Some people talk about poverty in terms of a lack of options. Using that criteria, prisoners in Cambodia are surely some of the poorest of all, lacking even the option of a traditional dentist pulling out a painful tooth. Instead, they normally have no choice but to put up with an acutely abscessing tooth until it settles, hoping that the infection won’t spread into the upper face or neck with potentially fatal consequences.
For the past three years the Christian organisation I partner with (the only provider of dental care for prisoners) has been locked-out as they attempted to re-negotiate a new MoU with the government. After much prayer and multiple attempts, I am happy to report that three weeks ago we were finally allowed back into the main men’s prison. Each Wednesday I take a team of 10 students to fill and extract teeth as we rotate every few months around Phnom Penh’s main prisons. Operating in high temperatures, we have already been struggling with equipment breakdowns and push-back from guards keen on wielding their power. However, we have seen God at work with positive outcomes in spite of the conditions. One man’s abscess had spread into his cheek and was serious enough require incision, drainage and antibiotics, for which he was really grateful. Our team values your ongoing prayers. Phones and cameras are not permitted in Cambodian prisons but for an up-to-date report from outside the walls watch the video above or click here.
In August we sent a newsletter fundraising for equipment for a new church-based clinic. Thank you to everyone who donated! We had a great response and now have all the money that we need. Phil has done all the purchasing and along with his students has been operating the new mobile clinic for a few months already. Recently Pagna, one of his key student leaders, pointed out how he liked working each Monday and Wednesday at the church-based community clinics because ironically, he could now do better quality dentistry in the middle of paddy fields than he could at the university clinic! As planned we have kept the extractions free and the villagers all seem happy to pay for the $2 fillings.
Take the tour by watching the video above.
No malaria prophylaxis is 100% and now I know that first hand. It all started when my friend Elizabeth and I decided we needed to get out of Mango for the weekend. We didn’t go far – 20 minutes down the road was enough to get away from work schedules and 2am call-outs to the hospital.
In the tiny village of Sadori there’s a Nunnery where guests can stay and where we invented the game of Ultimate Frisbee-Soccer. After a few rounds we decided it really would be a game better played with more than one player on each team: it’s quite difficult to kick a soccer ball and throw a Frisbee to ones-self at the same time!
Then came the dreaded mistake of trying to read peacefully outside. I believe that is when that nasty little malarious mosquito bit me. By the Monday I felt headachy and tired but didn’t think much of it. By Tuesday my joints had started to ache but only sometimes. First it was my knees, then my elbows, then my shoulders, and I felt unwell enough to go to bed at 7:30pm halfway through a movie. On Wednesday I ran 9 miles (somehow I now think in miles). By Thursday night I was so tired and achy I couldn’t leave the house to go to a birthday party. When I turn down the opportunity to eat cake it is a sure sign of illness! On Friday morning I felt way better but when I discovered I had goosebumps on a 40˚C day I knew it was time to take a malaria test even if they had to extract two whole drops of blood! (If I haven’t told you before, I am a pharmacist because tablets don’t bleed.)
After taking my treatment it took two weeks before the waves of exhaustion interspersed with feeling perfectly fine began to fade away. I’m glad I was taking my prophylaxis otherwise it could have been a whole lot worse.
Day 1. I finally arrived in Mango and it has been a long journey. Months of planning and working and saving, a Bible Collage paper, a million emails back and forth to Togo and NZCMS, learning to ride a motorcycle and a few rugby games – you have been caught up on what I have been up to for the last year.
A quick flight to Auckland then the not so quick flights to Hong Kong, Bangkok, Addis Ababa and finally Lomé left me all ready for the eleven and a half hour bus ride up to Mango. I was mentally prepared for it to take up to 18 hours so the shortened time and the air conditioning came as a pleasant surprise.
Day 2. A quick tour of the hospital to see where I will be working for the next two years. The most exciting part for me was to finally see the Pharmacy that I had designed while on a 36 hour whirlwind trip to Mango one and a half years ago. I am impressed how much it looks like the diagram I drew and could not wait for the shelves to be full of medicine. The rest of the Hospital looks pretty amazing too! We have a 40 bed hospital with separate Men’s and Women’s wards, a Maternity ward, NICU, Operating Rooms, Radiology, Laboratory, Sterilising Unit and a Clinic which sees about 100 patients a day.
Next was a quick tour of Mango to see the local market where I will be buying my rice, tomatoes and cucumbers. I have since learnt that it is worth paying extra for the bagged rice in one of the boutiques as this means you don’t need to pick out the rocks yourself and saves on potential dentist bills. Also you can not always buy Mangos in Mango!
Day 28. I had just got back from prayer meeting and was excitedly going through a box of donated kitchen supplies – it is amazing what becomes exciting when there is no Briscoes down the road! – when I received a Pharmacy call out. A little surprising as the Hospital was not open for another 18 days… I quickly pull my long skirt on over my shorts and borrowed a flash light to put in the basket of my bicycle so I can see as I cycle back to the Hospital. I entered the Pharmacy, picked up my jandal to squash a spider (I never know which spiders are dangerous so my current theory is to kill them all!), retrieved the meds then cycled off through the night to deliver Morphine to the poor nurse with kidney stones.
While dropping off the meds I had a conversation with the Chief Medical Officer about how the machine that gets water ready for making the IV solutions (we make them from “scratch” around here) needs a part that is coming from the USA. He asks me to order some IV fluids from Lomé. I cycle back off into the night with my IV fluids order scrawled across a scrap of cardboard, knowing that this is exactly where I am supposed to be and that tomorrow will bring more exciting adventures and challenges.
Day 30. Elizabeth, a Paediatrician from Texas, and I moved into our brand new cottage. It wasn’t until four weeks later that I got my bed and I still haven’t unpacked my suitcase yet but it is starting to feel like home.
Day 42. The Grand Opening! I was woken up at 6:30am by Hotel California blaring out of the sound system over the other side of the hospital compound. Four hours later, with the same song on repeat, I was well and truly ready for the President of Togo to arrive in the hope that this may cause the sound man to choose a new song! There was a lot of excitement and all the Hospital workers were dressed in the blue Hospital of Hope fabric, while many of the people from Mango were dressed in a green version in celebration of the day. It was fun to see some of the local dances preformed for the opening ceremony and while the speeches seemed long (it is always difficult to concentrate in a different language) I was rewarded for my attention by hearing ‘Nouvelle Zealande’ mentioned once.
Once the excitement of the cutting of the ribbon and the feast of roast beef and rice was over it was time to head back to work for the afternoon before collapsing into bed at 6pm and sleeping solidly until the next morning. Apparently opening a hospital is exhausting work!
You can watch clips from our opening day by clicking here.
Day 46. Monday March 2 saw our first patients arriving at the Hospital gates long before I woke up. By the time I got to work at 7am there was a well-controlled line of patients stretching out of the Hospital entry and down the dirt road that leads back towards Mango. We had a tent set up just inside the Hospital walls where the Doctors, Nurse Practioner, Midwives and Surgeons were screening people to decide if they were going to be our first patients or if they were not urgent and could come back later in the week. It was a slow start in the morning for the Pharmacy as it took a while for the patients to get through the system but we made up for it in the afternoon and we ended up having crowds of people waiting at the Pharmacy until 8pm.
Thank you for your continued support and prayers during this start-up phase.
A lot of people who know me will tell you that I’m a bit of a nerd. I love learning! In fact, I’m so nuts about learning this is my first year since high school that I have NOT been doing some sort of tertiary study!
Over time I have also discovered that I love to teach. I really enjoy the challenge of helping someone to really ‘get’ a subject by not just knowing it well enough to explain it, but being able to adapt the information to suit the learning style of the individual.
Put those two things together – a love of learning and teaching – and I’m sure you can understand why I am really excited about the latest developments happening in Potter’s Village and in the town of Kisoro!
Part of my challenge while working here in Uganda has been to look at how I can be the most help possible here. Yes I’m a help as a nurse but I wanted to help in a more lasting way and decided to do this through… yup, you guessed it, education!
The last few months I have started slowly doing a range of training sessions with the staff, writing some guidelines and protocols and discussing what they feel their professional development needs are. These training sessions range from group discussions to scenarios (yes I have played a dramatic mother and an anaphylactic patient!). Some of what I have been developing are just aids to support the staff, such as a resuscitation flow diagram designed to fit the context and an anaphylaxis response chart. Needless to say we have had a lot of laughs doing this and the response so far has been great.
The last few weeks I have taken the next big challenge and started to design and write a self-directed learning programme to train staff in neonatal nursing. I am hoping that by the time I leave I will have completed a full set of 3 information booklets and accompanying workbooks ranging from basic to advanced neonatal care, the idea being that even without a specialist nurse available to them, the staff still have access to the information and a way to train and advance their skills and knowledge base. The draft for the first set is complete so far!
Finally, the local government hospital, Kisoro Hospital, has just received equipment to open their own Special Care Nursery. This was something we were both excited and nervous about. Nervous because no one at the hospital has any training or experience in neonatal care (doctors included!) and excited because if the nursery is a success it could do huge things for infant mortality and morbidity rates in the region. Sister Jovia (our senior Ugandan nurse) and myself went down to the unit to have a look today and help them set up their incubators. What followed was a two hours question and answer training session on basic neonatal care, how to run a nursery and how to work and maintain their equipment.
Most exciting of all is that between us and the staff at Kisoro hospital the agreement has been made to build an education relationship between their unit and ours where we will visit about once a week to do training with their staff and their staff will visit us to get some hands on experience. I’m really excited for what this could mean for the development of neonatal care in Kisoro in the coming future and feel excited to be a part of it.
I have always been told that God uses not just our gifts but our passions. I came to Kisoro to nurse, feeling in many ways inadequate for the roles I was walking into, but God equips us as with the tools we need and I have been humbled continually by the gratitude of the medical staff for what I have been able to offer. Moving into an education role I feel truly privileged for the opportunity to use my passion for learning and teaching to benefit those around me in a lasting way.
Thank you God for the gifts you have bestowed on me to use for your purposes, for the courage you give me daily to use them, and the strength you fill me with to step up to each new challenge.
There are many different approaches which people take to living and working in another culture. For myself submerging myself into the culture and embracing it is important, however what about when cultural practices go against everything we are trying to achieve? What happens when health care and cultural practices clash?
Cultural practices isn’t a foreign concept for me, having been brought up in both Pakistan and New Zealand, and for the most part I am open minded. I respect and appreciate the place of spiritual practices in caring for the unwell and a huge number of our pharmaceuticals originated from herbal remedies. However, I do believe that there is a time and a place for traditional interventions and these needs to be weighed carefully for their benefits to the patient.
Here in Uganda it is no different to anywhere else in the world in that there are many cultural beliefs and practices surrounding health and healing. While some of these are harmless, others range in the degree of damage they can cause.
Probably the mildest of cultural remedies is the ingestion of herbs. I’m not sure what these herbal remedies are – the staff themselves aren’t sure – but they can be given for any number of reasons. The problems most commonly occur when they are given to newborn babies. Every so often we get a baby in who is very unwell and vomiting green fluid. Bile my medical friends might think and in the past I would have agreed, but here it is just as likely to be the regurgitation of the herbs the infant has been coaxed to ingest. The rationale for giving herbs can be anything from poor feeding, not breathing well, pale, feverish, vomiting or pretty much anything else. Unfortunately, when it comes to vulnerable and already unwell infants, it just adds another complication to the equation as we attempt to bring them back to health.
Prayer for the unwell is common here, we ourselves have a Chaplin who comes into the medical center every few weeks to pray for our patients and with our staff. The problem, however, is not with prayer, it is when a patient is believed to have evils spirits in them or be cursed. While, to my knowledge, no dangerous practices are used in these cases, the risk is that because the family believes it to be a spiritual issue, they do not seek medical help. By the time these cases reach a medical facility they are critically ill and sometimes it’s just too late.
Those are the milder issues. If you don’t have a strong stomach, I would probably suggest that you do not read the remainder of this.
To my knowledge, there are three more major local practices, though there are likely more that I have not yet come across. While they are all dangerous, the other major problem that arises with all of them is that families don’t bring their children to the medical center until much later.
The most recent one which I came across is mostly used on infants. This practice involves applying a hot object to a babies forehead to burn it. I’m not quite sure of the rationale of this one, but with one baby it was possibly done because of a high fever, the other because the baby’s sutures of their skull were wide spaced and the fontanelle was wider than usual. As you can imagine, besides the immense pain of being burnt, this practice can also result in infection and severe scaring.
Local tonsillectomy, or tonsil mutilation, is a practice that is more common to Rwanda than Uganda but many of the residents of the district of Kisoro were once Rwandan refugees and so the practice has become very widely spread within the region. For reasons unknown, tonsillitis is the disease of choice here. No matter the symptoms, it could be a stomach ache, head ache or diarrhea, even vomiting up worms, it is locally diagnosed as tonsillitis. The remedy for this is to visit a local practitioner who performs a “tonsillectomy” . This consists of using a sharp object, commonly a sharpened stick, and piercing multiple times first the inside of the nasal passage, then the tonsils and back of the throat. The last patient we had in with this had not even been unwell… she was 2 weeks old, a first child and the mother was worried about feeding problems, so she had a local tonsillectomy done. When she arrived at our medical center she was unconscious, cold and hardly breathing. We fought for four days to keep her alive and, this time, we were lucky. Previously in the medical center children have died from this procedure, either from severe infection it has caused or from blood loss. One of our continual battles is educating regarding this but, unfortunately, most people just don’t think that we understand.
The final practice that I am aware of is called false tooth extraction. Again, this is usually preformed on babies or very young children and it involves cutting into the gum and extracting the four eye teeth or canines. The two explanations I have received for this are that these teeth attract evil, or that they cause illness. Similar to the tonsil mutilation, the most common complications of this are infection and blood loss. This practice, however, is more wide-spread across Uganda.
Superstitions are another issue we battle with and come in a myriad of shapes and forms. We had a mother bring in a severely disabled baby recently but she had been told by the women in her village that, because while she was pregnant and out in the field she had seen a mole come above ground, that was the cause for her babys disability. Because of this belief she refused to take her child to the specialist referral hospital for treatment and took him home where he will likely die.
There is no simple solution. This issue requires a change in how people think, in their beliefs and in areas of their culture. In many ways, as a Muzungu (foreigner) this task cannot be accomplished by me because it is not my culture and it is too easy for me to be dismissed as someone who just doesn’t understand things here. Thankfully our national staff are passionate on this subject – in fact I would hate to be at the other end of one of their lectures on it! Education is not quick or simple solution, it takes time and effort and the progress can be painfully slow but here, in Kisoro Uganda, the process has begun. I hope and pray for its success in time ahead.
Image: A little village by lake Mutanda. Small villages are often very isolated and so older cultural beliefs are much stronger.
One of the difficult things here is to focus on the successes. The difficult and tragic cases stick far more easily in our minds because of those very difficulties, but it’s important that the successes be remembered too. In light of this, I’d like to tell you some of our success stories.
Let me start off with some statistics:
Last month in the Potter’s Village medical center we treated:
– 257 outpatients: These range from anything from minor injuries, home manageable malaria, mild malnutrition, chest infections, skin conditions and gastroenteritis.
– 55 paediatric inpatients: These are the children under 12 who are too ill to be safely sent home. This includes the most severe malaria, typhoid, severe pneumonia, malnutrition, dehydration, meningitis and septicaemia.
– 15 neonates: These are newborn babies brought in for specialist care for prematurity, birth asphyxia, jaundice, respiratory management and poor feeding.
– Immunisations: I can’t tell you how many we see in a month but the numbers are huge. Immunisations are government funded and so free for the community and I can tell you, they have a much better immunisation rate here than in New Zealand!
– 2 abandoned babies: Timothy and Abigale were both abandoned at birth. People have come to know what Potter’s Village does so, when these children were found, they were soon after brought to us for care.
So in a month we have seen, treated and cared for a total of 327 children in this community and rescued 2 babies. Imagine what is done here in a year!
If numbers are not your forte, let me tell you some stories:
Nsabimana is 6 months old. He was brought here by his father because his mother died of TB and his father, having 7 other children, wasn’t managing. Nsabimana also has TB and is only 5Kg. He will be with us for 6 months for treatment before he is reunited with his family. Having been with us only 1 1/2 weeks, he is already much healthier, happy to demand attention from everyone and has put on 500grams!
Stuart is 1 1/2 years old. He came in severely dehydrated having had diarrhoea and vomiting for a week. He wasn’t feeding and has stopped walking. He was floppy and glassy eyed when he arrived and promptly vomited live worms everywhere (a surprisingly common thing!) Diagnosed with tapeworms and Guardia he was treated and three days later was feeding well, alert and up causing mischief!
Milia is 11 months old. She arrived one evening in her mother’s arms unconscious. After doing some tests me found that she had the most severe form of malaria and it had gone to her brain. Treating Cerebral Malaria is very touch-and-go and it was for the first few days. Milia was having difficulty breathing and was only responsive to pain. Almost 9 days later Milia is conscious and breast-feeding. She is still weak but making a slow and steady recovery.
There are many sad and tragic stories here but there are also awesome ones of recovery. Children who are so close to death recovering before our eyes and leaving with a smile (though some still terrified of our white faces!!).
The tragic stories may stay with you more, but please remember our successes. This is what I’m here for, to play a part in these stories both tragic and miraculous and hopefully be a tool by which some of these success stories are achieved.
Sometimes, a day at work here astonishes me. On one fateful day last week the wonderful people that called on the Lacor outpatient stretched my head and emotions in so many directions, by the end of the day I was wondering if it was some form of daydream. Out of the 30 patients seen that day, here’s a little bit about 10 of them.
1) Skin diseases are the bane of most doctors, especially inexperienced ones. If something’s wrong with the heart or lungs, I can manage. The skin on the other hand… What are these spots that were all over her body?
2) As soon as this 7 year old girl walked in, I had my heart in my mouth. I’d only ever seen Sydenham’s Chorea before on videos. Two weeks of strange, involuntary faux break dancing movements was enough to drive her mother spare. Luckily, her heart was OK and the involuntary movements will most likely gradually get better!
3) The next woman has “Foamy macrophages” in her spleen (apparently). Having no idea what this means, I picture a huge pink foamy sponge in the bath. Not helpful for the patient!
4) The lovely old woman smiled at me as she handed me her bone marrow sample result. Like many samples it definitely showed cancer, but couldn’t say whether it was Lymphoma or Leukemia. It was fair enough that she didn’t understand why the clever doctors couldn’t figure it out after sticking a massive needle into her bone. We’re going to send the sample to Italy where hopefully they can shed more light.
5) “Benign hepatoma” was the ultrasound result from a small hospital. It seemed a bit fishy so we took a sample from his liver – He came back today with the heartsinking result – “Hepatocellular Carinoma”, universally fatal here. Discussing terminal illness is hard enough in your mother tongue…
6) The next healthy looking girl came in dragging her right leg. Two days ago ago she suddenly developed a splitting headache and then gradually started losing movement in her right side. Amazingly she could find the 200,000 needed for a brain scan in the capital, so I shipped her out quicksmart. Some things even Lacor can’t handle!
7) Next was a lovely old man who had forgotten his insulin for a week. He was looking very well but his blood sugar was unrecordably high. After having a talk with him about the importance of not missing a week, we kept him in overnight to be safe.
8) Often tragedy is unexpected. One 25 year old guy had a few episodes of swelling in his face and legs over the last year or so. After testing his kidneys over a one month period, we now have to communicate that he is dying of kidney failure, Dialysis is impossible, transplant costs an unfathomable amount. He asks me how long he has got left. How do I answer that?
9) The next woman who came in had a heart trying far too hard hard – I could see it pumping from a mile away. I made the mistake of making her lie down at which point she went blue and nearly passed out.
10) The last patient of the day was a near case of Doctor error. There was nothing much wrong with the guy, seriously – he just had a dry cough for 3 weeks! I asked him to try and cough something up with us, and my awesome diagnosis of “likely benign cough” (facepalm), made way for Tuberculosis! Sometimes it does pay to be cautious – not my strongest suit it must be said.
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Ethics has always come up in health care, but in the past it has not seemed as complicated to me as it has become of late.
I would like to tell you the stories of Rachel and Isaac.
Rachel arrived at an hour old, I calculated her gestation to be 35-36weeks with a weight of 1.52KG. She was born in a hospital but they have no neonatal facilities. Born pale, floppy and not-crying, she was resuscitated and then transferred to us. When I was called to come and see her she was in her mothers arms, pale and cold, not breathing, heart rate low. With the help of our visiting student doctor I resuscitated her with bagging and cardiac massage and put her on oxygen in an incubator. Her temperature rose well, her heart rate was good and strong, blood sugar was fine, but her breathing was still laboured, she continued to grunt.
After an hour her oxygen saturation began to drop and, despite increasing oxygen, it continued to drop, then her heart rate began to drop too. I recommenced CPR and, after 20 minutes of effort, finally brought her back to a point of stability, but I could no longer ignore the issue I faced.
Rachel’s condition of respiratory distress leading to respiratory failure was going to kill her. The only way I could possibly prevent this would be to provide respiratory support in the form of CPAP as oxygen therapy was obviously not enough. We have one CPAP machine and Maureen is on it. Maureen is a tiny premature baby who has been with us for a week, she is fragile but doing well. To remove Maureen from the CPAP would mean her death, but to not give it to Rachel would be her death.
How do you choose who dies? from an emotional perspective? from a logical perspective? When both choices seem wrong, what is the right choice?
Isaac has been with us for a week now. When he arrived he was five days old. Born at home premature, his family believed he would die so kept him at home, they fed him a tablespoon of expressed breast milk twice a day but otherwise left him to die. After 5 days he was still alive, so they brought him to us.
The fact that Isaac was alive when he arrived was a miracle in its self. He was cold and weak and had respiratory distress. On top of this he had a severe umbilical infection, abdominal hernia, distended loopy abdomen and a loud heart murmur. His facial features were abnormal indicating the presence of a chromosomal abnormality. I was certain that Isaac would die in his first day with us, but he defeated the odds, survived and stabilised. He is now stable, his infection settled. He still required 1.5L of oxygen and is tube fed. On assessing Isaac I have found that while he has some natural reflexes, his moro (startle) reflex is weak and he has no suck reflex. His pupils also do not react as I would expect them to. I suspect he may have brain damage.
Isaac has been unable to cope without oxygen, he is feeding through a nasal gastric tube as he cannot suck feed. If we can wean him off oxygen he can go home tube feeding but without health care readily available for severe disabilities he will likely die in the months ahead. If we cannot wean him off oxygen he will be unable to survive outside of our medical centre.
In God’s eyes all life is precious, no matter the age, condition, ethnicity or context. Both Rachel and Isaac are precious in his eyes.
As much as these decisions torture me, I think God would be glad they are torturing me because it means that Rachel and Isaac are precious in my eyes too. The day these decisions become easy is the day I should walk away, because then I will no longer care.
God give me the strength to do everything that I can, the wisdom to make the decisions that I must and the comfort of your love to cope with the consequences.