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

    

Day 6 – Panic

Louis Picard, board member of Bright Kids USA Foundation, is a well-seasoned world traveler, and he sends a message via Pauline that a rule of thumb for jetlag is that recovery may take 1 day for every 1 hour difference in time zones, and that days 3 & 4 are usually the worst.  With the 7 hour time difference from home, the good news is that I can look forward to normalization of my sleep pattern any day now (Sue tells me it’s never normal at the best of times).  Bad news:  perhaps another week of burning the midnight oil and dragging during the days after I return – but my schedule will be decidedly more hectic.

I am up early and stay up to enjoy seeing the little ones off to school.

Shira and Dan with Arnold behind

Sandra

Dan, Sandra & Shira

Rebecca

I just love the individual expressions on these faces!

Friday is one day before our big vaccination clinic, so Rose and I have planned to post more notices around the community.  She is lettering them all  by hand, so I take a stab at doing my first ever sign in Lugandan.  It is surprisingly difficult to copy a couple of paragraphs in a language I do not understand, and Rose chuckles at my frequent revisions.  We set out towards banana village then up through the brickworks quarry which has seen the landscape gouged out by decades of hand labour.  I remark on a pyramid of dirt the height of a man in a field, and Rose advises me it is an anthill.  Perhaps Alicia should fear the ants here more than some of the other critters.  It is interesting to see the different types of dwellings clustered along the winding red sand uneven roadway.  Folks are generally friendly and wave, and we need to move over for the occasional boda boda.  The roadway gets too narrow for any bigger vehicle to negotiate comfortably, except perhaps a jeep or land rover.

Rose posts a notice of our vaccination clinic

Anthills, Uganda style

It is developing into another scorching hot day, perhaps 38 celsius and several locals have remarked about the unseasonable warm weather.  I rinse off my dusty feet and just start to cool down again when Angel rushes outside, cell phone in hand, saying we have an emergency, and I must dress to go with Rose immediately.  Angel is Victoria’s daughter who comes to BKU 3-4 times weekly with her infant son Hakim.  Today she is watching over operations while Victoria has gone to Kampala.  “Mama” has received a phonecall stating that Ivan, one of the BKU kids, was badly injured in a road traffic accident and was taken to hospital but not expected to make it.  Ivan’s school is overcrowded and new classrooms are being built.  In the interim, students attend either a morning or an afternoon half-day shift.  Ivan would have been walking to his school around noon, and his route requires crossing the busy Entebbe-Kampala highway.  Ivan is 15.

I quickly don long pants and a dressier shirt, and we hurry the 1 km trek to the highway and catch a minivan to Entebbe.  A nurse at the ER checks and re-checks records and speaks to other staff, but states Ivan never came through their facility.  She suggests we try a medical facility a few blocks up the hill.  Sister Immaculate & Rose are frantically making calls, trying to ascertain more details, but the person who called Victoria with the information is not someone she knows.  Striding along the sidewalk, I am treated to a couple of unusual sights.  Across the road is a tall attractive Caucasian girl with long blonde hair and a flowing hippy style skirt walking along with a guitar slung over her shoulder.  Further along, not ten feet away from us on the grass, a monkey casually saunters parallel to our path, occasionally stopping.

The outpatient department at the medical centre has no record of Ivan, and they tell us that all trauma would go to the ER which we already visited.  I feel pretty helpless and useless, having no knowledge of the medical/transport/information infrastructure in this unfamiliar nation.  Sister & Rose decide the next logical step is to make our way to Ivan’s school and get some more information.  Three other BKU boys attend that institution, and surely someone can shed further light on the situation.  There is no land-line phone or administration office at the school, from what I can gather, and none of the children have cell phones.

Another minivan ride, then a march uphill in the heat, about a 2 km trek to Ivan’s school where we encounter Richard, the BKU employee who manages the animals.  He gives us the thankful news that Ivan is in school and fine.  Just to be sure, the ladies summon out each of our schoolboys to see and touch them for their own reassurance.  It seems a malicious hoax is more likely than an honest mistake as the explanation for this episode.  Victoria’s repeated phone calls to the unknown number are not picked up, and the ER staff had told us there were no schoolboy-aged trauma victims today.  Relieved but hot & thirsty, we are thankful for the downhill grade back to the compound, and much more thankful for the joyous outcome.

Ivan’s school is a series of 4 buildings, each consisting of 2-3 classrooms with open windows .  One building requires completion of the roof, but classes go on with tarps for shade.  Another building in the earlier stages of construction is unoccupied.  The classrooms are about the size of our Ontario equivalents, but crowded with benches in front of long desks in crowded rows.  I would estimate there are 70 boys in each room.  All teaching is done in English, from Primary 1 right through to post-secondary education.  Ivan’s is a public institution and I am told that such overcrowding is the norm.  Many of the BKU kids attend private schools requiring tuition, and a couple of these which we pass on the walk home appear from the outside to be better appointed with less crowding.

I am awakened from my brief nap to meet a special visitor, a remarkable lady named Hanifa.  I will tell you her story in a future post, since I want to confirm the accuracy of my account before publishing it.

Prayer service then bed and a more restful sleep straight through to 4:30 am.

Olivia holding Jovan, Gloria behind Dan:- four children orphaned by an acid attack which killed their mother

Janat, Gloria & Dan

Obama & Brenda

Day 5 – Entebbe

Once again, I fall asleep sometime between the second and third cock’s crowing but before my eyes detect early dawn.  I unwisely hit “off” instead of “snooze” when the cell phone alarm sounds, so I waken in a panic, realizing only 10 minutes remain before Rose is scheduled to come by with 13 yr-old Kato for our trip to Entebbe.  Splashing water on my face, I choose to forsake the shower in favour of a quick coffee and a few bites of Victoria’s excellent scrambled eggs – perhaps this choice will buy me a little more personal space on the minivan taxi.  Thankfully, Rose is a few minutes late arriving, allowing me time to remember sunscreen and antimalarial meds.  Alicia rises before I leave, in time to join Richard on his chores.

boda boda stand near BKU

cute child at her home along the road

Richard immunizes a chick

The taxi ride is fairly short and only costs us 1000 UGS (1 US$ = 2500 Uganda Shillings).  It is punctuated by a brief confrontation between a disembarking passenger and the conductor, settled only after the driver comes around for support, bolstered by shouts of advice from the other impatient riders.  On our walk to the clinic, Rose explains the situation.  Protocol dictates that riders may pay on disembarking provided they have exact change.  Otherwise, one is expected to pass larger bills forward (often via one or 2 other hands) so the conductor can make change between stops, and not delay the taxi unnecessarily at the roadside.  Apparently this scoundrel had large and small bills, but insisted on paying with a large bill at his stop.  Furthermore, he demanded he be given his change before he would hand over the large bill.  The event was interesting but not threatening.

Entebbe is much smaller and notably more sedate than Kampala.  Nestled on the shore of Lake Victoria, its’ choice as capital during the British Empire is apparent in the many colonial style buildings vying for a glimpse of the water.  I enjoyed my first sighting of a football pitch, abandoned on this weekday morning, and sporting goals without netting and more dirt than grass.  We pass a couple of nice hotels on our walk to the clinic.  The guidebook states Kampala also has some posh neighbourhoods and fine hotels, but we did not visit those areas on our brief sojourn to the larger city.

Construction on a classy hotel in Entebbe.  My friend Barry would be cringing at the scaffolding in use.

TASO is the acronym for The Aids Support Organization.  Their clinic is close to the lakeshore, and near the zoo entrance.  The campus is much more compact than the facility we visited with Isaiah, but the staff at the children’s clinic all greet Kato with friendliness and obvious recognition.  The main room is moderately large, with desks for the counselors and doctor, and a central TV set with muted cartoons that hold the rapt attention of several patients.  We go through to the covered deck in back, and I am glad for the steady breeze on this morning which seems hotter than others.  The heat in this part of Uganda is reminiscent of Ontario on a July day:  mid-30’s with moderate humidity.  Ugandans often ask me how I like their weather, and are surprised when I tell them our part of Canada gets just as hot in the summer months.

Kato's little friend and her mom

TASO paediatric outpatient clinic, Entebbe

A young girl of about 6 who is full of smiles and skipping rather than walking climbs on a tricycle and rides around the deck.  Rose and Kato know her and the mom, and Rose asks if I would take the girl’s picture.  She is fascinated to see the images on my camera back, and mom asks if I can give her a picture.  Alas, they do not have email, but I promise myself to send some prints to Victoria for Rose to take with her on their next clinic excursion.

The counselor takes Kato aside and spends 25 minutes or so in private conversation.  She advises Rose that the time has come to start educating this boy about his diagnosis.  The label probably does not have much meaning to him at this time, and he understands that he has some illness that requires medication and monitoring, but that is about the extent of his knowledge.  Information will be given in bits and pieces over the next few years, allowing him time between clinic visits to absorb the details and formulate questions.  He is fortunate in having Rose available to consult between trips to Entebbe.

While we wait, Rose speaks to one of the other moms who says her child of 7 can no longer attend school.  They live on an island community in Lake Victoria and the sole teacher on the island left in December.  They cannot afford the daily boat transportation to the nearest school, and cannot afford boarding school.  Apparently school transportation is not free although public school education is funded.

The counselor asks Rose for Victoria’s telephone number.  She describes a boy of 16, a patient of their clinic, who is living alone in Entebbe, trying to find work to pay his rent and survive.  Victoria says she gets calls about sad situations almost daily and wishes she could help everyone.  She apparently asked the counselor to have a report prepared by social work and probation services, and she will then consider the next step.

After the counselor’s session, Kato sees the doctor who advises us his disease continues well-controlled and he should stay on his Septra for maintenance.  She does not have an otoscope (ear light) available but notes the history of hearing loss and treated ear infection back in September.  She suggests he may have a chronic infection, and that a course of antibiotic & ear drops might help.  I indicated we plan to obtain an otoscope Monday, and perhaps we’ll hold off starting treatment until then.

Kato (left) and his twin Wassawa

I reflect on poor Kato’s plight.  If his hearing loss is not caused by some readily treatable condition (ear wax or persistent infection), he may need surgery or hearing aids – treatments which BKU may not be able to afford.  Ongoing hearing impairment will result in poor school performance and social isolation, compounding his hurdle in realizing the implications of his HIV diagnosis and the capriciousness of life that he should be affected while his twin brother is spared.  Gloomy thoughts for a sunny Thursday morning.

I respond to the greeting from another muzumbu, the first I have seen walking the streets anywhere, on our way to the supermarket where I am pleased to find Heinz ketchup and soya sauce. The Ugandan ketchup is thinner and has a more savory flavour.  I do enjoy it, but Heinz just seems right for certain dishes. I grab a couple of bottles of water for Alicia, a treat for Kato, and a couple of heavier rubber soccer balls.

Alicia has no appetite for lunch, but tells me she was also in Entebbe with Richard this morning, picking up supplies at the hardware store, and visiting the bank.  She still hasn’t found courage to actually milk one of the ornery cows, but she’s enthusiastically helping with all other aspects of the care of the animals, including gathering eggs from the chickens.

Gloria

BKU rooster

Do not be fooled by Arnold's charm

Neighbourhood schoolgirls

 

Elizabeth, who is Elijah Obama’s older sister, arrives from boarding school to request attention for her toothache.  Rose is at lunch in her room attached to the little ones’ dorm, so Elijah enjoys a rare visit with his older sister while we wait.  There is an obvious cavity in the girl’s bicuspid, and unfortunately the adjacent premolar has already been extracted.  She is given antibiotics and Ibuprofen, and we will need to arrange a dentist appointment.  Extraction of this tooth will leave quite a large defect in this girl’s upper palate, but restoration and probable root canal will stain the BKU budget significantly.  More tough choices for Victoria to weigh.

Arnold spent most of the afternoon with me in his football shirt, and fell asleep in my arms at bedtime

"Auntie", the little ones' matron

In the afternoon, Rose hand-prints some notices about Saturday’s vaccination clinic, and we have variable success gluing these to BKU building bricks and the occasional hydro pole.  Victoria posted some notices about the community earlier in the day, and Rose plans to produce more tomorrow.

There is a young family housed on a plot  near the little ones’ dorm, with about 4 kids between 5 and 12 playing about.  I have waved a couple of times in the past, and today they run out and let me take their photos.  They are thrilled with the results, and enthusiastically greet this muzumbu every time I subsequently pass by.

the neighbour kids pose

Alicia & I are able to visit Susan by Skype.  The connection is better today and she is able to meet many of the kids and get a little tour of the grounds.  We do miss her!

After dinner, I’m thrilled to see some boys are playing football on the patch of ground between the big house where we sleep and the clinic building.  I have posted a video at:   
                  http://youtu.be/N9kLs9SLIp8

I am standing on the main path with the big house to my left, the clinic to the right, and the piggery behind the soccer pitch.  I cannot believe how quickly they scamper across the hard grass on bare feet.

I have also posted a short video of the kids singing at the church service on our first day in Uganda, which seems like ages ago:           
                 http://youtu.be/knAQ0RGt5lI

Vincent

At the end of the video, I focus on brief close-ups of Esther and Elijah Obama.
These URLs may need to be copied and pasted into your browser, but I have tried them, and they do work.

Some random pictures from the day:

This pig & the chicks were donated from fundraising by Maria Cruz, a former BKU intern

Cow donated by Simon & Phyllis Barber and family & friends

Greetings, Mr. Pig

Rubegga with one of the pregnant dogs