normally a very bouncy girl, it's a shame to see Olivia so lethargic

Once the extreme heat of midday starts to wane, the older boys start another lively football game until the rubber ball falls victim to the multiple sharp edges of obstacles scattered about their pitch.  I fetch the leather ball brought from Canada, well aware that its’ life span will be limited under these harsh conditions.
 

Olivia feels much better even a few hours after her treatment

Friends enjoy the shade

Gathering firewood for cooking

Late in the afternoon I am reminded of my extreme limitations of function brought on by the language and cultural barriers.  About half the little kids received DPT vaccinations, and Alicia tells me that several hours later they are all crying miserably and holding their legs, so I decide to pay a visit to their dorm.  Rose is there, and introduces me to her brother.  She has just administered acetaminophen to the affected kids and is headed off to church, but Auntie has gone to the big house and is conducting a short choir practice.  I foolishly offer to stay with the brood.  Well, I sit down beside one girl who sits very still with tears streaming down her face, and pick up one of the tinier ones who is wailing the loudest, and work on settling them both.  That effort has results, but remember that half these kids did not get shots and are full of beans and ready to test the limits of monkey business while auntie is away.  Before very long, two are climbing on a bed and flicking lights on & off, while another 2 have scampered outside and are pushing long branches in between the bars of the window opening at the rear.  I am feeling tethered & helpless because the poor baby on my stomach is finally quiet and starting to fall asleep and my stern warnings & commands only elicit sly grins from the mutinous imps.  I lie the sleeping baby on a bunk and somehow manage to corral the escapees back into the dorm.  Just when I think I’ve restored some semblance of order, one of the healthy crew decides it would be fun to join the immunization victims sitting on the floor, and start wailing in chorus.  When auntie returns, she finds the dorm positively vibrating with vigorous wails and cries, and me frustrated and sweating profusely by this time with a warm and miserable Obama in my lap.  Making my way back to the big house for dinner, I mentally strike child care worker from my list of possible fun occupations in Uganda.

Rose and brother Martin

sore legs after immunizations

Yesterday I promised to relate the tale of the strong, remarkable woman I met yesterday.  Warning:  what follows contains scenes & situations that will probably be disturbing to most readers.

Hanifa’s Story

I am told this is becoming an increasingly familiar narrative in Uganda.

Hanifa Nakiryowa, at 29 years old, was living the African dream.  Her education in economics had gained her a lecturer’s position at the Islamic University, and she was close to securing a full-time position.  Her husband of 7 years was an academic doctor at Makerere University (college of business and management sciences), and their two daughters age 5 and almost 2 were the joy of her life.  She was able to share some of her income and help out her siblings.

In December 2011 she arrived at her husband’s place to pick up her daughters as arranged on a Sunday evening.  The couple had been separated for three months.  The young man who opened the door was someone she had never seen before.  Shock turned to searing pain and terror as he threw a cupful of acid in her face.

Hanifa was hospitalized for six months.  She underwent four surgeries and was afraid to let her daughters see her until her face was no longer a garish, open wound.  In addition to the terrible disfiguration, she is left with corneal scarring in her right eye that will require transplant, nasal disfiguration, scarring of her mouth which does not yet have proper movement, and prominent keloid scars on her left jaw, shoulders, chest and right arm & hand.  Her younger daughter who ran out and fell in the acid pool has scarring of her right under arm and trunk.

Hanifa’s husband was suspected and charged with attempted murder but was never prosecuted.  He continues on his normal life today.  She is left unemployed, depending on the good will of friends and the one sibling who has not abandoned her, and wondering how she can continue providing for her girls, let alone securing money for the reconstructive surgery that is not available in Uganda to improve her appearance and function.  She was quoted a figure of almost $50K USD by a surgeon in New York.  She is a strong individual and believes good people will see she is still the same worthy person behind the disfigurement.

Acid attacks, usually associated with domestic violence, are common in Cambodia, Nepal and Pakistan.  Over the past 5 years they are becoming increasingly seen in Uganda, and there have now been reports of such crimes in Nigeria and Kenya.  Potent acid compounds are readily available without permits or paperwork in many developing nations.  Perpetrators are often not vigorously prosecuted or punished, even when the attack has a fatal outcome.  Many attacks in rural areas or those resulting in death are not reported as acid attacks.  Uganda is only just starting to debate movement towards gender equality, and a recent bill to limit retail distribution of potent acids and increase punishments for perpetrators of such attacks died on the floor.

Hanifa is bravely willing to be an outspoken advocate to raise awareness and exert political pressure in Uganda, but she lacks resources to mount an effective campaign.  She has even considered giving up her girls to BKU, fearing she cannot continue to support them.  I am not directly connected to any agencies or groups that could help, but perhaps some of my readers are or know someone who is.  Perhaps, by reaching out through 7 degrees of separation we can muster support.

On the political front, I do belong to a Canadian organization named Avaaz.org (check it out), which takes on global political causes and mounts pressure for change through petitions and media campaigns.  I plan to take this story to the Avaaz organizers in the hopes they will take up the political challenge.

These are links to news stories about her attack, and the one that killed the mother of four of BKU’s children:

http://www.newvision.co.ug/mobile/Detail.aspx?NewsID=637806&CatID=396
http://www.newvision.co.ug/news/637259-i-endured-a-marriage-so-difficult-it-left-me-scarred.html
http://www.newvision.co.ug/news/638144-how-domestic-violence-affects-innocent-children.html

If anyone wishes to contact Hanifa directly, her email address is:

hanakiryowa@gmail.com

Hanifa's nose requires reconstruction and keloid scar mars her left jaw and right arm

Her right eye will require corneal transplant surgery

Jovan, Olivia, Gloria & Dan: the 4 children taken in by Victoria after their mother was murdered by their father in an acid attack