Why life is good, as explained by taxis

In case I gave the impression that life here is only sad, frustrating, and desperate - which would be a fair summary of the last 2 posts - I want to set the record straight:

Life is good.
Uganda is fantastic.
Kampala is one crazy city!

First, why life is good.

People here are nice. Really nice. I am constantly amazed by the goodwill, generosity, and openness of Ugandans. I don't have to think back very far for some examples.

The Kampala taxi park, which is cool to watch from afar in the day but not so fun when you are lost at night

Two days ago, I found myself in the kind of situation that new travelers are warned against - female, alone, in the dark, wandering through a taxi park that is famous for thieves. Good one, Mara. Luckily, as often happens when lone humans make stupid decisions, humanity came to the rescue. A driver noticed my predicament and assigned me to one of his deboarding passengers, a woman named Jesca. Jesca took my hand, and in so doing accepted full responsibility for me. She led me through the dark maze of taxis, over puddles, and around pocket-pickers. She helped me find a private taxi and negotiate a price. On the x-ray folder that she was bringing back from the hospital (it was her own x-ray, for her broken hand - at that moment I wished I could be an orthopedic surgeon and fix her, as thanks for rescuing me!), she had me write down the driver's license plate number. Jesca promised to track him down if I did not call her phone when I arrived at my destination. With a stern nod at the driver, a gentle goodbye for me, and a flourish of her good hand, she disappeared into the dark. My hero. And all she asked of me was to let her know when I had arrived safely!

(Epilogue:  Not surprisingly, the driver was a good guy. As we waited out a traffic jam for over 30 minutes, he taught me Luganda, crooned country music songs, and asked me to interpret the more cryptic lyrics. The traffic jam was actually FUN.)

Today I was feeling tired and worn out after a busy day downtown (and by that, I mean that downtown was busy, and I got wrapped up in it - even if my only agenda was to eat lunch, the process of weaving through the crowd while trying not to fall into a gaping sidewalk hole was exhausting). When I boarded a shared public taxi for home, I didn't want to socialize at all...just get me home, and find me a glass of cold water... But somehow, as seems to happen, I started talking with the woman next to me. Before I knew it we were exchanging life stories. She is Ugandan, and after working for 20 years as a social worker in the UK, she was delighted to retire back to Uganda. Of course - she grinned, this is HOME. Since she had a bag of oranges in her lap, we also discussed our shared passion for the "vite-ah-mines" in citrus fruits. When the taxi swerved to a halt at my stop, she pushed an orange into my palm. When I stood (more like crouched) up, she stuffed more oranges into my jacket pockets. I have to say, they smelled divine, but still I tried to stop her. No luck. My pockets bulged as my heart swelled. I arrived home with a lighter step, carrying 4 wonderful oranges to remind me of one more of life's extraordinary ordinary moments.

I realize that these stories have a lot to do with public transportation. Well, that's no mistake. I am kind of obsessed. In my opinion, Uganda's shared taxis (sometimes called matatus) are the most fascinating, heart-warming, not to mention cheap-as-dirt mode of transport. These 14-seater minibuses are recognizable by a necklace of blue painted squares on the outside, worn crushed velvet interiors, and constant honk/stop/start motion. Each one is run by a pair of guys:  a driver, expertly straddling the line between road caution (much more than boda-boda motorcycle men) and expediency (okay to detour through petrol stations and mount sidewalks), and a conductor, hanging out of the back window to recruit passengers, manage money, and open/close the door. Thousands ...thousands? okay maybe hundreds, but it feels like thousands... of taxis circle the city on the major roads, taking people to work, lunch, or home for anywhere 200 to 1500 Ugandan shillings (0.07 - 0.53 USD).

My daily taxi rides introduce me to so many interesting people. Even on the less social rides, I get to observe a group of strangers working together. I marvel at the constant shuffling of seats. How children are lifted in and out with a smile. The way that fares and change are passed back and forth, between passengers and conductor, and how everyone accounts for everyone else. When you get on a taxi, it's like joining a team. Your common goal is to get ahead - faster, cheaper, safer. A noble quest. An entertaining ride. And the best part is - it actually works (uh, just hope the door doesn't fall off).

OBVI I'm going to be a matatu for Halloween! Can't wait to post photos of how idea this works out...

it’s sad that d guy went 2 mulago is dead.

Alternative title:  "Patients get sick on the wrong days."

These are stories of recent deaths in our study. Sometimes there is nothing you would have done differently, and still the patient dies. At other times there is so much you could have done differently, if only the system had allowed. Regardless, all bad outcomes – inevitable or avoidable - are tragedies that I can’t, won't, and hope I never do forget.

1.

The guy who went to Mulago was a friend of mine. One of the few English-speaking subjects in our study, he became "my patient." I interviewed and examined him:  young face, easy smile, strong muscular body. The only worrisome finding was his skin, which was dotted with dark itchy spots, a classic sign of AIDS (advanced HIV). We talked about his work as a schoolteacher, his hobbies, and his family. I met his wife, a beautiful and smart woman in her 9th month of pregnancy. At the mention of his growing family, he beamed a big smile.

Bad news came at our next visit, 2 weeks later, with results from the lab – his blood was positive for cryptococcal antigen. Cryptococcus is a fungus that affects people with very poor immune function. The blood infection alone is treatable with antifungal tablets (for life), but it's much harder to treat if the fungus spreads to the central nervous system. When this happens, the fungus wreaks havoc on the membranes surrounding the spinal cord and brain, which is called cryptococcal meningitis (CM). CM is quite deadly – 60% die if not treated. With this patient’s positive blood test and complaints of a new nagging headache, we needed to check for meningitis. I helped put a needle into his spine and draw out fluid. This time, worse news – his spinal fluid was floridly positive for cryptococcus. That same day his pain increased, and his condition worsened. He was having trouble walking. All we had to offer at the rural site was oral fluconazole, which could not adequately penetrate the central nervous system; he needed to go to the Mulago hospital in Kampala for 14 days of intravenous amphotericin B. Only then would he have a chance of survival.

With the gold standard medication running into his veins, daily doctor's visits, and around-the-clock nursing all lined up in the biggest referral hospital in the country, I thought the my patient would do great. Besides, he was young, strong, and optimistic! My Ugandan research twin was less sure. She told me that if he could survive these 2 weeks in the hospital, then, yes, he would be fine. …But only IF.

We made a point of visiting my friend at Mulago whenever we were in Kampala. On day 2 of IV ampho, he looked sick but better - he had been able to eat and drink some, and even slept without pain at night. On day 5, he was in high spirits. "I finally feel that I'm going to recover. I am at peace now!" he told us. And let me tell you, he looked fantastic. On day 9, we found him surrounded by a worried team of doctors. A persistent cough had come on suddenly the night before, and not gone away. Now his rapid, shallow breathing and low oxygen levels pointed to a serious lung problem. What was it? Did he get an infection from a neighboring patient, have fluid in his lungs from all the intravenous infusions, or develop a blood clot from lying in bed that had traveled to his lungs? A focused physical exam and chest x-ray confirmed infection. (As you can imagine, infections are an extremely common - and morbid - outcome of hospital admissions for AIDS patients.) Our patient was moved down the hall to an "intensive care" bed, which was basically the same plastic mattress and rusted frame, with the addition of a nearby oxygen tank that he shared with 4 other patients. The low-flow oxygen coming into his nose did nothing. (Please note that the diagnostics were strong but the resources to treat were lacking. My twin laments, “we [Ugandan doctors] learn to diagnose, then watch people die.”)  I hoped that my friend would make it, but the frightened look in his eyes told me that he knew better. The doctors' faces also gave me no more hope. On day 10, I got the text, it’s sad that d guy went 2 mulago is dead. In just 4 days, he would have walked out of the hospital to see his wife and newborn baby. Instead he had become, as one visiting doctor put it, "just another unexpected death at Mulago".

It's hard to know what might have saved this man, but I wonder how little it could have been. A full oxygen tank, a private room, or an earlier screening test for CM come to mind. At the same time, I know that we did everything possible given the resources at hand. Despite appropriate screening, quick follow-up, and fast and effective therapy, some patients will still die. Perhaps his death was not avoidable in this reality. And yet,

For my patient:  to dodge a deadly brain infection, only to be killed by the process of the cure –

For the Ugandan health care workers:  to love medicine, care for patients, pour heart, mind, and soul into your work, only to feel defeated by the system you work for –

For me:  to follow guidelines, offer hope, and provide a treatment, only to wonder if you really helped at all –

– can you think of anything more tragic?

2.

The patient who got sick on the wrong day was semi-conscious by the time we saw her, on Tuesday. Obviously she hadn’t gotten the memo:  DO NOT get sick around the weekend! There will be no doctors in the Kiboga hospital for at least 2 days! Her fevers and headache had started on Monday, and by Friday had turned into seizures and loss of consciousness. Another deadly brain infection. She was admitted on Saturday with known meningitis. Then, for 3 days, she lay in the hospital bed. She suffered frequent full-body convulsions and started frothing at the mouth, and was rapidly losing the ability to speak, swallow, or respond to voice. Aside from the nurse who kept a close eye on this patient’s deterioration, there was just her brother to stand stoically by her side and the less-sick patients to watch her go downhill. The doctors were not in. Maybe they had accepted defeat a long time ago.

Our study nurse told us about this patient on Monday, over the phone. After hanging up, my twin looked at me sadly and said, “Oh, patients get sick on the wrong days.” We traveled to Kiboga extra-early on Tuesday in order to see this unfortunate patient before our study clinic opened. From car to ward to writing orders, it felt like a split-second before we had tested her blood, checked her spinal fluid, and started drugs for a long and scary list of diseases (until the lab results came through):  bacterial meningitis, TB meningitis, cerebral malaria, and of course CM. Hopefully it wasn’t too late. If only a doctor had done rounds on Saturday, Sunday, or Monday… If only she had gotten sick on a Tuesday... If only there were no wrong days…

After about 1 hour, the blood and spinal fluid tests came back positive for CM. In 3 years of medical school in the U.S. I never saw a case of CM, and now I had diagnosed 2 in 1 week. Believe me, there was no intellectual satisfaction; all I could think was, what a horrible epidemic. The next terrible feeling came when we had to decide on a treatment plan. Having just learned of the other patient’s death, I didn’t have a lot of faith in the “best” therapy. In fact, I kept thinking that 60% mortality if left untreated means 40% survival if we don’t try to mess with it… But, at the same time, we have to rely on pooled data in medicine lest every decision become an emotional reflex to the last patient we saw. The gold standard of care for CM is IV ampho for 14 days, and that’s what she needed. So we prepared to send another patient off to Mulago, this one much sicker than the last.

With a diagnosis and a plan, the gears were set in motion. We confirmed that there was IV ampho in stock, and that it would be provided at no charge. The patient’s family consented to sending her to the city. We found an ambulance, with a driver who showed up promptly and didn’t overcharge us for fuel (normally the patient's family would have to pay). The patient was still alive when the ambulance arrived in Kampala, and her med infusion was begun. Regular phone calls to her family told us that she survived the first day and night. Everything seemed to be going well. Cautiously, we found some scraps of hope. The possibility of survival to believe in. But I remembered the "IF" of IV ampho - one must hope for the best, prepare for the worst.

When day 2 rolled around and we got the phone call that the patient had died, I was not surprised. I had seen a much healthier patient succumb to the dangers of CM treatment. My shock was replaced with anger and frustration, when I thought about all the delays in her care. If course it’s impossible to know what might have led to a different outcome, but I’m pretty sure that an earlier exam, diagnosis, and treatment would have significantly improved her odds. Tragic - yes. Avoidable - maybe. This means that we might have been able to do things differently. Strange, but somehow that gives me hope. 

This week we have a meeting with hospital administrators to discuss the lack of doctors in Kiboga on the weekends. Maybe her death will not have been in vain. Maybe one day, there will be no wrong days to get sick.

No milk, no sugar, no service

Milk was the first to go.

The tea stations at work stopped stocking milk right before my arrival. People told me it was because of the budget. Yet I couldn't understand how cutting out tins of powdered beverage could possibly have an impact on the budget of a major research institute - unless we were talking about symbolic impact. Then yeah, okay, maaaaybe.

That’s what I thought, until I learned the actual cost of last year's milk supply. I won’t quote the exact figure here, but let’s just say it was high enough to give the accountants a headache (and, if actually consumed on the job, every single employee a serious stomachache). So obviously the milk had been feeding more than just the research staff. Spoonfuls…cupfuls…tinfuls of milk had poured out of the research center every day and into the mouths of workers’ friends and families. You see, even at a well-funded research center where people have decent salaries and official job contracts, personal budgets are tight. You have to take what you can get.

This is a very common problem in the research centers and hospitals where I work (and, I assume, almost everywhere in Uganda). I have learned so many euphemisms for disappearing items:  chairs "walk", binders "get lost", mugs "go home early", and laptops "grow legs". Milk is just one example. Photocopy paper is another – this is why I spend 2 hours per week by the copy machine as our 500 pages run through. On guard, ever vigilant. Just in case the tray might "empty itself" before our work finishes.

((Did you know, it’s a new evolutionary biology paradigm? Anything of value can grow legs and learn to walk!))

Next went the sugar.

Sugar is a hot topic in Uganda these days. Sugar prices have been volatile for the past few months, but the general trend is UP - a kilo that used to cost 3000 Ugandan shillings now costs about 7000. (Incredibly, soda prices have remained constant. Wide profit margin, you think?) Most food items cost a little more than before, but nothing matches sugar for price hikes and unpredictability.

If you haven't heard, President Museveni is now proposing (threatening?) a solution to the sugar problem. He wants to sell 7,100 hectares of the Mabira Forest Reserce to a nearby sugar plantation, which would then be able to produce more of the sweet stuff. However, there are many controversies with this plan:

• Environmentally:  Museveni's political advisors, the opposition, and the general public want to protect the forest. Museveni says that he is only selling the "damaged" land, but surveyors have failed to find evidence of such damage. Mabira is one of the few protected forests in Uganda, and it would be a shame to lose it – especially on the basis of false data.
• Politically:  Museveni has been discouraged from going through with the sale, but still he insists. This historically diplomatic leader seems unwilling to listen to others. There was a big to-do when a senior presidential advisor called the President an “autocrat”. Tensions continue to rise between Museveni and his administration... Could this be a sign of an aging, less agile, more extreme leadership in Uganda?
• Economically:  Sugar is small beans compared to the inflation problem in Uganda – the rate of inflation has risen from 6.4% for the year ending February 2011, up to 21.4% for the month of August 2011. The last time the Ugandan shilling performed so poorly was in 1993, in the post-Amin years when guerilla warfare, child soldiers, and the Lord’s Resistance Army held reign over the land. So sugar production may not be the real concern. Some onlookers think that all this fuss is just a decoy from the failing economy. I don't think that insufficient sugar supply explains the fluctuating prices, and I don't think that increasing production will solve the problem.

In the meantime, children have started bringing their own sugar to school. Perhaps we should check the sugar budget soon – we may find that sugar crystals have learned to walk.

Finally, the service.

Last weekend all mobile phone companies increased their rates, by as much as 30%. In a country where most people use mobile phones, this has had a noticeable effect on communication. People now “flash” dial more than ever (instead of waiting for someone to pick up, they hang up and wait for a return call). Conversations are shorter. Texts are reserved for the off-hours. And, when you have time to chat in person, there is endless discussion on what caused the rate increase.

Obviously the economy is hurting, and companies are trying to recoup their losses on a failing currency. But I have also heard that the President holds stock in all the mobile phone services (as well as the sugar industry), and he has forced up the prices in order to make money for himself. Honestly, I don’t know what the truth is. But it's clear the Uganda is in bad financial straits. It's anyone's guess which commodity will embody the struggle next, but I'm certain that "no milk, no sugar, no service" is not the end of it.

ROTW (4): When you have too many eggplants, Part 2

I call this one "Eggplant Jazz". Just keep adding and improvising to last night's tune, and if you're lucky you'll have a brand new jam that both soothes your soul and makes you wanna dance!

Isn't life without recipes FUN?

Ingredients
1 cup leftover stuffed eggplant, 1 can diced tomato, 6 cloves garlic, 3 tbsp olive oil, 2 tbsp cinnamon, 1 tbsp oregano, 1 tsp parsley, 2 tbsp honey, 1/2 cup green olives, dash lemon pepper, salt and black pepper to taste

Instructions
1. Saute sliced garlic in olive oil
2. Add the eggplant and everything else, as you find it around the kitchen...
3. Let simmer for at least 15 minutes
4. Serve over butter-garlic-parsley spaghetti

We paired this dinner with Kitara Red, a Ugandan wine with an exciting list of ingredients. It is made from the fruits that are bountiful here (sorry Toto, we're not in Bordeaux anymore):  pineapples, tomatoes, mangos, and passionfruits. You can imagine how curious I was to taste it! The Kitara was smooth and surprisingly tasty, but quite sweet. The pineapple base was most apparent. Given the relatively high alcohol content, I'm going to propose that the makers call this beverage "Cocktail in a Bottle" - a more accurate name, and way more likely to fly off the shelves at the local grocery store!

ROTW (3): When you have too many eggplants, Part 1

Bad experiences make good stories, right?

Instructions
1. Read this NYTimes recipe
2. Be delighted that:
   a) all the ingredients can be found in Uganda (unlike this heartbreaker), and
   b) it calls for a stove, not an oven (good for those "without power" nights)
3. Ignore words like flameproof casserole dish and flame tamer on the stovetop
4. Proceed fearlessly
5. Smell the burn
6. Hear the POP!!!
7. Find pieces of exploded casserole dish and eggplant all over the stove and kitchen floor
8. Scrape, salvage, serve what's left. Piles of fresh tomato, avocado, cilantro, and homemade yogurt do wonders to cover up the sorry-looking main dish

Flame tamer - maybe not so optional?

I am reminded that the French for "experiment" is experience. This was, I guess, a good experience.

ROTW (2): Chapatis, made right

Everyone has that one dish that they make so expertly themselves, they have no interest in ever trying it away from home. It could be a fresh-ground morning cup of coffee, your Kraft mac-n-cheese, or that family recipe for matzo ball soup. You know what I'm talking about.

Enticing chapati, to which I did succumb
(Ggaba, outskirts of Kampala, on Lake Victoria)

Anyway, my "twin" has this thing about chapatis. Fresh and incredibly delicious chapatis are sizzling on almost every street corner in Uganda (see exhibit A above), and she doesn't even sniff in their general direction. Meanwhile, I am drawn to them like a mosquito to my ankles! That's how I came to realize that I had to find out her recipe.

So, I here present you with the secrets to making a most superior chapati:

Ingredients
1 cup warm water, 1/2 packed cup grated carrots (or grated coconut, onions, or some other flavor of your choosing), 1/2 tsp salt, 3 tbsp oil (or ghee...mmmm), 2-3 cups wheat flour, lots more cooking oil

Special equipment
rolling pin, hot skillet (preferably cast iron)

Instructions
1. Soak carrots in warm water
2. Add salt to taste  - it should taste just a little too salty at this point, since this is going to flavor the whole dough
3. Add oil to look

Oil - this is what makes the chapatis soft, but not too soft! I know it's not the most gorgeous photo, but I wanted you to see what I saw - the precise science of adding just enough oil for the oil droplets to barely cover the surface of a shallow mixing container

4. Gradually add the flour - first turn with a spoon, then with your hands. It is ready when the dough is soft, springy, and no longer sticky
5. Roll the dough into a rough "baguette", cut into 8 chunks, press into small discs, then roll out each disc into a chapati about 8'' in diameter - keep them about 1/4'' thick, since you want nice, chewy chapatis that you can maneuver through the cooking process
6. Heat your skillet over medium flame, then roast each chapati til bubbles form on both sides. Set aside

Roasting - I am told that this is they key step in making a great chapati, for it brings out the carrot/coconut/onion flavor. Just like some greedy person in the shadows of this photo (who IS that?), you're going to want to eat them right now, but hold on for one final step

Seems pretty healthy so far, right?
Well.
That is about to change.

7. Heat about 1/4 cup oil on the skillet til smokin'. Lay down roasted chapatis 2 at a time so the lower side sizzles while you smooth over the top side, adding oil between turns and flipping every minute or so til you have nice big brown bubbles on both sides of all chapatis

 Frying - apparently the top chapati is very important to the chapati below. First, it keeps in the moisture; second, it applies even pressure. You can also use a spoon or your hands to press down 

Chapatis - (left) fried, finished, ready for feasting; (right) roasted, waiting for a hot oil bath

8. Keep chapatis covered until ready to eat. Then, DEVOUR THEM ALL! These are particularly yummy with just about anything, but beans and eggs are the most common pairings here. Avocado good, too.

Our dinner of chapati and white beans

Without power, but not powerless

What do you do when you walk into work and find a large mass slumped over your desk - rising, falling, shuddering - - - a body?

You wipe the sleep from your eyes, for the 2-hour journey from Kampala is over, and you think to yourself, Welcome to Kiboga.

I remembered seeing this teenage boy (one of the participants in our study) the week prior. At that point he had come in for extreme fatigue, with blood counts so low that his tongue and palms were white as chalk. We diagnosed him with AZT-induced anemia, which is a rare side effect of AZT (stands for zidovudine, one of our first-line anti-retrovirals). In unlucky cases like this one, AZT stops the body's production of red blood cells. The resulting anemia is often severe and sometimes fatal, but it can be reversed by stopping the medication. Unfortunately, despite changing this boy’s regimen 7 days ago, the AZT had lingered in his body and continued to bring down his blood counts. Now he could hardly stand up. To make matters worse, when we placed a needle in his vein to draw a blood level, he started vomiting. Projectile yellow muck - all over himself, the chair, and the clinic floor.

What do you do when you have a super sick anemic patient?

You make an urgent order for 3 units of blood. (His hemoglobin came back at 3.5 - for reference, normal is above 12.5, and many clinicians would consider this value "incompatible with life".) Sadly, you are told that blood is in short supply (3 units total in the hospital) and only 2 units can be spared; the other must be saved in case any one of the 200-300 patients in the waiting area and wards needed it. So you find a volunteer to carry your young patient to the ward, and you hope for the best. Welcome to Kiboga.

And, what do you do when you have vomit all over the clinic?

You ask for a janitor. Sadly, the janitors are missing. Someone tells you that it was hard enough to get them to sweep a clean floor this morning - let alone help with a dirty one now. Your intrepid study nurse and community health worker take matters into their own hands and go on a search for cleaning supplies (almost as hard as finding a janitor), then clean up the mess themselves. All this, before clinic even starts. Welcome to Kiboga.

Kiboga is a town of 16,000 people, about 120 km northwest of Kampala. For this research project, I will be spending half of each week here with my Fogarty twin. We come up on Tuesday morning, work for 3 days, and return Thursday night. Eventually I'm going to get used to the aspects of work and life here that make it so interesting, frustrating, and exciting. But before that happens, let me record a few early observations:

Kiboga District Hospital

1. The Kiboga public hospital takes all comers:  healthy (rare), sick (many), rich (none), poor (all), and even animals (as residents, not patients). I would say that there are more chickens than doctors in the hospital. Infinitely more, I should say, because isn't it true that any number divided by zero equals infinity? Yeah, that's right, ZERO. I have yet to meet a doctor here (except for those in our research team), even though the government employs 4 of them to work in the hospital full-time.

Chicken at the back door

2. Health privacy exists at a minimum. The study clinic is set up for interviews to be conducted 2-at-a-time in a shared room, with physical exams behind a screen - however, we often have so many patients that exams have to be done out in the open. For a generally modest society, it’s remarkable that patients are comfortable baring their breasts, exposing their rashes, and revealing their pain in front of anyone who happens to be in the room. The upside is that there is a tremendous amount of camaraderie among the patients. I hear constant pep talks taking place in the waiting area, and patients share rides to and from clinic. It's a case of confidentiality down, community up.

My research "twin" and the study nurse, hard at work in our office/clinic
(Obama's got our backs)

3. The shared space does allow for some amazing clinical experiences on my part. I was the first to feel a patient’s swollen axillary lymph nodes, signs of likely lung infection or breast cancer. I inspected an invasive mouth cancer, a thick fungating mass on one side of a woman’s tongue. The smell was so bad that the whole room smelled like rot whenever she opened her mouth – I had never smelt a cancer before. I held the hand of an AIDS orphan, who came by (alone) after school to get treatment for her infected salivary glands. She didn't flinch when we stuck a syringe into her cheek and sucked out 10 mL of fluid, and she just bowed her head in acceptance when we asked her to come back for another poke next week. I talked with a woman dying of AIDS. Young, emaciated, beautiful, in a wheelchair pushed by her robust but wrinkled mother, she embodied more paradoxes than that Alanis Morisette song, “Hand in My Pocket”.

I didn't photograph our patient, but here's another chicken
(I'm beginning to think we should have a poultry immunization program)

4a. It is inspiring to see how much a doctor at a desk, with a stethoscope in one hand and a pen in the other, can do for a sick patient. Medication prescriptions, counseling, and continuity of care keep a lot of these patients alive – even well. At the end of a clinic day, small bags of groundnuts, tomatoes, and sugar cane left behind by our patients show their gratitude for these free services.

4b. On the other hand, it is upsetting to admit that good intentions and years of medical training sometimes cannot overcome the systems issues. Yesterday our doctor performed minor surgery in the clinic - cut and drained spoonfuls of pus from an abscess in a young lady’s leg - only to stop at the point of closing the wound. We didn’t have sterile gauze. How do you keep an opening from getting re-infected, if you can’t pack it with clean material? We searched high and low and thought of many possible replacements, but there is no substitute for a little 4x4 inch square of cotton that comes in a sterile wrapping. Probably costs pennies; I know we throw out handfuls of them in a single procedure in the States. But that didn’t help the lady with the hole in her leg. Eventually the doctor just leaned back on the paint-chipped wall, her bloody gloved hands held high, idle, unable to properly finish the job. It was the look of defeat. We ended up putting on a loose bandage and sending the patient home with antibiotics, to fight the infection that almost surely would come back.

...This reminds me. I haven’t even mentioned that the hospital operates with no running water, power about 50% of the time, and intermittent network access for internet and faxing capabilities. Thank goodness for bottled water, fire, batteries, cell phones, and wireless USB sticks! Some combination of Stone Age and Digital Age inventions keeps this place functional.

5. Outside of our clinic space, a few formidable personalities run the entire hospital. There is one extremely maternal nurse – big-bosomed and big-boned, with a white cap perched on top of her head, just like you would like to imagine her! – giving those motivational speeches in the waiting area. Her most recent topic was couples treatment, with a message directed at women to bring their husbands in for care. (Women outnumber men in ART clinics because they are more willing to seek treatment, but they often have to come in secret. I am told that a husband may blame his wife for his HIV infection if she suggests that they need treatment. Furthermore, if she or her husband has multiple partners, she may be constantly exposed to different HIV strains and at risk of developing medication-resistant infection. If she asks her husband to use condoms, he may accuse her of infidelity - even though the man is MUCH more likely to have multiple partners. And remember that most of the women are completely dependent on their husbands for financial and social stability, so it's not so easy to go against his will. The result is that many of the women - even those who are married, sexually monogamous, and on ART - remain in very risky sexual relationships.) There is one palliative care worker, an old man who recently realized his passion for this work and got certified, who can be found carrying meals and smiles to the bedridden. When he has free time, he sifts through the waiting patients to bring the sickest ones to our attention:  starving babies, a schoolgirl failing ART, a possible malignancy. And, of course, I have to get back to the research group. Our team of 6 manages hundreds of patient files, knows each subject individually, and bravely cleans up vomit when no one else will do the job. I am ever impressed with their sense of purpose (and sense of humor), hard work, and both practical and people skills.

Outside the hospital, Kiboga town awaits. See, it has the look and charm of an extended rest stop:

Very average roadside view

Into the jungle

There are about 100 tiny shops (well, mostly bars) situated along the paved road (that connects Kampala to Hoima, an oil town 70 km farther northwest), plus a few guesthouses and a hospital. Rough dirt roads snake down the main road to a row behind the shops, past a few residences, and into the jungle-ish forest, where most of the people live in villages. Green rocky hills circle the horizon, and a huge sky spreads overhead. I don’t know why – maybe it’s the low man-made structures, or could it be my enhanced sense of isolation? – but the sky just feels SO BIG here. Looking up, I think I can see different cloud formations at every layer of atmosphere, from thick whipped cream peaks blanketing the hills to wispy strands reaching for the sun. 

View from the balcony of my bare-bones guesthouse in Kiboga

When I snap out of my celestial wonder, the main road offers a parade of sights. There’s a man single-handedly rolling his truck to the nearest fuel station, since he ran out of gasoline 1 km back. Then, look, a motorbike with 2 live sheep (large! the size of small cows!) strapped on back. And finally, always, a gaggle of kids who find me much more interesting than the hills, sky, and traffic that so fascinate me. My soundtrack through Kiboga is a chorus of “Mzungu, hi! Mzungu, bye!” as they chase and follow me down the street. I feel a little ridiculous, a little celebrity, a little Pied Piper.

Even though “Mzungu” can be/feel pejorative (especially when barked by grown men sitting in in the shadows of Kampala), the Kiboga kids’ song is not unfriendly. Full of smiles, it is a joyous and innocent tune. Like everything else – at first strange, now it is growing on me. Though I'll never quite blend in, I believe that I can start to feel at home here. Yes, really. Welcome to Kiboga!

Now that I’ve written too much, let me wrap up the night in my favorite Kiboga fashion. I am off to devour a passionfruit (or four) for dessert, then retire to my dark (generator off) quarters, hours before a normal bedtime. Oh, this complicated and simple life!

Sulabulungi.