Goddamnit. Once again, time after time, without fail, I have to spray the entire content of my passionfruit around the room, walls- on ever bit of clean clothing I have, yes – even the white ironed button down shirt that I lay on my bed for the Malaria Consortium Conference tomorrow. I don’t know how I do this every time, but I’m really good at this. A nice, little orange blob, with the slight crunch of the seed in the middle, that had the potential of being so scrumptious. Good job Angle, nice work.
Picture of passion fruit on my white shirt:
*** malaria and the meeting ***
So today is the first day of the first meeting ever on the implementation of RDT’s for the diagnosis of malaria in Uganda; the pinnacle of Heidi’s research and organized by the Uganda Malaria Surveillance Project and the Ministry of Health (aka a 3 day retreat away from Nagon to hang out with some very cool people to listen to some very cool things in).
If you’ve been able to read as far as this, maybe I owe you an explanation behind this whole endeavor. Malaria, while completely preventable, treatable and curable, still stands as the leading cause of mortality in tropical diseases. Now this is a crazy massive burden of disease - it costs Uganda about 120,000 lives annually and drains the economy by US $600m (a value more than all exports put together). However, there is a strong new influx of funds with a new global interest in malaria - coming anywhere from the Global Fund, the Gates Foundation, WHO. Now the health-economic interest is in how to approach this question… with drug resistance on the rise, the first line of treatment and most effective drug (artemisin based treatment- ACT - an example being Coartem) is an expensive drug, standing at about US $8 per treatment. And people in highly endemic areas, Nagongera being one of them, seem to catch malaria more than the common flu- Vicki was telling me that she’s had a good year- only had it 4 times since September! And for a country with such a small budget, with such a limited health care system, whose annual per capita income is less than US $300- you can’t start dispensing anti-malarial left and right… But this is just the top layer. Ugandan physicians are taught to treat every fever case as if it were malaria unless proven otherwise, since the consequences of letting malaria go undiagnosed can prove to be fatal very quickly. So the common way of diagnosing is to make a blood slide and analyze it under microscopy- but this is terrible and rarely works for many many reasons. This means that malarials are dispensed far more than they should, to far more people than those actually needing them, many times at the wrong dose, leading to drug resistance and ending up being far more expensive than it should be. Anyway- it goes on and on, very interesting stuff, but the point that I’m trying to make, and the purpose behind this research project and this RDT implementation conference- is that a method to diagnose malaria at US $1 per case; through an RDT, a pregnancy test looking thing that works by placing a drop of blood in the case, which might also be much more accurate, easily interpreted, transportable, etc... So is it more cost-effective to have RDT’s to diagnosis malaria, and then the obvious why, when, how, by whom, bla bla bla? Fantastic stuff.
The invitation said 8:30 at the bling bling Hotel Africana. Expecting to get lost, I show up at 8 am in this huge room overlooking a rather sad looking pool, expecting a massive crowd of people for this ground-breaking meeting – not a soul, a few people are setting up chairs. 8:30, no one, 9:00 – yes, Ugandan time. Anyway, the room eventually fills up and the scene is definitely an interesting one. A few misungus- the world specialists on RDT’s and malaria, practically all women, and then the majority of the room are Ugandan male doctors, rather young, then there are the two presiding doctors, the elders, who taught all of the other doctors in the room, including the State Minister Otaala – health minister for primary health care – who marches in, only after everyone else has sat, with his whole entourage, with all the charm in the world. The meeting proceeds, all are so enthusiastic about the international interest and the potential of this new tool, and all of this with a very interesting dynamic in the room… the two elders give their closing honorary speeches- unbelievably – on their dangers of RDT’s and modernization, which completely goes against everything everyone in the room is advocating, but their presence is very respected because they are the elders. At the end of the second day, the first draft for the implementation of the use of RDT for malaria diagnosis in Uganda was written.
*** leaving Kampala ***
The 3-day retreat in the city turns out to be exhausting- the big bustling cities, with constant grit and people, and honking and black exhaust, and having to follow schedules and be social – seems to drain all motivation and energy. But as the bus inches its way out of Kampala, picking up speed through the greenest fields of tea, significantly accelerating across the Jinja dam (which marks the head of the Nile), I’m feeling more and more alive. Baboons clutter the sides of the road. The countryside constantly seems lusher, greener, more beautiful. Someone’s music is happily resonating with Caribbean-like beats throughout the bus. Flipping through my guidebook, reading about prospects of climbing Kili or diving in Zanzibar. Work is finally on track. Thinking about recent emails from good friends from Shenzhen to Bangalore to New York to San Francisco. Ah, I’m happy. The road has turned from 80 % cement 20% dirt + potholes to 20 % cement 80% dirt + potholes. Apparently, a few years ago, the government had commissioned this road through the Mabira Forest- overcome with corruption and the embezzlement of funds, the project was abandoned in the midst of everything, literally. From one day to the other, shovels, piles of rocks, foundation, cement, everything was just left in the open. Only now, the dense tropical Mabira forest is quickly being replaced by sugar plantations.
The bus finally arrives in Tororo. The shadows are getting longer, and with the Equator only a few miles away, the sun will be down in the blink of an eye. I don’t know if I’m just paranoid, if I just have a knack for attracting people who enjoy freaking lone women travelers out, but the conversation I’ve just had with a Jehovah’s Witness on the bus is fresh in my mind. Apparently, just last week, a group of Japanese resea\rchers were working in Tororo. The one responsible for the group’s finances ha9ol.\d an armed guard – the armed guard killed him. Lovely.
So I just wanted to make a quick stop by my passionfruit lady and find a green/fruitful dinner before spending the night in my beloved weekend-get-away-hotel… oh, a squeeze of lemon/lime drizzled over avocado, chopped up tomato, a dash of salt sprinkled over – maybe a little chili powder, a little onion? And if only they had cilantro- bam, there they’d have it! And if they could cut the chiapatta in little strips and either bake or fry them as they do so many things – or then maybe make plantains chips – Ouh, plantain chips, themselves drizzled with lime juice and a hint of chili salt, coupled with our newly created guacamole… so why, oh why, rice and beans?
But the sun is already down and the walk to my beloved hotel is far, so I opt for a seedy hotel just at the entrance of the market, right by the taxi stand for Nagongero, which I find out is seedy and full of sketchbag truck drivers only too late, and confronted with its seediness as someone was trying to get in my room at 2 am– not helping with the whole paranoia situation… But not before long, the morning sun is coming up, music can be heard from the street, and a new day full of exciting unknown is dawning.
*** little detail at the clinic ***
The cutest thing happened today – this woman comes, sits to get her blood drawn. The medical record (or her blue book) in my hands says her age is 40 +. Our study sheets require exact numbers, so what is it? And with laughter in her eyes and the shrug of a shoulder, she says she doesn’t know. She forgot how old she is. She’s right- what’s the need?
*** weekend in Tororo ***
Sunday morning, in the main hotel in Tororo, savoring my CNN and scrambled eggs over white toast and coffee made with coffee grinds in it- Uganda is one of the top coffee producers and yet, they can’t make a cup of coffee to save their life. When asking for coffee, you’ll be served with a thermos of hot water and with a bowl of either instant coffee or coffee grounds. So stir in three spoons of grounds, let sit, and spoon out. I just don’t get it.
The Oscars gossip comes on the news. Jaffar Amin, the son of Idi Amin, is interviewed about his reaction to “The Last King of Scotland” and naturally criticizes it as having a “euro-centric point of view” as well as creating ‘a fictitious portrayal of his father’. The movie has been overwhelmingly well received and supported by Ugandans, including the government. Theatres have been sold out.
*** Afternoon in Nagongs ***
A spontaneous, furious and powerful equatorial rainstorm is passing through. Huddled in our room, Joanne and I are howling with laughter and shouting above the storm’s rumblings like two teenage girls, as rain spills in through our only light source. Joan finds refuge under her covers and I finish threading a frangipani/plumeria and red hibiscus wreath by the bars of the open cell window; intoxicating and delightful aromas creeping in the dark corners of the TB cell.
*** scratching, the anti-malarial ***
The wife of the doctor at the surveillance site prior to Nagongera just died of a practice known as ‘scratching’. Now this brings in question western versus traditional medicine. Not that that one is right and one is wrong, but sometime you just wonder. I remember writing a paper in college justifying the virtues of traditional healing. And now I find thinking otherwise.
Scratching is the local traditional healing treatment of malaria. It is believed that the fever associated with malaria is due to witchcraft. The patient is to scratch himself until he bleed profusely- freeing the body of witchcraft. And so too often, the patient dies of severe infection. How can malaria, proven and solved by modern science, still be put in the hands of traditional medicine Now one would think that seeing victims of this parasite, embracing traditional medicine, and still dying time after time, would associate scratching with ineffectiveness. I guess not…
*** white ants ***
The day is coming to an end. A few patients are still lingering on the veranda, waiting for their blue books – the hustle and bustle that belongs to the halls has finally subsided- and this strange surge of howling can be discerned at a distance. It’s a very strange, war-like cry – constantly howling. The girls in the lab barely raise their heads; “Oh, someone must have died. It’s a common practice to howl when mourning”. Alright. We carry on the days work, close the door, lock the lab. This is now an hour later – the howling is still in full force. What in the world is going on? So right outside of the health clinic’s gate, with the chiapatti man on my right and the bore-hole on my left, is a crowd of little munchkins- a few of them crouched on the floor, howling at plastic bags buried under ground. Apparently, they’re yelling at white ants- termites- a local delicacy. Since the rains have not been frequent enough to incite the white ants to come out, kids put plastic bags over a few white ants, kneel and hover above these bags, howl their brains away, and white ants apparently come out…. Absolutely wonderful
***
Fish eyeballs. I just had fish eyeballs for dinner- a delicacy here – with a silky oyster-like consistency, and a crunch at the end. And the worst part about it- it wasn’t that bad.
*** work ethics ***
Now while I am just a ‘newbie’, have been here for such a short period of time, and have no idea what I’m talking about most of the time, here’s an attempt to a illustrate why Africa seems to fall victim to a certain stereotype. Purely observational.
So it’s now 10:00 AM at Nagongs. Electricity is out and has been since yesterday. No one is in the lab. The clinic opens at 9. The lab techs aren’t here to make or analyze the blood slides because power is out, and so the doctors aren’t here because the lab techs aren’t here – since protocol has it that treatment is carried out based on microscopy readings. Bref, this cycle continues.
The only consistent thing is the stream of patients.
The dishes for morning coffee are still sitting where they were sitting Saturday morning, which also means no coffee, only adding to my caffeine-craving grumpiness, but no one does their job here without being supervised.
So maybe I fall in their stereotype of the crazy anal misungu. This morning I woke up to be here early – was by the car waiting, and waiting – about a dozen men standing around the car, chit chatting, while four women wait completely squooshed in the back seat. I start becoming frantic, seeing the minutes go by – minutes that were now going to be minutes late. I get out of the car to show frustration, that I’m soon to learn is a game to be played. The men standing around, you say “when are we leaving”, they will say “we’re leaving right now”, then you go back in the car, and so on and so forth. 45 minutes later, we leave. It’s all a game they play because bottom line is that we leave when they want. Finally, the car starts moving- laughing and shouting and the guy who I’m sitting on with his fish imbued fingers resting on my warm-showered and soaped shoulder- smells mixed in with the soothing aroma of just-passed rainfall, raw mud, fresh grass and humus- And everyone’s laughing, and it’s a great time.
The car zigzags, somehow 10 people managed to fit in the car today – weaving through potholes as if trying to sow the road together – specks of kids dot the road- there must be at least a dozen schools along this road, if not 15, 20. Each school has a uniform, so as we happily bump along, we pass patches of bright purple, blue, crisp whites with khaki shorts- in sharp contrast with their soot-black shaved head – kids on bikes, four huddles on a motorcycle – all scurrying, and skipping along with their little blue books.
So it’s now 10:30 and the halls are packed with patients, there must be more than a hundred. Still no a member of the medical staff here. Unbelievable. It feels like 3rd grade – or forcing children to go to Catechism – How is it possible that you have to go and knock on people’s homes to coerce them to show up to work. But the funniest part is that you’ll knock, knowing the person is in there, and (with the reaction of an ostrich when it puts its head underground and whatever has been the issue, disappears) they just don’t answer the knock or calls. Not a peep. And this is a regular day at the health clinic - no power, no work.
***
Onward and forward- so it’s now Saturday night. I’m about to have another sleepover with Vicki. I’d rather stay here- I somehow feel part of the compound of women, inside the walls and can finally enjoy Nagons – a shower by jerry can – an outdoor shower, that is such a novelty and treat anywhere from Napa to Court’s place on the Vineyard, with my Kiels body wash, Redken shampoo for blonde highlights, loofa, face goo… and who would’ve known that all you need is 4 cement walls in one’s backyard.
And there’s so much to look forward tomorrow! After a fairly short day at work, I realized I needed to get some water to do laundry – at this point I had three little visitors sitting on my bed, legs dangling and kicking, nibbling on cookies and bananas that I had brought back from Tororo, so we all headed to the bore hole… (the middle one had malaria, oh, and she was impossibly adorable.
She’s the daughter of one of the lab techs who lives here alone– and what I’m about to say is terrible, but she had a wet cough, that made it sound like she was purring when she breathed which just added to her charm)
One of my favorite things is the kids. Children absolutely everywhere. Granted, the average age here is 15, yes, 15- everywhere you look, munchkins. You can also sense their gaze over you, the whisper of ‘misungu’, whatever it is- but when you establish eye contact, oh, they smile, giggle, with the most incredible warmth. The contrast of their white white teeth and dark skin – their smile just lightens up their face – happens to be contagious too.
***
On the road back to Kampala, savoring the surroundings with the biggest smile, warm wind streaming the window, uplifting crackling beats on the radio, petrol trucks ahead. The highway is basically a one-lane pavement road. Nuhu overtakes the truck ahead by swerving to the right onto dirt, only to realize there’s another petrol truck using the dirt shoulder as his side of the highway. Nuhu then swerves even more to the right, right in the bush. I gasp, plunge back in my book. Total ostrich reaction, but it works. If you can’t see it, it’s not happening or at least is not as bad as it would look. I’m getting hot flashes – the roads are notoriously bad. And Nuhu, Joanne, and Kambale all laugh “hee hee, welcome to Uganda!” and the radio goes up.
***
After looking back at what I’ve just written, I realize that this all may seem very negative- but no, not at all… yes, maybe the work ethic is a bit strange, appearing inefficient, but it’s so foreign, so different that what we’re used to in the west. And this feeling of insecurity is a learning experience to being more cautious, of being aware of your sense of preservation, of your reactions, of your independence, of your dependence. To quote Tamara after tonight’s dinner – it’s important to know how 90% of the world feels like and lives by. As the Lonely Planet describes and enumerates in the ‘psychological well being” section of culture shock; there’s the initial awe, delight, natural high of new things (the honey moon stage)- then there’s the disillusionment, disorientation, and then there’s now. I’m finding myself questioning what makes people here act and be the way they are. How do people think this way, how do people emerge from such a serious and dark past, and have this pervading lightheartedness and day-to-day sense of mortality? How can people be so individualistic, so careless of pollution? What makes a nurse watch a child convulse because he’s not being administered his medicine, simply because she’s on her lunch break? What is it that makes a matatu crash turn into a public spectacle and have a crowd of 20, 30 people run towards the crash, with the sole intent of robbing and observing those stuck inside? So I think that it can be only now, staying in Uganda for a longer period of time, that I can try to make some sense to these questions, under the spell of these people, their stories and their country.
