A Ugandan Way of Life

On Sunday 22^nd June me and Sophie left Kagando for the final time, and whilst the last three months have been full of both the high points and the low, we were both genuinely quite sad to leave.  However, apart from my briefest of introductions when we first arrived, I realise that I never properly explained what its actually like to live in this small Ugandan village. I therefore hope that my subsequent musings will not only entertain my friends and family at home, but will also act as a reminder for myself in the years to come when this mini-adventure in Africa has become all but a distant memory. 

Our Humble Abode

When I last came to Kagando three years ago our current house was being lived in by two British doctors, and at the time I was incredibly envious of them having such a lovely place to themselves (especially as we had to make do with the rather basic student accommodation). Whilst it wasn't partially cosy when we first moved in, by the time that we had unpacked and added our ‘own little touch’ to the place, it really did feel like our home away from home. All I hope is that the next person who moves in will feel just as welcomed by its homely interior as we did.

The Outside of Our House

Situated in the large compound opposite the hospital, our home consisted of a small white bungalow with a corrugated roof and surrounding gardens that contained a wide array of plants and butterflies. Inside the walls and floor were bare concrete, but with the colourful curtains and a mix-match of African themed wall-art the house itself was very welcoming. The front door opened into the lounge, which contained a couple of basic but comfortable chairs that were arranged around a small wicker coffee table; there was even a rocking chair - much to the amusement of all our visitors. Immediately oppose the front door was an alcove that contained the dining table; to the right of this was the kitchen, and to the left was the bathroom. The bathroom was perhaps the most basic room in the house, and contained just a sink, toilet, very cold shower and a light that worked occasionally (the novelty of having to wash in the dark has definitely worn off). However, whilst it was a far cry from the luxuries that we have grown accustomed to in the west, it was a lot better than what I had been anticipating; for one thing, it had a western flush toilet (rather than a squat loo – something which I still struggle with despite having spent almost three months now in Africa). The house has been lived in for over twenty years by British volunteers, and as a result contained a large collection of assorted kitchen utensils. In addition to a gas hob, toaster, kettle and fridge freezer, the cupboards contained, amongst other things, a fully functioning toasted-sandwich maker (not quite what we were expecting in an African kitchen). The house also contained two separate bedrooms; a double room immediately to the right of the front door (which was Sophie’s bedroom), and a single room that was next to the bathroom (which was my bedroom). I'm not going to lie and say that the bed had the most comfortable mattress that I have ever slept on, but with a mosquito net and enough space to store all of my belongings I was more than happy with our accommodation.

The house itself was in the most perfect of locations (even if it was halfway up a rather steep hill); not only were we less than five minutes away from the hospital, but we had stunning views of the Rwenzori Mountains and surrounding countryside from the comfort of our own front porch. The only downside to our close proximity to the hospital was the large amount of noise each night; in addition to the nightly chorus of the crickets and birds, we could often hear the students at the nursing school or the late-night choir practice in the chapel. Whilst we managed to get used to it by the end of our time in Kagando, both me and Sophie have lost count of the number of sleepless nights that we have had because it!

View from Our Front Porch

The Practicalities of African Living

In England we often take from granted that out homes are supplied with gas and electric, and apart from having to phone up the respective company and asked to be connected, there is nothing more that we need to do. If only life in Africa was so simple. Apart from seeing my family and friends, the one thing that I am looking forward to most about going back to the UK is being able to drink water directly from the tap. For the past three months me and Sophie have had to boil all of our tap water for ten minutes, and then let it cool before we can use it.There have been times when there has been a storm and the water has turned a lovely brown colour, or even the odd occasion where there has been no water at all. Most of our house (i.e. lights and electric sockets) was powered by pre-paid electricity, and when we first moved in we were presented with an electricity card that we had to take to Kasese (the nearest town) to top-up. Once we had placed money on this card, we had to take it back to our house and insert it into the electricity meter on the outside the back door to activate it. Usually, twenty thousand shillings (around five pounds) should have lasted us a couple of months. However, there was a problem with our electrical wiring, and despite our multiple attempts to get an electrician to come and fix it (which unsurprisingly they never did), we would often use this amount up in as little time as a week, leading to a couple  interesting evenings of cooking and washing by torchlight. Cooking itself was done using a gas hob that was supplied by a large butane canister. Although this was less problematic than the electric, it also ran out halfway through our time in Kagando. It could only be replaced in Kasese, and with no way of getting there for at least a couple of days we managed to get quite inventive with what we could cook using just a kettle and toaster.

What with being in the middle of Africa, power cuts were a frequent (almost daily) occurrence and would often occur at the most inappropriate moment, such as whilst showering, cooking, or even in the middle of an emergency laparotomy. Whilst our house was fortunate enough to be supplied by a generator, someone would still have to turn it on. There was often a rather anxious delay between the power going off and the back-up supply kicking in, and on several occasions it never went on (leading to a couple of romantic candlelit dinners between myself and Sophie).  The generator itself was fuelled by petrol and powered both the accommodation and hospital buildings. Although in theory there should always have been enough fuel to supply power at all times of day, there was a story from not too long ago of the generator running out of petrol halfway through an emergency operation. Without any lights or diathermy, the operation was paused at a critical point and the theatre nurse sent to the nearby town to buy more petrol; understandably the surgeon was not best pleased.  

In terms of communicating with the outside world we had two options; mobile phone or internet. The phone network that I chose (MTN) was pretty cheap, and had coverage pretty much anywhere in Uganda; I was even able to make a phone call in the middle of lake Victoria (unlike in the UK where there are several parts of my own house where I have no signal from O2).  The internet on the other hand was considerably less reliable. The main source of our internet was the Wi-Fi outside the nursing school (which was about a two minute walk from our house), and although there were a couple of benches scattered around outside I would often have to sit on the ground amongst the mosquitoes and the ants. When it was working (which was very intermittent), the signal was pretty awful and I would often have to wait for ten minutes or more for a single email to load; anything like Skype or streaming music was definitely out of the question. However, we later discovered that one of the main reasons that it never seemed to work was because of a man in the I.T. department who had a rather large power complex; he would often change the password and subsequently refuse to tell anyone what the new one was (for no reason other than it made him feel important and in control). Me and Sophie finally had enough of this and brought ourselves an internet dongle. Whilst this was marginally faster than the Wi-Fi at the nursing school, it wasn't much better and seemed to be just as unreliable. One thing is for certain though; I am never going to complain about broadband internet in the UK again!

Housework

I don’t like having to do housework at the best of times, but with a distinct lack of washing machines, dishwashers, hoovers and other such appliances, I like it even less in Uganda. The only way to clean clothes here is to place them in a plastic bowel with soap powder, add hot water and scrub; you only stop when your hands are red raw and the clothes look about ten times dirtier than when you began (I think it’s fair to say that my white shirt is never going to be white again). Whilst I got better throughout my time in Kagando (for example it only took me five minutes to wash one T-shirt compared to the thirty minutes that it had taken me at the start of my three months here), I was by no means up to the standards of a true African women. Once washed we would normally hang our clothes outside to dry. However, as it was culturally unacceptable to for women’s underwear to be seen on a washing line, our bathroom used to become a drying room for bra’s, knickers and socks. 

Drying Clothes in Our Bathroom

Apart from having to wash all of our clothes by hand, we had nothing but a mop and a broom to clean the house with, and to do the washing up we had to boil hot water in the kettle (as only icy-cold water came from the taps). There was no such thing as a garbage collection service in Uganda, and all of our rubbish (from food scraps to glass jars) got thrown into a large rubbish pit behind our house. If the magpies didn't manage to scatter the contents of this pit around the compound first, the maintenance men would periodically set fire to this rubbish (causing a lovely aroma to spread through our house and garden). 

In reflection I really don’t think that we have it all too bad in the UK. It isn't really that difficult to throw some clothes into a washing machine or quickly put the hoover around the house. Naomi (the Ugandan surgeon that I was working with) couldn't quite get her head around all of the luxuries that we have in the UK; she used to laugh at the idea of washing machines, and didn't quite believe me when I told her about bread makers (I have promised to send her a photo of one when I get home – just to prove that I wasn't making it all up). However, whilst living in Africa has taught me one or two important life skills, I think it’s fair to say that no matter what happens to me when I get back to the UK, I will lead a happy and contented life if I never have to wash another item of clothing by hand again!

Food

In the UK I think I had developed a bit of a ‘Waitrose’ habit, and would often visit this supermarket as a form of relaxation after a hard day’s work. Sadly there were no big supermarkets in Kagando, and instead me and Sophie used to buy our food from the local village market.  Whilst the available food was limited (basically any form of fruit or veg that was in season at the time), what we did buy was full of flavour (and also very cheap). However, I'm not entirely sure how the stall holders ever made any money as they would all be selling the same types of food (and all for the same price). All of these vendors spoke in the local dialect of Lokonzo, and very few of them knew any English. Although me and Sophie made an attempt to learn the local langue, we didn't managed to get much further than ‘Good Morning’ (Woburturie), ‘Good Afternoon’ (Wasurburi) and ‘Thank-You’ (Wosinger). When we went shopping in the village our animated attempts at sign language and ‘pigeon lokonzo’ would often be a great source of amusement to the locals, and they would frequently erupt into fits of laughter when we tried to say thank-you. However, this was never meant to be malicious, and the vendors were more than fair to us; we were never over-charged (which is sadly a common occurrence for mzungos in Africa), and they would always throw in a couple of free tomatoes or potatoes if we had brought a lot from them that day.

The Local Market

Our average shop from one of these market stalls would consist of tomatoes (five for twenty-five pence), a pile of potatoes (also for twenty-five pence), an large avocado (for about five pence each), an aubergine (ten pence each, irrespective of size), passion fruit (twenty-five pence for six), bananas (ten small ones for twenty five pence) and a couple of small green peppers (about ten pence each). Also, when they were in season we were able to get hold of a pineapple (between thirty to sixty pence each, depending upon size), mangos (less than five pence each), and even the occasional watermelon (for fifty to seventy-five pence each, again depending upon size). In comparison to a lot of imported fruit and veg back at home (which is normally very bland), the food here was full of flavour and often very sweet; I don’t think I'm going to be able to eat a mango or avocado in the UK again without being slightly disappointed!

In addition to these market stalls there was also a couple of shops in the village, including a tailors, fabric shop (which sold beautiful cloth) and even a small off-licence (where you could buy 50mls of Ugandan gin in a plastic bag – all for as little as twelve pence; we were never brave enough to try it). There was also a small supermarket which had become affectingly known as the ‘Mzungo Shop’; I think we must have been the only people to shop there as they always seemed so pleased to see us. From here we were able to buy pasta, flour, sugar, jam, some cereals (although they were mostly out of date by a year or two), a selection of spices, eggs (that came in a plastic bag rather than a carton), and even the occasional apples (albeit for a much high price than any other form of fruit as they had to be imported from South Africa). 

The 'Mzungo' Shop

There was also a canteen inside the hospital that consisted of an old metal container next to the main gate. Despite its rather small size it somehow managed to sell a surprisingly large amount of things, including bread, soap, margarine, UHT milk and strawberry yoghurt (which, once opened, was a lovely shade of florescent pink). The canteen also sold soda’s, and as were weren't allowed alcohol inside the hospital compound mine and Sophie’s treat was to have a ‘Crest Bitter Lemon’ or ‘Stoney Tangawizi’ (i.e. non-alcoholic ginger beer) once or twice a week (we really did lead a very simple life in Kagando). However, these drinks came in glass bottles that were reused many times over, and we would literally be hunted down by the canteen staff if we didn't return our empties within a day or two. Despite the well-stocked mzungo shop and hospital canteen, we still couldn't get everything that we needed from Kagando, and instead would have to travel to the nearby town of Kasese to buy things such as oats, real butter, kidney beans and hot chocolate. We were even able to buy a form of Ugandan cheese, and although this was nowhere near as good as English cheddar or French brie, it was definitely better than having no cheese at all! Of course there were many home comforts that we just couldn't get in Uganda, including proper English chocolate that actually melted in your mouth (rather than the Ugandan equivalent which quite frankly ruined chocolate for me during my last visit to Africa). However, Sophie’s mum (who was amazing) sent us a couple of food parcels whilst we were still in Kagando. These packages contain everything from Cadburys chocolate to Marmite and Nutella; I cannot even begin to explain how exciting it was to open one of these parcels after a long and tiring week at work and indulge ourselves on a bit of western luxury.

When it came to cooking we would mainly use our gas hob, and even after three months were still pretty obsessive about peeling everything that we ate (I will be quite happy if I never have to peel another tomato again). As I am vegetarian the meals that we were able to make were pretty limited, and consisted of a repertoire of about five different dishes (pasta with tomatoes and aubergine, vegetable curry, bubble and squeak, egg and chips, and our own personal favourite - bean burgers with chips and guacamole). We did however get more inventive towards the end of our time in Kagando, and in my own personal opinion our bean burgers were almost up to the standards of those served in an English gastro pub.

Our Gourmet Bean Burgers

The only type of bread that we were able to get hold of in the village was white sweet bread (it really isn't as nice as it sounds), and after managing to buy a loaf of brown salty bread on our way back from Rwanda we were inspired to try to make our own bread. Despite a couple failed attempts (such as finding weevils in our only bag of bread flour), we managed to get the hang of making rolls from just yeast and normal white flour in the rather strange electric oven that we had inherited. We even branched out and made pizzas, and whilst they weren't quite up to the standard of ‘Zizzi’s’ or ‘Pizza Express’, I personally think that they were pretty good given the fact that they were cooked in the middle of a rural Ugandan village.

Making Bread

Whilst me and Sophie have tried to embrace most of the local food, one Ugandan delicacy that we just couldn't bring ourselves to eat was deep-fried grasshoppers. These are considered to be a luxury in Uganda, and every time there is a big swam people stay up all night trying to catch them. Even when I was on the surgical ward I saw people up ladders trying to pick them off the lights and ceiling; I initially thought that they were doing a good deed by cleaning the hospital, although later I found out what they were really up to.

Leisure Time

Unlike the UK where we are often spoilt for choice when it comes to deciding how to spend our free time, life in Uganda is much simpler. The ancient TV that was tucked away in the corner of our lounge never worked, and without a decent a Wi-Fi connection we couldn't even rely upon the internet to entertain us. Also, with a 10pm curfew for the entire village (where you will get thrown into jail for the night if caught out and about after this time), visiting the local bar was also out of the question (not that there was a mzungo-friendly bar in Kagando anyway). Instead me had Sophie had to resort to good old fashioned talking to pass away the time, and when we finally had enough of each other we would either have to read or try to write our blogs. 

As much as me and Sophie like each other, if we only had each other to talk to for three months I think we may have gone slightly mad. Luckily there would always be visitors to the house to add variety to the conversation topic. There would often be British medical students in Kagando who would pop over for a hot chocolate and a chat, and Naomi would regularly come over for dinner or to paint our nails. We would also have a lot of unexpected visitors to our house, and whilst some of these were a pleasant surprise (often doctors and nurses who came to check on Sophie when she was unwell), many of them were not so welcome (and were almost always only after me). In the space of just one week there was the headmaster of the local school who came to try and convince me to come to his school, a bunch of school children after my email address, and even a patient who had managed to make it past the security guard so that could invite me to his nursery school (and ultimately ask me for money). Whist the others were just frustrating, the last one really did annoy me; I don’t think I have ever shouted at a patient before, but I was far from nice when I told him never to come to my house again. Combined with other patients who kept asking me for money to pay for their hospital treatment and a pharmacy student who seemed to think that it was his divine  right to have  my email address and mobile number (neither of which get got), it really was a bad week for unwelcomed requests. However, it wasn't just me who received these unreasonable demands. Despite being a Uganda doctor on a rather small wage, Naomi frequently has patients turning up at her door to ask for money or free treatment.

When me and Sophie had a day spare, we would often try to get out and explore the local area. About an hour’s drive away was the town of Kasese where there was a supermarket, bank, post office and even a small cafe called ‘Jambo’s. We would often go here every couple of weeks to stock up on essentials and get a decent cup of coffee. However, with the blazing sun and endless dust it was rather reminiscent of something out of the ‘Wild West’, and we would often find ourselves wanting to leave after just half a day spent there. In addition to these outings to Kasese, me and Sophie would visit Kingfisher Safari lodge when we had either had a bad week, or simply just wanted to treat ourselves. Located just outside of Queen Elizabeth National Park on top of a ridge, this small lodge had spectacular views over the Savannah and surrounding area. With several infinity pools and a menu that was a lot more exciting than anything that we were able to cook, it really was a welcomed retreat away from the stresses of the hospital.

Kingfisher Safari Lodge

Back in the UK I usually try to exercise at least four to five times a week, and whilst I had every intention of carrying this on in Uganda, it ended up being a lot harder to do than I had originally thought. There was nowhere to swim near Kagando, and anyone who tries to run will be laughed at by all the locals for doing such a foolish thing (and this is before you even start to consider the dusty roads and almost unbearable heat). Instead I had to settle for skipping with a rope (something that I haven’t done since I was about six years old) as a way of remaining fit and active. The hill leading to our house was also pretty steep, and considering that Kagando was at an altitude of around fifteen-hundred meters I would also count the walk to and from the hospital as part of my daily exercise regime. 

Ugandan Weather

When people think of Africa they often picture a dry and dusty Savanah that is desperate for just the smallest drop of rain. South-western Uganda definitely is not like this. We arrived in the middle of the wet season, and despite there being at least one thunderstorm a day the weather was still relatively warm. As a result the landscape was lush and green, and the crops more plentiful than they have ever been before. Unfortunately, like everywhere else in the world Uganda is starting to see its fair share of global warming; whilst the wet season was officially meant to finish at the end of May, it appeared to be raining more than ever when we left Kagando and the end of June. In fact, it was so bad that one of the neighbouring hospitals had been forced to closed after the nearby river burst its banks and washed away many of the wards. However, unlike England where it tends to rain all day, after the storm has passed in Uganda the sun will come out and it will often become unbearably hot (especially if you are wearing scrubs and a surgical gown in theatre). Although me and Sophie struggled with this heat, we seemed to fair a lot better than some of the Ugandans did with the cold. If the temperature dropped to anywhere below twenty degrees they would promptly pile on three or more layers and refuse to do any more work until it started to warm up again; some have even to been known to complain of being ‘allergic’ to the cold.

No sooner had we begun to settle into our lives in this small African village when it time for us to leave. Without realising it we had stopped noticing the mountains each morning, and our routine of visiting the market each day had become so familiar that we found it difficult to imagine doing anything else. The three months had gone by so fast, and our previous ways of life had become all but a distant memory. Whilst there is a certain part of me that can’t wait to get back to the comfort of living in the west, I really do feel that I have learnt some important life lessons during my time in Uganda. However, even if I have forgotten them all by the time that I am eighty, I will at least still have this blog to remind me of my mini-adventure in Africa. 

The Life of a Ugandan Doctor

The purpose of this blog is not to give the reader the impression that working as a doctor in Britain is easy; with endless targets to meet, increasingly high expectations from the public and often incorrect criticism from the media (and this is before you even start to consider the responsibility of having to look after acutely unwell patients whilst trying to complete a never-ending amount of assessments and reflections for your portfolio), it is no wonder that it is a profession with one of the highest levels of stress and rates of burnout. In comparison, although a Ugandan doctor may meet with these pressures to some extent, the main barriers and difficulties that they face in their everyday working life are vastly different to ours. Therefore, the main aim my blog is to help my fellow colleagues realise that whilst working as a doctor in the UK is a highly stressful job with its own set of problems, there are some aspects of our daily lives that we often take for granted, and I therefore hope that my subsequent musings will help them (myself included) come to appreciate certain aspects of the NHS that we have never really considered before. 

Money and Resources

One of the biggest factors that influences healthcare in Uganda is money (or rather, lack of), and whilst medical care is free in the government hospitals (although the patients still needs to pay for the transport to get there), Kagando is a private hospital where patients have to pay for everything. This includes the operation that they underwent, the drugs that were given, and even the rubber gloves that were used to examine them. The final bill is paid at the end of their stay; if they don’t have the money they simply have to stay in hospital until they can raise enough funds (thereby increasing their fees further by using the hospital bed for longer than they need to). And it is not just the patient’s treatment that is affected by lack of money, but also their decision to come to hospital in the first place. It is so often the case that due to lack on money a patient will delay coming to hospital until there is no other option; they will try traditional remedies and local health clinics, all without much benefit. It is only when their illness has reached the point that they can no longer live with it that they eventually come to hospital; the end result of this is that we often see patients with diseases that are just too far advanced to treat. This was sadly the case for a ten year old boy that I saw during my first month in Kagando who had presented with over a year’s history of abdominal pain and swelling. Despite the realisation that something was wrong, the boy’s father just couldn't afford to bring him to hospital sooner. He subsequently underwent an emergency laparotomy and was found to have a large mass (roughly the size of a football) attached to his right kidney with similar smaller masses in his scrotum. Whilst the surgeon did his best to remove all the masses, ultimately there were small bits that he had to leave behind. This biopsy result came back as showing that he had a high grade Burkitt’s lymphoma, and he was referred to one of the government hospitals for chemotherapy. The sad reality is that this form of lymphoma usually responds well to treatment, and if caught early enough he would have been expected to have made a full recovery. Unfortunately his presentation was too late, and the chemotherapy was more than likely going to be for palliative measures only, rather than a cure. 

Once a patient has presented to hospital, and after a history has been taken and examination performed, the next logical step is to perform the investigations that will help to confirm or rule out a diagnosis. In the UK where most investigations are available to us, it isn’t unusual for a patient  to have a whole host of diagnostic tests performed upon them, irrespective of whether they are really needed or not. Whilst this no doubt means that we normally (but not always) find a diagnosis and can therefore start treatment as soon as possible, it does make you wonder whether we are losing our clinical ability to make a diagnosis from signs and symptoms alone. In a dramatic contrast to the UK, where we never really consider the costs implications of the tests that we order, in Uganda money is always at the forefront of your mind when deciding what investigations to perform.  Of course, this largely depends upon what tests you have available to you in the first place, and with a lack of money and limited resources in smaller rural hospitals, you can only perform the most basic of tests. In Kagando we can perform x-rays, abdominal ultrasounds, basic microscopy and a small selection of blood tests (including malaria diagnosis , blood sugars, HIV screening, and a full blood count); in theory we should be able to test for renal and liver functions, although due to a lack of money the regent has been out of stock since I arrived. Outside of this rather limited supply of investigations you either have to refer the patient to larger hospitals if they can afford it (although many can’t), or, more commonly, rely upon your clinical judgement to make a diagnosis and subsequently decided upon what treatment to give. Although this definitely helps to improve your ability to interpret clinical signs (and perhaps become a more well-rounded doctor in the process), it often means that you have to make decisions without as much confidence as you would like. Whilst this is something that I still struggle with (despite having worked in Kagando for almost three months now), the Ugandan doctors manage to use what little information they have to make sensible, and often correct clinical decisions. For instance, it was only last week that we had an eighteen month old boy brought into us with an acute onset of abdominal pain, distension and bloating. Whilst we suspected intussusception from the history and examination findings (this is where part of the bowel slides inside of itself, thereby causing an obstruction), the radiographer was off sick and we were unable to confirm the diagnosis using an x-ray or ultrasound. Intussusception is a surgical emergency, and we didn’t have time to wait around for the radiographer to return to work. With nothing more that her clinical findings to go on, Naomi made the tough call to take the child to theatre for an emergency laparotomy where the diagnosis was confirmed and the obstruction removed. Although it was nerve-racking to have to make that sort of decision without any radiological investigations to back it up, it was obviously the correct one as the child would have almost certainly have died if we had waited around long enough for the radiographer to return and take the x-ray.  

Whilst we were able to use the clinical signs to make a reasonable attempt at the diagnosis in this young child, there have been many patients where we have not been so fortunate. I cannot begin to describe how infuriating it is to have a patient in front of you who you know is sick, but without the appropriate investigations there is no way of knowing what the correct treatment to give is. Instead you have to stand by and watch them deteriorate in front of you; blindly treating can sometimes help, but more often than not they pass away without a diagnosis ever being made. An example of this that is all too fresh in my mind is of a sixteen year old girl who came in just under a month ago following a road traffic accident (she had fallen off the back of a motorbike, and, like most people in Uganda, had not been wearing a helmet). She had a reduced conscious level on admission and we eventually managed to persuade her parents to pay for a CT scan at the nearby government hospital; there was no obvious injury on the scan and her symptoms were therefore attributed to concussion. However, whilst her conscious level improved over the next couple of days and she had no obvious signs of an evolving intra-cranial pathology (i.e. a head injury that only becomes apparent some days after the initial accident), there was something that just wasn't quite right about her. She kept complaining of feeling hot and was unable to stand by herself; after a week she became more and more drowsy, and was persistently spiking temperatures and vomiting. Whilst we were concerned about a head injury that was not picked up on the first scan, her parents were unable to pay for her to have repeat CT. Worried that this potential head injury could have been causing an electrolyte disturbance we tried to test her sodium and potassium. Unfortunately the reagent was still out of stock and we had to treat her blindly, based purely upon her clinical signs. Despite our best efforts she continued to deteriorate and subsequently developed severe breathing problems, vomiting and high blood sugars. Again there was a whole magnitude of conditions which could have been causing these symptoms, but without any appropriate tests we were forced to treat her for every possibility; we didn't succeed and she died several days later. However, the sad reality is that if we had just the few simple tests that we needed (such as the ability to measure her serum electrolytes), we may have been able to diagnose her correctly, thereby allowing us to give the correct treatment. However, even if I find out that the investigations that I want are available, I always have to think twice about whether they are really necessary or just something that I am doing to make myself feel better.  Although it wouldn't always be acceptable practice in the UK, if the diagnosis is obvious from clinical signs alone and the patients don’t have much money I will often treat without investigating. Whilst this is by no means ideal, it has meant that I have had to think a lot more about the cost implications of everything that I ask for; perhaps when I go back to the UK I may actually stop to consider whether an investigation is really necessary, rather than ordering every possible test that I can think of.  

Compared to our hospital where there is a very limited set of investigations, the larger government centres have more advanced diagnostic tests and can perform procedures such as CT scans and endoscopies. However, the patients still has to pay for these investigations and whilst the cost may not appear to be too much to us, it is almost always unaffordable for most of our patients in Kagando (who generally fall into the category of the rural poor). For example, a head CT scan costs around 100,000 shillings (equivalent to £25), and when you start to consider that the average cost of food for an entire day is less than one thousand shillings you can begin to appreciate why so few people can afford these expensive, yet lifesaving investigations. Even if a patient can afford to pay for an investigation in one of the larger hospitals, their relatives are often reluctant to spend such a large amount of money (irrespective of how much time you spend trying to persuade them otherwise). Instead the patient will sit on the ward and deteriorate right in front of you, and it is only when it is all but too late that the relatives eventually agree to pay for the test. Sadly, this decision may come too late for some patients, like the young man who was admitted to our ward several months ago following a road traffic accident. He had been the driver of a motorbike that had collided head-on with a car, and after being rushed to hospital was found to have signs of an obvious head injury with a significantly reduced level of consciousness. Suspecting that he had sustained an acute intracerebral bleed (i.e. bleed in the brain) we tried to convince the relatives to take him to the nearby government hospital for a CT scan; if the diagnosis of a bleed was confirmed they would have been able to operate on him immediately. However, despite having enough money available to them, the relatives were reluctant to pay for the scan and leave Kagando, believing instead that he would get better on his own (in spite of our best efforts to convince them otherwise). We tried to treat him conservatively over the next few days with mannitol, a diuretic that helps to reduce the pressure within the brain. Unfortunately this was not successful and he continued to deteriorate; he had developed a definite left-sided weakness with a fixed and unreactive pupil on the right (all indicating a right-sided bleed), and after the fourth days he started to have uncontrollable epileptic seizures. It was only now that his family finally agreed to pay for him to be transferred to the nearby government hospital for a CT scan. We later discovered that the scan had confirmed a massive right-sided intracerebral bleed; unfortunately he had died on his way to theatre, something which may have been prevented had he been transferred just a day or two earlier.  

Whilst I appear to have written a mini-essay on the influence that poverty has upon the patient’s decision to come to hospital and the subsequent investigations that they will undergo, the biggest effect of this scarcity of resources is often seen when deciding what treatment to give. The most common occurrence is that the treatment that I would want to give just isn't available here. Sometimes there may be the option of being referred to one of the government hospitals which have a greater selection of resources, but this still costs money and the patient is often unable to pay for the transport there (even if the treatment itself is free). A rather sad example of this is when I got called to the paediatric ward to see a two year-old boy who was thought to have inhaled a bean. He was having severe difficulties in breathing and every time we removed the oxygen his saturations dropped to a dangerously low level. The only treatment for an inhaled foreign body is to perform a bronchoscopy (which is where you insert a camera into the windpipe and remove the offending object). We were unable to provide this service in Kagando, but the government hospital in Mbarara could offer it for free. Because he was dependent upon the oxygen he would have needed to have travelled in an ambulance (rather than on the back of a motorbike, which is the usual mode of transport to and from hospital). However, this journey would have cost over six thousand shillings (around £150), which was just too expensive for the parents. Without the means to get him to Mbarara, all that was left for us to do was to give him oxygen and treat the other possible causes of his breathing problems, such as malaria or a severe chest infection. Not wanting to stand by and watch him die, we had to make the heart-breaking decision to turn and walk away, fully expecting him to be dead by the following morning. This child was fortunate and he recovered without a bronchoscopy (either because the foreign body had moved, or, more likely, was never there in the first place and the cause of all his problems was severe malaria); others have not been so lucky.

Although there have been many patients who cannot afford to be transferred to a nearby hospital for treatment, there are some who are so poor that they can’t even manage to pay for their treatment in Kagando; in the worst cases you have to stand by and watch them die, all the while knowing that you could quite easily have cured them - if only they had had the money to allow you to do so. Whilst this is upsetting enough with adults, it is even more heart-breaking when it is a child. Even when the parents have the money, if they refuse to fund their child’s treatment you have to respect this wish, rather than overruling them as you would do in the UK. Furthermore, it is always the father who has the deciding vote; despite the fact that the mother may want to save her child’s life, if her husband won’t pay it is his word that is final, not hers.

As frustrating as it has been to have patients who cannot afford the available treatment, what I have struggled with the most are the patients for whom there is no treatment. By this I do not mean the patients who have reached the end stage of a chronic disease that nothing more can be done for; I have come across plenty of these during my time in England. What I am talking about here are the ones for whom the treatment exists in the UK, but just hasn't made it across to Uganda yet. For instance, we currently have had a ten year-old boy on our ward with a high output enteric-cutaneous fistula following an emergency laparotomy six months ago. This basically means that he has a connection between his bowel and the outside world through a hole in his abdominal wall; it also means that he has become incredibly malnourished as anything that he eats comes straight back out again through this defect. Whilst we want to operate on him to close this hole, his poor nutritional status means that anything that we may try to do will almost certainly fail. Instead we have been trying treat his malnutrition with high energy feeds and milk; sadly we have made no progress as he has lost pretty much everything through the fistula. We really don’t know what to do next; in the UK we would be able to give ‘Total Parental Nutrition’ (i.e. TPN, which is where all the required nutrients are infused directly into the veins, thereby bypassing the bowel and fistula). Unfortunately TPN isn't available anywhere in Uganda, and I cannot begin describe to how frustrating it is to know that a potential solution to this child’s malnutrition exists but we are physically unable to get hold of it. At times like this I really appreciate how lucky we are in the UK, both as doctors and patients; if a patient needs an investigation or requires a certain treatment they will often receive it, with little or no thought given to the actual cost. Maybe the average ‘Daily Mail’ reader should come and spend some time in an African hospital before they start to criticise the NHS again. 

The Surgical Ward at Kagando

One of the things however that I admire most about the Ugandan healthcare system is how resourceful the people are; if a patient is unable to afford the best cure or the most appropriate treatment is unavailable, healthcare workers will always try to come up with an alternative option. Even when we run out of the basic hospital supplies, such as gauze or iodine (which happens a lot more frequently that you would imagine), rather than causing a fuss and refusing to work, people here just accept it and look for an alternative with what they already have. This is not to say that I haven’t had to make some difficult decisions during my time here. With a limited number of oxygen concentrators in the hospital I have lost count of the number of times that I have had to decide which of our critically unwell patients need the oxygen more; when their needs have been equal I have had to ration them to a couple of minutes each with the face mask, something which is unheard of in the UK.

The Practicalities of being a Ugandan Doctor

One thing that I am immensely jealous of my Uganda colleagues for is the amount of paperwork that they have to do (or rather, lack of). In the UK I can quite easily spend the best part of an afternoon sat in front of a computer screen mindless typing out discharge summaries, referral letters, or anything else that my seniors deem important but are unable to do themselves. With no computers and only small pieces of card and paper to write a patient’s entire discharge history on, paperwork takes up significantly less time in Uganda; there are no computers to book investigations on, and referral letters need all the briefest of histories (unlike the UK where you have to include everything from where the patient does their weekly shopping to how many times they have had a cold in the last ten years before someone will even consider looking at it). The flipside of having no computers in the hospital is that you can’t look things up; whilst this definitely has its advantages as it has encouraged me to go back to using good old fashioned text books rather than relying upon ‘Google’ all the time, there have been several occasions where what I have wanted to know just hasn't been in any of the books available to me. For instance, about a month ago I was called to see a critically unwell patient who had taken an overdose of Aluminium Phosphate (a form of rat poison). In the England I would have been able to access ToxBase (the UK’s national poison register), where I would have instantly found out exactly what this drug was and how best to treat it; in Kagando there was no internet access in either the hospital or our accommodation, and none of the books that I tried listed this poison. Instead I had to treat symptomatically, assuming that aluminium phosphate was a form of organophosphate. Despite the best efforts of the team that I had with me, the patient continued to deteriorate in front of me, and eventually arrested. It was only later that I found out that aluminium phosphate was not an organophosphate, and although I wouldn't have changed my management in this case as there was no known antidote, it still reminded me of how lucky we are in the UK to be able to instantly look up almost anything on an endless supply of online resources.

I think it’s fair to say that a Ugandan doctor has to work hard each day to earn their wages (which is significantly less than what we get in the UK). However, the sad reality is that all of those who are employed by the government have not been paid in over three months. Although they are unsure exactly why, it is thought to have something to do with the government running out of money. Whilst they should have been protected by a contract, as it turns out not many doctors in Uganda have one. However, they don’t seem too worried about the lack of a contract, and even appeared quite upset last week when there were rumours in Kagando that the management were going to make everyone sign one if they wanted to remain employed.

In the UK the public’s expectations and awareness of the NHS has increased over the past few decades, and as a result the rate of litigation has also risen. Whilst a doctor should always be cautious and only act within their competencies, the threat of being sued has meant that even if a trainee is fully competent with a certain procedure, they are often less willing to perform it without someone more senior being present (or at least nearby). Although this is by no means a bad thing, it does however mean that things can frequently take twice as long to complete (and that is before you even start to consider the endless pages of paperwork that need to be filled in once you have finished). Unlike the UK, this culture of litigation doesn't exist in Uganda; even if a person wanted to take a doctor to court, in most cases they wouldn't be able to afford the legal fees. This is not to say that doctors don’t get sued, but it is such a rare occurrence that hardly any of them have indemnity insurance. The consequence of this is that the doctors here have a greater sense of freedom with what they can choose to do. This is not to say they are irresponsible or act outside of the competencies; nothing could be further from the truth with regards to the doctors that I have been fortunate enough to work with Kagando. What I mean instead is that with fewer doctors and less senior support they frequently find themselves in the situation where they are the only ones who can do something for a patient. If there are no other doctors and a patient requires an operation that they are unfamiliar with, they will show a tremendous amount of initiative by going away to learn about the procedure; if after this there really is no other alternative and they feel confident with the technique the doctor will often attempt the operation themselves. For instance, we recently had a lady on our ward who had had her lower lip bitten off by another woman following an argument. Whilst this made eating and drinking very difficult, she was unable to pay for a referral to a plastic surgeon for reconstructive surgery. Realising that no one else was going to operate on this lady, Naomi went away to learn about the procedure herself. Despite having never performed reconstructive surgery before, her attempt was highly successful and the patient was able to eat and drink again with no difficulties. During my time in Kagando I have had multiple opportunities myself to learn how to do several different procedures, including caesarean sections. However, I have had to decline theses offers; I would not be allowed to do these operations in the UK at my current level of training, and I don’t see why things should be any different just because I am in Uganda.

Kagando's Operating Theatre

Fellow Colleagues

In the UK I have grown accustomed to working in a large team of other doctors; even when you think you are on your own there are always people nearby that you can ask for help. Unfortunately the luxury of working in large teams doesn’t exist in Uganda; with so few doctors in the entire country they will often find themselves having to look after a ward of forty or more patients by themselves. Whilst this may happen occasionally in the UK, you always know that it is only temporary as your consultant will be back the following day. However, in Uganda there is often no senior support, and the doctors (who are often at the same level of training as myself) have to work alone for months on end. Whilst the sheer workload of looking after a ward by yourself is hard enough, with nobody to double-check their work, the doctors here have the constant worry that they have missed something important or made a mistake that will never be corrected. If this isn’t bad enough, the lack of other doctors means that the ones that are here have to be on-call almost all of the time; even when they are meant to be off, the nurses on the ward are almost always guaranteed to call them in for one reason or another. 

The Surgical Ward at Kagando

Whilst there may not be many other doctors to work with, there are always other members of staff that help with the day to day running of the hospital. A large proportion of the workforce is made up of nurse; like in England there are those that are amazing, some that are good, and a couple that are pretty bad. However, I have too much to say on this topic to be able to include it all here and will instead save it for another blog. Also, unlike the UK where you have to be a doctor to work as an anaesthetist or radiologist, in Uganda these jobs are normally carried out by clinical officers. These are people who were usually nurses before and have undergone a further eighteen months of training in their chosen speciality (similar to a nurse practitioner in England). It is also very interesting to speak to people out here about their views of doctors. The charge nurse on the surgical ward was telling me that there are still a few old school doctors in Uganda who expect nurses and other members of staff to literally ‘stand up and bow down’ in front of them every time they enter a room; it is nice to know that we still share some similarities with Uganda.

The Patients

Of course, no doctor would be able to carry out their job without having any patients to look after. Although the population is varied, the patients that we tend to see in Kagando fall into the category of the rural poor where the main source of income is from farming. Whilst most come from the surrounding villages (where they speak the local language of Lokonzo), Kagando is only twenty or so kilometres from the border with the DRC, and as a result we often see patients from The Congo in our hospital. With such a mix of tribes in the area, even Uganda doctors (who are often multi-lingual) can’t possibly  be expected to speak all the different languages, and therefore have to conduct most of their consultations through an interpreter (i.e. a nurse). However, unlike the average British patient who has incredibly high expectations of the NHS and will subsequently question everything that you do, the patients in Kagando are a lot more accepting of what you tell them; I don’t think I have been asked even once about my choice of treatment during my entire three months here. 

It is not just the cost of the medical care that a patient is expected to pay for whilst in hospital; they must bring in their own bedding and cook their own food. As most of them are too unwell to do this for themselves, an attendant (normally a family member who sleeps on the floor besides their bed) must do this for them. If they have no relatives, they simply can’t eat. However, whilst I am well aware that I may have created a rather negative theme throughout this blog, I would like to take this opportunity to point out that not everything is so bad.  We had a man on ward several weeks ago who was HIV positive and has sustained a broken leg. Unfortunately he had no attendant, and was too unwell to cook for himself. However, rather than letting him go hungry the relatives of the other patients would share what little food they had with him; it is nice to know that even in the most deprived areas people are still able to show a small amount of compassion. 

I am due to leave Kagando tomorrow, and although I have thoroughly enjoyed my time here and learnt a lot in the process, there is a small part of me that is very much looking forward to working in an English hospital again. Amongst other things, I have come to realise how fortunate we are to live and work in the UK; all healthcare free, and as doctors we have the resources to treat anyone who is sick - irrespective of how much money they have. Whilst it is not without its faults, I personally believe that the NHS is by far the best healthcare system in world; perhaps after reading this blog some of you may start to think this too. 

The Training of a Ugandan Doctor

Like so many other Doctors in the UK, I have been known to complain on the odd occasion about how hard my job is and the fact that I feel more like a paper-pushing administration monkey than an actual doctor. However, after spending the last two months working alongside Uganda doctors, I think it is fair to say that we definitely have the better deal; with an almost unmanageable patient load, limited diagnostic options and even fewer treatment choices, life as a Ugandan doctor is far from easy. Yet, despite this relentless workload and the near impossible expectations that are placed upon them, the doctors that I have met never appear to complain, and are instead passionate about their career and grateful for any opportunity presented to them. 

I have therefore decided to write my next two blogs with the aim of highlighting the difficulties that a Uganda doctor faces not only during their training, but also throughout their daily working lives. It is my hope that if any of my colleagues in the UK read this, they may be convinced that we really do have very little to complain about, and instead should be grateful for all the opportunities and support that we have received during our medical careers; suddenly the endless discharge summaries or the occasional missed lunch-break appear almost insignificant compared to what a Ugandan doctor has to endure on a daily basis.

Medical Training in Uganda

 

As in the UK, Ugandan medical school lasts for five years, and consists of two non-clinical years and three clinical years. However, unlike British medical students who have little responsibly and tend to turn up to a ward when it suits them, Ugandan medical students are each assigned duties and patients to look after, and are very much included as part of the medical team. Furthermore, whilst we had very little exposure to clinical procedures outside of the usual cannulation, catheterisation or, if you were lucky, the occasional bit of suturing, medical students here are expected to learn how to perform procedures that are technically more advanced, such as minor operations or caesarean sections. Also, unlike the UK where over sixty percent of classes are now made up of girls, Uganda is still a country where medical students are predominantly male (despite girls getting an extra point on their application form – just for being female). 

In the UK, once you take into account all of those who fail their finals and have to repeat the year, everyone who graduates will ultimately end up with a foundation job (albeit somewhere they may not want to be). In comparison, although there are theoretical jobs in Uganda for all of those who graduate, the government cannot afford to fill all of these vacancies. As if to prove this point, during my time at Kagando there was a final year Ugandan medical student who was on her last placement before qualifying. Whilst she was here she found out that of her forty seven class mates, only eleven of them had been successful in finding jobs; unfortunately she was not one of them. For those medical students who are fortunate enough to secure themselves a job, medical school is followed by one year of internship (the equivalent of our two years of foundation training). During this year they will be expected to complete rotations in paediatrics, obstetrics & gynaecology, medicine and surgery, and whilst these rotations are often in separate hospitals spread throughout Uganda, they are only given two weeks’ notice of where their next placement is to be (the six months’ notice that I was given before starting my foundation training in Dorchester doesn't seem so bad now). As with our foundation programme, this intern year is supervised and the trainee is expected to fulfil certain criteria before being allowed to pass the year. However, compared to the UK where the first year is mainly about paperwork and you aren't allowed to so much as sneeze without your seniors being aware, a Ugandan intern has much greater clinical responsibilities. For example, by the end of their first year as doctor an intern would be expected to be able to carry out a certain number of surgical procedures on their own, including a caesarean section (something which you wouldn't be allowed to perform by yourself in the UK until you had completed at least several years of obstetric training).

Following the completion of their internship year a Ugandan doctor becomes a Medical Officer; similar to a ‘staff grade’ in the UK, this position is not included as formal training and lasts for an indefinite amount of time. During this period they rotate through the different specialities, gaining more experience before eventually applying for specialist training.  Despite being qualified for as little as a year, a Medical Officer has a great amount of clinical responsibility, and can often be the most senior doctor of a particular speciality in the hospital. This is true for Naomi, the surgeon who I have been closely working alongside; she had been working as a medical officer for a little over a year, and since our Consultant left at the end of April she has been the most senior surgeon in Kagando.  However, despite only being qualified for two years she is incredibly competent and can perform most procedures that a British surgeon could only do after three or four years of surgical training, such as a complicated skin graft or emergency laparotomy on young children. 

For a Ugandan doctor to become a specialist, they must first complete a three years Masters in their chosen field. However, unlike the UK where our specialist training is free and we still earn a decent wage whilst we are learning, a Ugandan doctor must find sponsorship to pay for their training programme. Furthermore, despite having to work and study full time, they don’t receive a salary for the whole three years, and instead have to find night or weekend work to cover the costs of their daily living; somehow having to pay for exams and membership fees in the UK doesn't seem like such a bad deal now. Following the completion of their three years Masters programme a Ugandan Doctor will become a consultant. However, unlike the UK where a Consultant is very specialised, due to the high number of patients and shortage of doctors in Uganda they must remain a generalist. For example, whilst a surgeon can operate on a perforated bowel one minute, and perform a complicated thyroidectomy or mastectomy the next, they still retain enough general medical knowledge to be able cover the medical and paediatric wards when required. Can you imagine telling an orthopaedic consultant in the UK that that they had to cover the acute medical ward, or asking a paediatrician to perform an emergency laparotomy?  Whilst this would never happen at home, is more than an occasional occurrence in Uganda!

 

Whilst the training of a Ugandan Doctor is difficult, some may argue that their daily working lives are even tougher. I have been fortunate enough to have a small insight into the many barriers and difficulties that they face, although I have too much to say to be able to include it all in this current blog. Instead I plan to write a second entry that will allow me to share some of these experiences with everyone at home. However, it is my last week in Kagando and while I hope to finish it within the next few days, with a special ‘Vesicle Vaginal Fistula Camp’ planned and some loose end to tie up, I will apologise in advance if it takes a bit longer than this to actually be published.

Speak Soon

Half-Term Holiday in Rwanda

When most people think of Rwanda, they imagine a tragic country with a violent past; a country where, in 1994, over one million innocent people were slaughtered in what was to become one of the worst genocides that the world has ever seen. However, despite its deep scars, if you delve a little deeper into Rwanda you will discover a small country that is rich is culture and full of optimism for the future. With ancient volcanoes, bamboo rainforests and the picturesque Lake Kivu, it is easy to see why tourism is rapidly becoming the country’s leading source of income. Having passed to within a stone’s throw of its border with Uganda when we trekked the gorillas in Bwinidi National Park, both me and Sophie felt that this was the perfect opportunity for us to finally visit Rwanda and learn a bit more about this diverse, yet tragic country.

We decided to travel on Monday 26^th May, and after a surprisingly smooth border crossing at Cyanika we found ourselves in Rwanda. Now, I'm not sure about anyone else, but when I walk along no-man’s land, I half-expect the scenery that surrounds me to magically change as I cross from one country to another. However, with the exception of the occasional French signpost, the Rwandan side of the border looked identical to that of the Ugandan. Our driver to the border that morning had been called Ema, and he subsequently found it rather amusing that Emma was a girls name in the UK; he was also from Rwanda, and, in an act of kindness that is so common in Africa, insisted on accompanying us across the border and helping us onto a bus. The transport that he found for us was in the form of a matatu minibus (a.k.a. tin can on wheels), which, after stopping every two minutes to squeezed more and more passengers inside, finally arrived at Musanze bus station. Having spent the best part of an hour cramped together on the backseat of the matatu, me and Sophie were very much relieved to find that the bus to our final destination of Gisenyi was considerably more comfortable; we were even allowed to have an entire seat to ourselves, rather than having to share it with two others.

Gisenyi (26th – 29th May)

Located in the north-west corner of Rwanda, the town of Gisenyi sits idyllically along the shoreline of Lake Kivu, which, with a maximum depth of over five-hundred meters, is thought to be one of the deepest lakes in the world. However, whilst this lake may appear to be a perfect example of tranquillity, it has a rather dark past as it was here that the bodies of many genocide victims were disposed of, only for them to be washed up several days later along the shoreline of the neighbouring Demographic Republic of Congo (or DRC for short). Lake Kivu is also one of only three lakes in the world that has the potential to explode; when carbon dioxide suddenly erupts from its deep waters a large explosion is produced that is capable of suffocating all living things in its path. However, these so called ‘limbic eruptions’ have only occurred twice recent history (albeit with human fatalities on both occasions), and with Gisenyi being described as the ‘St Tropez’ of Rwanda, me and Sophie decided that we would take the risk and spend three lazy days relaxing on the shore of this picturesque lake.

Having spent the best part of an hour driving past mountains and through tea plantations, we finally arrived in a small town that we thought could be Gisenyi. However, no one on the bus seemed to be able to tell us exactly where we were, and, deciding to take a gamble, we jumped off the bus into the sweltering midday sun. After walking up and down the road for the next fifteen minutes, desperately trying to find someone who spoke either English or French (Rwanda’s national language is French, although there has been a recent political move to change this all into English), we finally found a man who was able to confirm for us that we were indeed in Gisenyi. Our hotel was only a short taxi drive away, and after passing sandy beaches and rocky cliffs that reminded me of holidays in the South of France, we finally arrived at Paradise Malahide, our home for the next three nights.

Lake Kivu

The hotel itself was located on the shore of Lake Kivu, and consisted of several small bungalows that were surround by colourful flowers and lush mango trees. After waking up the sound of the waves breaking each morning it would have easy for us to convince ourselves that we were on our own little tropical island. There was also a rather intimate restaurant attached to the hotel which contained traditional wooden furniture, interesting artwork, and even an indoor campfire. With nothing to do all day apart from relaxing on the private beach and gaze out at the mountains of the neighbouring DRC, both me and Sophie were concerned that we would soon grow restless and be wanting to leave before our time there was up. However, despite only leaving the hotel once to buy water in the local village, we were never bored and those three nights went by all but too quickly. We passed our days lounging by the lake, watching the many small fishing boats leaving at sunset (only to return the following morning to the sound of chanting), whilst our evenings were spent sat in the restaurant, huddled around the campfire. The staff themselves were incredibly friendly, and would literally bend over backwards to make sure that me and Sophie were okay; we were even presented with a small cake wrapped in a  banana leaf as we were leaving for the Kigali - just in case we got hungry on the bus.

Kigali (29^th May – 1^st June) 

Now, anyone who has travelled by public transport in Africa will be all too familiar with the African version of  departure time; irrespective of what time the bus was meant to have left, it will sit in the bus station (often for several hours or more) until every seat have been filled. However, Rwanda was a breath of fresh air, as, in addition to their policy of ‘No Plastic Bags’, they insisted that all buses should leave on time. Whilst me and Sophie didn't believe this to be true, we were soon proved wrong when our bus to the capital city left exactly when it was meant to (and without all the seats being occupied). A little under three hours later we arrived at Kigali bus station, and were promptly mobbed by the mass of taxi drivers who all wanted to take us to our hotel. Whilst taxis in the UK are required to display a form of identification to confirm that they are a licenced driver and therefore safe to use, the Rwanda way to do this is to merely wave their car key at you (as if by having a vehicle confirms their eligibility as a taxi driver). After picking one of these drivers at random, we proceeded to drive to our hotel, ‘Heaven Inn’, which we had booked for the next three nights. Being more of a restaurant than a hotel, ‘Heaven’ consisted of a large outdoor dining area which had stunning views over Kigali and its surrounding hills. There was also a brand-new art gallery on site, and it was though here that the three bedrooms (ours being one of them) were located. 

The remainder of our afternoon was spent exploring Rwanda’s capital and indulging in a little bit of ‘westernised’ culture. With indoor shopping centres, coffee shops and a multi-screen cinema, it would have been easy to mistake Kigali for a European city; with a supermarket that sold an array of western food, including ‘Marmite’, ‘Nutella’ and even ‘Dorset Cereal’ (albeit for about ten times the price of what we would usually pay for it in the UK), Kagando and its small village market was soon becoming all but a distant memory. By the time that we arrive back at ‘Heaven Inn’ the opening night of the art gallery was fully under way, and all the ex-pats in Rwanda were there to join in with the celebrations (or at least that was how it appeared to me and Sophie who had grown accustomed to being the only white people in a small Ugandan village). Neither of us felt partially sociable that night, and after eating dinner we promptly retreated to our room, leaving the mingling and art-themed talk to people who were considerably much cooler than ourselves.  

Dorset Cereal selling for £10 in Kigali

Whilst we could have wallowed in westernised comforts for our entire stay in Kigali, both me and Sophie felt that we could not have come all the way to Rwanda without spending at least a small amount of time at the genocide memorial. Having decided to dedicate our second day in the capital to doing just this, we passed the better part of the morning walking from exhibition to exhibition, leaning more about the violent history of this country. The memorial was spilt into three sections, with the first being about Rwandan Genocide itself. It was here that we learnt about how in 1994 over one million innocent Tutsi's were slaughter by the Hutu government in just a hundred days; all whilst the rest of the world looked on and did nothing. By targeting the women and children, those who were the most important for the succession of the Tutsi tribe, the results were devastating. Even in those who survived, the lasting effects of torture and sexual abuse left deep running scars that are still present today. And if the stories weren't sad enough, there was a room at the end where the victims’ family could place a photo of their loved ones, thereby ensuring that the world would never forget their faces.

The second section of the memorial highlighted some of the genocides that had occurred elsewhere in the world, and by the time that we reach the third exhibit both me and Sophie were feeling very sombre. However, whilst the previous two sections had been upsetting, the last one was harrowing enough to break even the coldest of hearts. For it was here that a few families had created a tribute to the children that they had lost, and as we walked from wall to wall reading the tragic stories of those innocent lives that would never grow up, we couldn't quite believe how evil some human beings could be. We learnt about each child’s favourite toy and their life-long ambitions, and our hearts broke every time we read about how they had been brutally murdered; for some this was too much and they had to leave the room in a flood of tears. One theme that seemed to stand out throughout the whole memorial was the fact that the Rwandan Genocide should never have occurred; not just because of the moral injustice of it, but also because the rest of the world stood by and just let it happen. As me and Sophie later walked through the rose gardens and past the mass graves, we reflected upon the main message to be taken from the genocide; that the rest of the world should learn from this tragedy, and that it should never be allowed to happen again. 

It is fair to say that following this rather emotional morning both me and Sophie felt rather subdued, and whilst it was a very educational visit we both wanted to leave as soon as possible. After finding a taxi back to the city centre, we spent the remainder of our afternoon sat in Bourbon Coffee Lounge, consoling ourselves with endless fruit smoothies and over-indulgent food. We had arranged to have dinner that evening with an old friends of Sophie’s who was now working in Kigali; they had originally met in France and hadn't seen each other for almost nine years. However, through the power of Facebook they had both realised that they would be in Rwanda at the same time, and somehow we all ended up sat together in small Italian restaurant overlooking the hills that surrounded Kigali, eating Pizza and sharing our stories of what it was really like to work in Africa.

The following day was Saturday, and was unfortunately our last full day in Rwanda. After passing our morning sat in yet another coffee shop, we spent the afternoon doing some last minute shopping and sightseeing; if anyone has seen the film ‘Hotel Rwanda’ they will be all too familiar with ‘Hotel des Mille Collines’, as it was here that hundreds of Tutsi’s were hidden during the Genocide. After a picnic lunch in our hotel bedroom (as, in a bid to save money, me and Sophie had opted to make our own lunch), we decided that we couldn't have come all this way to Kigali and not visit this famous hotel. And so, after concluding that money was no longer an issue, we proceed to have afternoon tea in the garden of ‘Hotel des Mille Collines’, watching the sun set for the last time over the thousand hills of Kigali. 

We spent our last evening in Rwanda at an open mike night in our hotel, and the following morning we set off bright and early for the bus station. As we were stood around waiting our bus to leave we met a Canadian medical student who was travelling to Mbarara for his elective, thereby proving my theory that, no matter where in the world you are, there will always be a medical student. After taking our seats on the most luxurious bus that I have ever been on in Africa, we set off for the border crossing at Katuna. However, unlike our previous crossing, this one was a lot more hectic. By following the general flow of the crowd, we somehow made it through customs and once again found ourselves back on Ugandan soil. For the next few hours we entertained ourselves by watching the Ugandan music videos that were playing in the bus; whilst the rap videos about love and money weren't too dissimilar to those that we have in England, the song about vesicle-vaginal fistulas (and the devastating effect that they have on the women who suffer from them) was certainly different!

We were met in Mbarara by our driver Sabuni, and after bidding goodbye to the medical student we set off on the long drive back to Kagando. We spent the remainder of this journey worrying about how hard it was going to be for us to readjust to our simple lives back in the village, especially after a few days of westernised overindulgence. However, as we passed familiar places along the way we slowly began to forget Kigali, and by the time that we had arrived back at our humble abode, Rwanda was all but a distant memory.