Global pulse, photo essay

Just in case you are interested, some of the pictures I took during my last trip to East Africa were recently published in "Global Pulse," the American Medical Student Association International Health Journal.

The web address is: http://www.globalpulsejournal.com/

Scroll down to an article entitled: An African Essay.

shock, anger, blah

Yesterday I was filled with the most shock and anger I have experienced during this trip to Uganda.

Soon after arriving at the delivery ward, the third year medical student asked me to assist her for a delivery. I helped prep and got a clean sheet ready for the baby. The third year student did an expert job of delivering the baby. This was the young mother's second baby and she didn't tear at all. I helped hold the baby on the mother's stomach while the third year student tied off the umbilical cord. The baby was very healthy and beautiful baby girl and she let out several strong cries immediately after delivery. After the cord was cut, we showed the sex of the baby to the mother. One of my favorite parts of delivery is when you show the baby (including the sex) to the mother and she gets a huge grin across her face. However, when we showed the baby to this mother she glanced at the baby and looked away in absolute disgust. Confused, I tried to show her the baby again and said, "Congratulations mama! you have a beautiful baby girl!" The mother continued to look away with contempt and refused to look at me or her child. Still confused I took the baby, weighed her, cleaned off her face, examined her toes and back, etc. She was looked perfect - she had all her toes and fingers, she was actively moving and breathing/crying very well. I wrapped the baby up in several sheets and went back to the third year student to ask what was going on. The third year student told me that the mother doesn't want the baby because it was a girl. The young woman's first child was a girl and she wanted a boy because their family needs a male child. The third year medical student then spent about an hour telling me of how common a problem this is. Many women, if you do not show them the sex the the child and get a witness will later accuse the staff of replacing a "less valuable" female child with the male child they claim to have delivered. Apparently, boys are seen as a way to wealth and security, but girls are seen more as a liability in some aspects of Ugandan culture. It was so sad. This beautiful baby wasn't wanted because she was a girl.

I asked the third year student what we were going to do. She said that there really isn't anything you can do besides give the baby to the mother and hope she will care for it. The third year student said that she would hope that mother would have some counseling and someone would make sure she wasn't suffering from post-pardum depression, but the facilities/resources just weren't available there. After the woman was cleaned up we placed the baby next to her. I watched in horror as she apathetically stared at the ceiling while the baby screamed next to her and she made no attempt to console or breastfeed it. What is wrong with the world? Something seems so inherently wrong in a mother not wanting her newborn baby. I calmly tried to maintained my self control despite the feeling that if I could shoot lasers from my eyes everyone in the room would be a singed skeleton, and talked to Annie over lunch. It is great that we have each other to talk to!

Unreasonable fear

This week was awesome. I asked to be placed in the delivery ward of the hospital for uncomplicated cases (there is another ward where complicated cases, such as breach presentation, hypertension, twins, etc are referred) with the hope that I might be able to assist in some deliveries and perhaps deliver a baby (supervised, of course) at the end of the week. The week was by all accounts a success, but it was definitely stressing at times. I got to watch so many births. There weren't any doctors in this delivery ward, but there were about 5 or 6 midwives and a third year medical student. About a couple hours after I arrived in the ward, the third year medical student let me watch while she delivered a baby. She was really good about explaining every step and helping me understand why they did things certain ways. Apparently, one of the most important things to do during the delivery process is to give a shot of oxytocin within 1 minute of the delivery. The third year medical student also taught me how to deliver the placenta with continuous cord traction. She also taught me the basics of delivery and how to minimize tearing and what position to hold the baby. Did I mention it was amazing?

The delivery process itself is surprising fluid-involved. By "fluid-involved" I mean that every fluid that could possibly come out of your body comes out during the delivery of a baby. [Warning: Don't read if you are eating lunch]. First the expectant mother must urinate and empty her bowels to allow maximum room for the baby to descend. The delivery process may or may not be accompanied with vomiting from the mother. Then the delivery itself is accompanied by large amounts of blood and amniotic fluid. Profuse sweating also takes place by the mother while she is pushing. The baby usually defecates as well sometime during the process, making the circle of bodily fluids complete. However, despite these many possibly offensive odors, I found the delivery ward a surprising pleasant place to spend time in and birth a miraculous processes.

Anyway, sorry about my rambling. You might be wondering why I have entitled this entry, "Unreasonable fear." I have entitled the entry thus, because of an experience I had on my third day in the delivery ward. Early on in the morning, a midwife assigned me to monitor a woman who was HIV positive and on HAART (Highly Active Anti-Retroviral Therapy). I looked forward to monitoring this woman and possibly being present while she delivered. I was not concerned about her HIV status as many women in the ward are infected with HIV, and just noted to myself to be extra careful to wear double gloves anytime I had to contact bodily fluids.

A couple hours later, the woman in the bed next to my patient started pushing and a midwife told me to quickly draw a syringe of oxytocin. The oxytocin are in little glass vials that each contain 1 dose of the medication. The women bring their own gloves, cotton, syringes, plastic sheets to deliver on and clothes for the baby. I quickly got a dose of oxytocin from the supply cupboard, put on a pair of clean gloves and used a piece of cotton to break open the vial of oxytocin. Then I opened a package with a sterile syringe and needle. However, while I was trying to un-cap the needle I accidentally stuck myself with the tip of the needle. I instantly froze and my pulse went up to about 250 beats per minute as I started to feel a small trickle of blood go down my finger inside my glove. I was so scared. I had just stuck myself with a needle! It didn't matter that it was a clean, sterile needle and my hand was clean and covered with a clean glove. All the secret fear of a needle stick came to me in a flood. What if I had just finished giving the injection to my HIV positive patient when I accidentally stuck myself? For the first time since Annie's blood-splash scare, I was glad that the UW made us bring HIV prophylaxis with us. I took a couple deep breaths, and then dropped the contaminated needle/syringe in the sharps container. With slightly trembling hands I successfully filled a new syringe with oxytocin and handed it to the midwife. I then excused myself and washed my hands about 5 times and called Annie (who was rotating in endocrinology) and asked if she wanted to have lunch.

During lunch Annie was really nice about listening to me and was very reassuring when she told me that a needle stick with sterile needle into a clean gloved finger is actually safer than cutting yourself in the kitchen with a knife. I am now fine and completely calm. It was just rattling to realize how easy it would be to stick yourself with an infected needle.

The week's tally...

Whew! I just finished one of the busiest weeks so far during my visit to Uganda. I spent this week in the obstetrics ward for uncomplicated deliveries at the large hospital in Kampala. It was tiring, but so much fun. I have a lot of good memories from this ward that I will share shortly. I just wanted to give you a summary of my week to start off the entries:

Deliveries observed/assisted on: 13

Guided deliveries (a midwife put her hands on top of mine): 1

Unguided deliveries: 2

Placentas delivered: 4

Newborn babies named after me: 1

Scary experiences: several

Adrenaline rushes: countless

A Green Mamba Story

As Annie and I were leaving Kumi we saw one of the most poisonous snakes in East Africa - the Green Mamba. It is a thrilling tale, but unfortunately I don't have any pictures to accompany my story so I have taken one from the Whozoo website in addition to some interesting facts.

Green mambas are very poisonous but are less aggressive than their relatives, the black mambas. (Black mambas will hunt you down if you make them mad and they will probably be successful in their attempts to kill you as they can travel as fast as a human can run, climb trees and swim). Anyway, green mambas don't get upset as easily but they are still very dangerous. There was a joke in Tanzania that the "medicine" for a green mamba bite is this: you see that you have been bitten by a green mamba and then you get out a piece of paper and and a pencil and write a quick note, "Mom and Dad, I love you." You then have just enough time to put the piece of paper back in your pocket before you die.

Back to the story: Annie and I had just packed our bags and were taking two motorcycle taxis to catch the bus when Annie's motorcycle, which was riding in front, swerved drastically on the dirt road. Annie asked what was going on, and the driver said something about not to worry because it was "a green one" and the motorcycle didn't hit it. My motorcycle also swerved to miss a 5-6 foot long snake that was bright green. The motorcycle driver told me it was a green mamba and that they are, "Very common" in the area. He said it that he was very good that we didn't run over it or make it mad. Anyway, that was my second close-proximity story to a poisonous snake in East Africa.

Shoe project...

I posted earlier about the projects that Annie and I are trying to do in Kumi. They are going well and I thought I would give you some update pictures:

First some of the posters we made:

One of Annie's posters in English.

Translated into Ateso. For some reason some of the letters went funky when I tried to convert it into a JPG and upload it. The Ateso posters aren't the final drafts either, but you get the idea.
My poster in English. Essentially just trying to get people to wear shoes and advertise the reduced prices I was able to get for diabetic patients.
Then also translated into Ateso. Once again, not the final draft, but you can get the idea.

This is another poster and Annie made (I helped a little, but she was the mastermind).

Now some pictures of the tire shoe guy making shoes. We made 48 pairs of shoes in 2 weeks! Whew! Hopefully, he will continue to make shoes.

The guy is cutting the tire. He has dismember the tire before he can make shoes out of it.

The diabetes focal person. She was very very nice and extremely helpful.

The shoe guy is fitting a patient for a pair of shoes with the leather straps for a diabetic patient.

A pair of happy feet. One of the women we made shoes for had never worn shoes before and she had to practice several times before she could put her foot through all of the leather loops at once.

Our shoes! They have leather straps instead of rubber to make them more comfortable. The tire shoe guy is making them for us for slightly less than $2 US a pair. A pretty good deal. They also look nice which makes the patients very happy.

Kumi pics

Some pictures from Kumi, Uganda. I wish I could put up even more, but maybe this will give a taste for what our lives were sort-of like.

This is Dr. Ekure, the super super cool orthopedic surgeon that we spent a lot of time with in Kumi. He was very nice and taught us a lot while we observed in the wards and watched surgeries. He does a lot with the limited resources. This is the office he runs the Friday orthopedic surgery clinics in. Next door was the room that they ran the club foot clinics on Wednesday.

Annie and I got to visit the local school while we were there. There were 135 grade 1 students in this room. The government school was also doing a lot with limited resources. The school asked if a school in the United States would be interested in starting a pen-pal program with their school (which they hope may eventually result in some fund raising after a few years). If pen pal program is something you are interested, please email me.

The school had a whole program for us including a demonstration of their sports programs and signing by the children. They also have us some beautiful flowers that grow around Kumi. Annie and I gave them some soccer balls, crayons, and a Frisbee that I brought from the States. Thank you to those who donated money or supplies before I left! I think the kids at the school will appreciated it.

Here are some children we me while going for a day trip to see the Kumi Rock Paintings. It wasn't the most exciting thing ever, but still it was fun.

More kids.

Here is a woman we met in Kumi. She is over 100 years old. She is such a beautiful and friendly person.

There were a bunch of people hanging out on Sunday afternoon and playing the local board game. I forgot the name of it in Uganda, but in Malawi the children called it, "Bao." People can get really into the game and soon there will be a group of men all watching the match. The guy in the white shirt kept winning the matches. I think he gets a lot of practice.

A sort-of sunset. The sunsets here are very beautiful. I have been trying to capture a good one, but it never looks the same. Here was one of my attempts.

A field of millet, one of the local staple foods. It is so pretty against the sky. they make "millet loaf" out of it which is millet flour mixed with cassava flour. They also make some drinks with millet.

Pictures!

I got some pictures from Theresa's camera that I decided to share with you.


Grace, Theresa and I at the Uganda soccer match.

Campfire picture during our Sipi Falls weekend.

Here is a picture of me abseiling down next to a 100m waterfall at Sipi Falls. I look more athletic in this picture than I actually felt being very scared on my way down, but don't tell anyone.

Tips for bargaining - "the Christy method"

When I am old and retired maybe I will spend my days of idleness writing a book called, "Christy's tips for travelling in East Africa." Or maybe not... Actually, when I am old and retired then everything I have experienced in my 20s will be completely out of date and the world will have exhausted its supply of fossil fuels so airline travel with be much more limited and cross-continental travel will be much slower. Sad. Anyway, if I ever do write a book on traveling tips it will definitely have a chapter on methods for successful bargaining.

Allow me to illustrate with an example from the art fair in Kampala. This is a true story:
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How foreigners usually shop in East Africa:

A group of 5 or 6 white people are meandering along being loud and talking rapidly amongst themselves as they walk between Ugandans selling handmade art, carvings and souvenirs. White people are saying to each other: "Yes, I know I couldn't believe that she has two cars! My car is such an old clunker... (more rapid conversation) .... the food here is so fattening, I mean do they NOT fry anything?"

The group of white people spot a Ugandan woman selling a medium sized drum. They walk up to her and someone says loudly, "How much is this?" while pointing at the drum. She gives the white people an appraising look and says, "50,000 shillings." They decide it is too expensive and walk away.

The white people continue browsing and eventually buy a couple over-priced items.
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Try #2, my personal attempt to get the exact same drum for a cheaper price:

I leave the group of white people and approach the woman who is selling the drum. I pause briefly smile and say in the local language of Luganda, "Oli otya, Nyabo?" (This means, "How are you, respected older woman?") She responds with a phrase that contains the word "bulungi" ("good") and asks me how I am doing. I respond in a similar manner. She realizes that I actually don't know much Lugandan and grins at my attempt at her language.

Then she asks in English how I am and I respond that I am well. I ask in English I ask, "How is your business today?" She responds that business is good but slow. I tell her that she is selling many beautiful things. She then asks if I am interested in any of the things she is selling. I respond with, "Yes, but I am a student and I didn't bring much money with me today, so I don't know if I will be able to buy anything." She says, "Tell me what interests you and we will see if we can work out a good price." I point at the exact same drum as before and say, "Mama, how much is this nice drum?" She responds, "25,000 shillings" (note: this is half of the price from the above situation). I then say that I can tell she is giving a fair price, but that I am about to leave and I only have a 20,000 bill left in my bag (a true statement) besides some change I need to catch a minibus back to the house. I ask if she will take "20,000" instead. She smiles ad says "yes." After making the transaction I stand and chat with the woman for a few more minutes. We are both pleased with the exchange.
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Now, this is just one method to bargaining. I am by no means an expert. I am sure that many people could have gotten the drum for less. However, note a few key concepts from the above scenario:

1) Bargain individually. You will get a much better price if you are able to get the vendor alone without a group of white people hanging around and talk to them for a while.
2) Be respectful/nice. White people generally have more money than Ugandans if you flash it around or talk in such away that emphasizes your difference in situation the person is going to be more likely to what to get more money from you.
3) Respect local cultural customs. In many parts of East Africa it is considered polite to spend some time greeting before you move on to business. It is sort-of like saying, "I am interested in you as a person and not just for the business transaction."
4) Don't take too much money with you and emphasize that you are student (if you are indeed a student). This will reduce your chance of getting a highly inflated price.
5) Learn a couple simple greetings in the local language. It doesn't take long to do and it shoes that you have been around for a while and know what is up.
6) Be patient. Sometimes it can take a while to talk someone down from a high price.

7) When possible, buy items from women. They are generally nicer and countless studies have shown that when women earn income in a developing country it is more likely to go to the health and well-being of the household than when men earn money. Thus you are more likely to improve the health of a family by giving business to women.



Here is a woman I bought a basket from at the art fair. She was pregnant and really nice and I decided that I wanted to give her my business over other vendors.

Our Project - shoes and footcare education for diabetic and leprosy patients

For the IHOP program Annie and I both have to do a preventative public health project. We were quite stressed over the last couple weeks trying to figure out what we were going to end up doing. At first we wanted to do something with HIV/AIDS or malaria, but these turned out to be much bigger diseases/problems than we could have managed in the period of a few weeks. However, now we have selected our project and are working towards our goal so we feel much better.

While working in Kumi hospital we have met a lot of patients who have had to get their leg or foot amputated because of (type II) diabetes or leprosy.

Some of you have asked how diabetes or leprosy leads to foot problems. Here is a basic explanation of what happens (I am sure I have mad a few mistakes, but it is the general idea anyway):

Diabetes (mostly type II, adult onset, in this area):
1) Trouble with, or insensitivity of, the insulin receptors makes it difficult for glucose (sugar molecules) to get inside fat and muscle cells in the body (some of the main tissues that use glucose). Type I diabetes is a little different because the body doesn't make insulin.
2) This results in higher than normal levels of blood glucose because it can't get into fat/muscle.
3) The high levels of blood glucose cause some of the initial symptoms: excessive thirst (body is trying to dilute the extra sugar), excessive urination, weight loss (the fat cells can't get glucose), and fatigue (muscle isn't working probably).
4) Prolonged uncontrolled diabetes leads to constant high blood sugar. These damages many parts of the body, but primarily the nerves and blood vessels.
5) Damage to the nerves and blood vessels predisposes people to get sores on their feet. This is because they can step on something sharp and injure their foot without knowing it. Then the sore can get infected and there is poor circulation to help repair the injury.
6) If the infection gets out of control the person has to get their foot amputated.

Therefore people with diabetes should control their blood sugar, wear good shoes, and clean/examine their feet everyday to look for injuries, etc.


Leprosy leads to foot problems because the leprosy mycobateria damage the nerves in the cooler parts of the body such as the ears and extremities and patients can't feel injury to their feet.

It turns out that many patients with diabetes and some with leprosy in Kumi don't have shoes and therefore it leads to the very bad foot problems. (see following pictures).

My part of the project is to try to make good shoes affordable for patients with diabetes and leprosy. Annie is going to do educational foot care posters and information about diabetes.


People with diabetes and leprosy should wash their feet and examine for injury every day. This can be hard in rural areas of Uganda where water can be hard to come by.

Here is a pair of shoes that can be purchased for 1,500 shilling (a little less than $1 US). They are made from old tires and last for about 20 years. I am trying to get the shoes modified so they will have a leather strap which should be more comfortable.

A craftsman making the tire shoes.

Splitting the rubber tires.

A view of the tire shoe guy and his work area. Guess what? There are lots of tires in his work area. Go figure.


Below are some pictures of wounds from the hospital. I got every patient's permission before taking each picture.

A patient with leprosy and a wound on her foot. She has already had all of her toes amputated.

A person with diabetes who had dead tissue removed through surgery after allowing the foot to get infected.

A person with leprosy who needs an amputation.

Anyway, you get the idea. A had a picture of some one with diabetes who had their foot amputated, but it showed his face, so I couldn't put it up on the website.

A recipe for the best shower ever

Some of you may be aware that Kumi is currently undergoing a water shortage. Most of Kumi and the surrounding area gets its water from the nearby lakes. The water is taken by a plant from the lake, chlorinated and then pumped to Kumi Hospital, various water spouts and some homes. However, the plant that chlorinates the lake water and pumps it out broke down 2 weeks ago resulting in a lack of water for the Hospital and the surrounding area.

This has resulted in a crisis for Kumi Hospital which now has no supply of water. There were back up tanks for 3 buildings (surgery and 2 others), but now even those are running out. Basics such as washing hands, instruments, cleaning the floor, etc. become exponentially harder because water must pumped by hand from a well and carried to the hospital.

The water shortage has resulted in a minor inconvenience for Annie and I as well (although nothing compared to what the hospital is going through) because the house we are staying in no longer has water. We do have a barrel of water that we can use for hand-washing etc., but still water is in short. We used some of the water to take a 'cup bath,' but the water from the barrel has been there for a long time and is dirty and cloudy looking. That means Annie and I have had minimal bathing opportunities for the last 2 weeks. This weekend Annie and I went to the larges city near Kumi (Mbale) to get some school related stuff accomplished and stayed in a mid-level hotel for one night. Our hope was that the hotel would have running water, we were pleasantly surprised to find that the hotel had HOT running water and therefore hot showers! I took one of the best showers I have ever had in my life. It was amazing. I looked at myself before the shower and noticed how disgustingly greasy my hair was. Also my skin was so dirty that you could write a word on my arm (or my feet) just like how people write on dirty cars. hmmmm.... disgusting. However, the shower was amazing. I was radiating (clean) happiness after a shower and I decided to take a picture so you could share in my joy about finally being clean:

So nice to be clean! Hot showers are amazing!

I decided to write a recipe for an amazing shower just in case all of you wanted to share in the experience:
1) Take an empty garbage can from your back yard.
2) WITHOUT cleaning it, fill the garbage can to the brim with water
3) Now, turn off the water to your entire house.
4) Water from the garbage can may be used to flush the toilet, wash your hands or bathe.
5) To 'bathe' take a couple small buckets of water from the garbage can and place in a basin. Then use a cup to splash water from the basin on your body.
6) Every day put SPF 50 sunscreen on your exposed parts of your skin. Then walk outside in 90-100 degree F weather. Ideally it should be very dusty. That way the dusty sticks to your sweat and sunscreen.
7) Repeat the above instructions daily, you may wash in water from the garbage can with the understanding that there is a water shortage and it will be very difficult to replace the water you use. This means if you have long hair - you probably won't end up washing it more than once a week. Wash hands, face and feet to look presentable for work in the hospital.
8) After 2 weeks, turn your water back on and enjoy a long hot shower! I bet you will really enjoy it!

Gas for $6.20 a gallon?

The cost of living has gone up dramatically in Uganda over the last couple of years. Particularly the cost of fuel and food (two of the most essential commodities). The cheapest gasoline is 2,690 Uganda shillings a gallon. Today I decided to calculate how much that would be a gallon as just a small measurement to see how the cost of living compares in the USA versus Uganda.

According to my calculations, there are 3.785 liters in a gallon (Google converter).

That means a gallon of gas in Uganda costs about 10,182 Uganda shillings.

The exchange rate from the last business day was: $1 US dollar equals 1,645 Uganda shillings.

If my calculations are correct, it means that gas is approximately $6.19 US dollars a gallon here. No wonder transportation, and any food item that has to be moved or imported costs so much!