Taxi Wars

Good Tuesday to all of you,

I imagine that most of you are getting to work about now, having had to warm up your car, scrape off the ice, and I do wish you a great day!

I started my morning by being startled awake by my alarm, and then became more startled when I couldn't find it.. apparently I thought it was a good idea last night to put it across the room. I have been having trouble waking up in a timely fashion, so this was my brilliant plan. It worked though, and I managed to get a taxi/bus to work at 6:50. Why this early hour? Because, dear friends, our lovely transportation system has become the bane of my existence. The issue of speed governors (those devices which keep the taxis from going at ungodly speeds and killing hordes of people) has come up again, and in protest of the high cost at installing these devices (which are worth more than the taxis, most of which have to be push started) many drivers are just refusing to drive. The result is that every single morning I wake to a battle--will I get a ride to work? Won't I? Will I decide to start hitchhiking? NO! have no fear, i have only done that once (or twice, by accident, really--I thought i knew the guy, or that someone did, or that maybe he was a cousin. really). I stand at our stop for awhile, assessing the situation. how many people are also waiting? what will be my chances if there is one seat and I have to fight these people for it? Will I win? I have tried walking to different stops to gain an advantage, I have tried to guess where people might be getting off, and wait there...to no avail.

My solution has been to leave for work earlier, and earlier, and earlier... and soon, I will just decide to sleep at work. I could, of course, decide to walk (which has happened at least once when there were absolutely no taxis at all). i might. i just might. for now though, I just hope and pray that some kind driver will allow me to try and jam myself into the doorway of an already over-crowded bus so that I can get to know a neighbor very, very well as we lurch to and fro over the rutted roads to work.

The battle also happens coming home from work. the other night I stood in the quickly darkening taxi park with at least 70 other people waiting for the bus. As I waited I geared myself up for what was sure to be quite a tussle--trying to beat down old women and small children just to secure a ride home takes work-- : ) kidding, yes, kidding. i am still a card-carrying pacifist (most of the time).

As I was standing there, though, waiting, i spied one of our buses just outside the taxi park, allowing its passengers to disembark before entering the fray of the park. a few people at the fringes of the crowd started sauntering towards the bus (as if we wouldn't catch on-HA!). then I started sprinting. then everyone was sprinting, holding up our dresses and bags, elbows out..we all reached the bus..which was moving, by the way, and by the way, there were still people getting off (or trying to). i lost my balance once, but then regained it, yelped as people uncaringly tried to get in front of me..I braced my arms against the sides of the doorway, effectively blocking my assailants...and grabbed for the handlebars, hoisted myself up the steps into the bus, and raised my arms in excitement..I was going home! I had won a seat on the bus to busega. if only we could all be so lucky...

so think of me, friends, as you head home from work tonight...think of me as I fight and claw my way to work, so that I can do the Lord's work in this blessed country...only to claw my way home again.

Peace!

Homecare

We are supposed to leave for our home care visits at 9:00 AM sharp. In reality, we are usually on the road by 11:00AM, or later. Delays come from sick patients appearing at the clinic (in which case our only clinician, who is coming with us on homecare, must first see these clients), late staff (transport makes arriving at work at any consistent time nearly impossible), our driver being called away for other duties, etc …

This week our delay was the food supply. Because it is the end of a fiscal year, the money for “needy patients” that might otherwise pay for food supplements has run out. In my frustration last week, I talked to a counselor who frequently has individual donors send cheques for “poor people.” She is then in charge of distributing this money as she sees fit. She agreed to use some of the money to buy food (so let this be an encouragement to you who might be a bit cynical about the good your small cheque can do…our clients are so grateful for the goodness of those faithful few who send Marian money that buys the extra food)…so on this particular home care morning I am faced with 50 pound bags of rice, sugar, beans, maize flour and Soya. We try to pack the food in 1-2 kilo bags, but realize we have no bags. So the driver goes out, and returns an hour later with bags. We begin packing…the food seems like so much, but from my experience with our last supply of food, I know it will maybe last a month.

We eventually grab our suitcases of drugs, bags of food, and personal stuff and squash into the pickup truck. We have seven patients scheduled for today, a few of whom I know, some which are new clients. Our first visit is to a man recently started on first line anti-retroviral therapy. After a week of therapy, one of the drugs in the combination (called Neveripine) has caused a bad reaction (our clinical officer claims he has only seen four such reactions to this drug in his years of work)—the man has a horrible skin rash over his body and down his GI tract- he has open and oozing sores on his eyes and lips and hasn’t been able to eat for awhile. He visited the clinic yesterday where we started him on IV antibiotics (open sores with a CD4 count in the 100’s makes for some bad infections)…again, we could only supply a few of the doses of ceftriaxone that he needed, and none of the metronidazole (both are too expensive for use to keep on stock for very long). Luckily his family has found money to buy the remaining doses. The plastic IV tubing and empty bottle are hanging from a nail on the cement wall (the end of the tubing is open, ie, not capped off and I shudder to think what sort of crud might be floating around in the air that we are going to subsequently inject into his bloodstream…) I hang a bottle of metronidazole, and Dorothy draws up 2 grams of ceftriaxone to give by slow injection. We also give an IM injection of a pain reliever; provide a bag of food, say a prayer, and leave. The antibiotic drip will finish soon, and then our client’s wife will find a nurse in the neighborhood (each neighborhood usually has at least one small “clinic” with a nurse and a few drugs) to hang a liter of normal saline. I hope someone will take the IV out in a few days when the doses of antibiotics are done, but I have seen the IV’s left in for a week or more because no one knows who initially put it in, and doesn’t want to be responsible for taking it out.

We next visit a man who was also in clinic yesterday and started on IV quinine for malaria. We hang the next dose, make sure that he hasn’t developed any new symptoms, and pray for him—he asks for prayers for healing, and for his family.

George is a client who first appeared in clinic about a week and a half ago—his neighbors realized he was very, very sick and brought him to Mengo. He is a known TB client, but hadn’t been tested for HIV. Blood was drawn on that visit but he hasn’t been able to return to the clinic for results (I am not even sure of his sero status). His caretaker is his 15 year old daughter Flavia—his wife left some time ago. They are originally from the north, now outside their tribe and family area. They are indeed blessed to have neighbors who nevertheless are caring and concerned. When we found George at home last week, he was barely conscious, with a blood pressure of 80/52. He had been on IV injections of quinine for malaria, but hadn’t been eating or drinking. As we had sent him home from the clinic with oral rehydration salts, I asked Flavia if she had been preparing the drink for her father. She showed me that she had indeed mixed up the solution, but then said he had been refusing to drink. The clinical officer gave George a bit of a lecture about making an effort to drink and eat—it seemed a bit lost on the very, very ill man. We asked Flavia if she had food to prepare, what she was going to prepare…she had very little to say, shrugging her shoulders in response. This week we are glad to see George on the couch and awake (I had been afraid he would die in the days between visits), still not eating very much, and complaining that his daughter often runs off and leaves him alone. It is clear that this family needs intervention--soon, and we urge them both to find their way to the clinic tomorrow so that both can be counseled, and we can try and make a plan for their welfare.

In the scope of the AIDS epidemic, women bear a huge share of the burden. In Uganda specifically, women are twice as likely to be infected as men (specifically urban women are at risk) and also are generally under increased work load as they are the primary caretakers for their parents, spouses and children who are infected. Flavia represents thousands of girls who are not going to school (it has apparently been several years since she has been able to attend) and are losing their childhood caring for dying parents.





Another client, Godfrey, is cared for by his elderly mother—she also is not at a stage of life where she should be doing hard labor, trying to care for her dying son and his seven children (Godfrey’s wife died a few years ago). Godfrey has been unable to gain weight (tips the scales at 40 kg, or 88 pounds). He has been tested for TB (negative) and had a chest x-ray (suggestive of pneumonia). We leave food with him, give him some vitamin supplements and antibiotics for the pneumonia, and again, pray—this time for provision of food and money for his family. He says his mother has been working so hard trying to make ends meet, but without very much success.

James has been attending the clinic since I started working in August; he started antiretroviral therapy with a CD4 count of 4. Unfortunately, after six months of therapy he has a CD4 count of 2, has developed Kaposi’s sarcoma and is racked with intense abdominal pain (most likely from metastases. We had referred him to hospice care, which provided him with a supply of liquid morphine. However, he has been only taking it every 12 hours for fear of running out--and so is in incredible pain, taking very small gasping breaths and is understandably angry and depressed. It seems that since the first line ARV therapy failed to boost his CD4 count, he needs to start second line therapy- soon. Mengo, however, does not have any 2nd line therapy available so James will have to be referred the government hospital. Another problem is that since he is having chemotherapy injections of vincristine and bleomycin for his cancer, he can’t start on new ARV drugs for fear of drug interaction/reaction. A definite catch-22- without the ARV’s, he could die very soon from opportunistic infections. Without the chemo, he will die very soon from cancer.

To make everything more complicated, he is now being cared for (and given medicine by) Mengo, hospice, and the cancer center at the government hospital. He has no paperwork from any of these three that might inform the other two what the plan is, which medicines were prescribed when…etc…in short, a care management nightmare. The clinical officer tells James to come to the clinic tomorrow morning for consultation with a physician and possible referral. When James does come in the morning, he appears haunted, and begs me to pray that he be released from the “devils” that tell him to kill himself. He fears so much for the safety and well being of his eight children, four of whom are still in school and four of whom have finished—but don’t have jobs yet.

By 4 pm we have still not finished our patient visits, so we stop at the hospital for lunch. On the way to our last home visit, we stop at the burial service for the brother of one of our coworkers. Like so many Ugandans, he fell sick very quickly and died yesterday. It gives one pause, when looking at statistics of HIV/AIDS to know that there are many people who die without ever being tested. The 6.5% infection rate begins to look more and more erroneous the longer I work here, and I wonder what good these statistics are?

After our last visit we return to the clinic, exhausted and sore (from bouncing on bad roads in a pick-up truck whose shocks have long since ceased to work). I get discouraged sometimes, looking at how few patients we managed to see (6) in an 8 hour day and knowing how many, many HIV+ people are dying each day without any chance of receiving care. Most of our homecare clients could indeed use visits every day; we manage to go once a week, if that.

I gain some hope from individuals making progress towards health, from smiles of clients who improve, gain strength and return to work, and from stories told by my coworkers about life in Uganda pre-antiretroviral therapy. Kind of like that lame starfish story, we work with one person at a time, and pray that God will use our efforts for His glory, that we will in fact be his hands and feet in this community.

Half-way

Dearest friends, I want you to know that I have completed half of my service here in Kampala. (well, half as determined by time spent here...) I am overwhelmed daily with the great love and compassion our God has shown to me as I have been learning and struggling and growing here! Not to mention, I am overwhelmed that he has managed to preserve my life through all of my antics and mishaps : )

As I have been commuting to work the last few days (because the kids started the new school term this week, the taxis have been overcrowded and the rows in the bus that are meant to hold three people, but usually hold four people, are now holding five people... It really encourages a sense of "family" and "togetherness" when you get to sit on your neighbors' lap for the thirty minute ride!) I have been reflecting on the things that I love so much about living here.

1. I love pineapples! Did you know that I can eat a whole pineapple, by myself? I can!
2. I love that the men that sell the pineapples out of the pickup truck in the taxi park recognize me and have the same conversation in Luganda every time I come by: "Hey, this mazungu knows Luganda." "this is the one that knows luganda?" "Yes, this one." "Hey you! (to me) YOu know luganda?" I respond with the typical ugandan responseof "I try." I found I can get a lot of mileage out of pretending that I understand everything, while straining to get one of the 50 or so words that I do know...
3. I love our clients, who are so appreciative of the care we provide. One of our homecare patients gifts us with groundnuts, or papaya, or whatever happens to be around when we visit her at home. A few of the homecare clients have started requesting that I pray for them before I offer it. One gentleman this past week said "You prayed that I would have an appetite, and now I do! Now pray that we will have food to eat." So we prayed (and also gave him food out of our supply.)
4. I love that my coworkers are passionate about the work they do. They frequently have ideas for improving our services, improving care, changing systems...as always, change is slow and painful but it is wonderful to be in an environment where small changes can make a difference. At our weekly CME meetings, we are discussing "quality improvement," how can we make the experience of coming to the clinic, when you are one client out of 120 that day, be faster and more pleasant??
5. I really love the bootleg movie collections that can be purchased from the street vendors for 5000 Ush (about 3.00$)...you can buy the Brad Pit collection, the Julia Roberts collection, or my personal favorite, The JLO collection (have YOU ever watched three JLO movies in a row??)
6. I love our MCC team here...no where else can you have a party based around the fact that someone has received cheese in the mail, and someone else has splurged on a can of pringles!
7. I love the afternoons after we have had rain all morning...the sun is bright, but the air is cool and clear of dust..the banana trees are washed clean and everything is so green.
8. I love all of you! Thank you for your prayers, support, packages, letters, calls... I look forward to the work that God has for me to do in the next six months.

Peace!