One Mzungu's Adventure
An African Journal

Article and photos by Dr. Elizabeth Blalock

In the fall of 2001 I reassessed my priorities, as did many Americans. I had always planned to retire early from the only job I ever had, as neurologist at Kaiser Permanente in southern California in the U.S.A., to serve a more needy population. With my patients with AIDS springing back to health on anti-retroviral drugs, there was no question in my mind where the greatest need was. So, I began my search on the web for opportunities to work in Africa. It was a search that greatly informed but also frustrated me, as it led nowhere with regard to work for a neurologist new to medicine in the developing world. As it turned out, the usual formula for success in such ventures is through FOAF’s – ‘friends of a friend’ – and serendipity. I mentioned my plight to a friend in New York who is not in medicine, who, incensed that I was having such bad fortune in finding placement, put me in touch with the dentist father of a friend she met at a wedding a year earlier. She thought he had gone somewhere in South America to operate on cleft palates. I called. He was the first person in a year of searching to be encouraging. He happened to know someone at Health Volunteers Overseas and was happy to make an introduction. Under their auspices, I taught neurology at Makerere University in Kampala, the capital of Uganda.

Having prepared myself by reading about Uganda, taking course work in tropical and emergency medicine, and talking to physicians who had preceded me, I arrived in Kampala in October 2002 for a 2-month stint and immediately knew that I was sorely unprepared. How does one prepare to work in a hospital overflowing with deathly ill people who will die for the lack of $20 for an antimicrobial, where the MRI I depended on is 800 miles and 2 years’ wages away, and where an 18-year war continues to deplete the funds that should go to public health? One just steels oneself, hunkers down and does the best one can.

Health Volunteers Overseas had arranged for me to stay in the guesthouse reserved for visiting health care workers. Fortunately, it was well stocked with a miniature medical library of books left by those who came before, as well as tips on getting around and having fun.

After a couple days of orientation and biologic clock retraining, I was introduced to the team of residents I was to teach. It was immediately clear that they were at least as much the teachers as I. Suddenly I, who half-joked at home when shown a rash, ‘I only do brains,” was trying to help care for every sick organ in the body. I was quickly transported back in years to medical school, where the whole human system was my domain and CAT scans were still in development.

My days were busy on wards, in lectures, in the library; nights were largely for pouring over textbooks of tropical medicine and sharing the day’s events with my housemates.
Excerpts follow from several letters I sent home to friends and colleagues, because my October and November were so different as from theirs, and because they were so different from any other I had spent before.

Dear All,
It’s Sunday afternoon, my second in Kampala. I had all my chores done by noon, a unique and very pleasant feeling I will miss terribly when I come home and find the garden still begging for my attention, the garage and rear deck wanting rebuilding, and the myriad chores that never end. It makes one think of divesting, of renting. But of course, I won’t.

It rained hard all night, as it often does here, and with a tin roof it makes quite a racket, but the day is as usual, warm and still. The weather is just to my liking.
Yesterday a friend and I went to Jinja, a small town on the edge of Lake Victoria about 1.5 hours and 2,500 Uganda shillings (US$1.50) by bus. That’s where John Speke ‘discovered’ the source of the Nile in the 1860’s. Folks here will point out that when he arrived he asked the fishermen in the river what their name for the river was, so they say he was just the first to make a picture of the place, nothing more. But, there’s a monument to him anyhow, as he was a brave and determined man. The lake is the second largest in the world, and lovely to look at, but full of crocodiles, hippos, and snails that carry shistosomiasis, so swimming is ill advised. The lake is overgrown with water hyacinths, which locals collect and feed to the pigs, or use to fertilize the fields. When I told our guide that I pay $1USD a plant for them at home he was quite amazed, and I’m sure started thinking of the possibilities.

We stopped for lunch at the Jinja Sailing Club – no sailboats, no membership, but enjoyed wonderful fried Talapia, fresh from the lake, and then returned to town via bicycle taxi. There are hoards of young men who provide lifts for a living wherever you go, with bikes fitted with padded seats over the rear tire. On arrival in town 10 minutes later, they wanted 15,000 shillings each! They thought they had a couple of country bumpkins. After a good-natured discussion, they laughed and left with 1,000 each.

Town looks a bit like Dodge City: broad dusty roads and storefronts opening out on covered porches on which vendors and tailors work at pedal-powered sewing machines. Most of the children greet us enthusiastically with ‘how are you?’ which is usually the limit of their English, and shake hands with us. The digital camera evokes a lot of amazement and broad smiles from all who see themselves captured there. Some will ask for money for their photos, which they think we will sell at home. After convincing them I am no commercial photographer, they pose for free, except those who fear the power of the camera, and there are many, so one must ask permission first.

The week has been very full. When I don’t have a lecture to give or attend, or medical students to teach, I join rounds with the senior residents and their attending physicians, contributing when I can, which is pretty often with all the encephalopathy cases on the ward. There’s even a case of “sleeping sickness” - trypanosomiasis, caused by a parasite passed by the bite of the Tsetse fly. There was an epidemic early this century that killed two-thirds of the population at the shore of Lake Victoria, but there are only a few hundred cases yearly now. The current problem is getting the appropriate drugs for patients, as the manufacturers are less enthusiastic, the demand being low. They are still searching for a supply for this man. Isn’t it funny how if you name a disease ‘sleeping sickness’ and a bug ‘tsetse,’ we will remember it?

I have learned my way around the wards. I know where the working loo is, where I can get a hearty lunch of Matooke, rice, goat meat, Talapia, soup, millet, how to find current literature in the library - journals from 1900 to the 1980’s are on the shelves, and anything newer is kept secure. I recognize many of the staff by name, and have had visits from a few. My Luganda remains limited to ‘webale nyo’ or ‘thank you very much,’ but I have purchased a phrase book and have hopes.

With warm thoughts of home, and remaining hopeful for a future for Africa,

Love, Elizabeth

My dear friends,
It’s Thursday evening and as I sit on the screened-in front porch of my little yellow house watching the rain clouds come and go over the corrugated tin fence, while the monkeys play in the yard, I miss home. An occasional rainstorm comes of an afternoon and is a welcome drama in otherwise consistently balmy days.

Time is flying by. I have been here for four weeks and it feels like days. But I know my way around, know folks by name and they me, and I have finally found a computer that works, at least first thing in the morning, at least most of the time, though it’s expensive: 3,000 Ugandan Shillings per hour ($1.75USD). It’s quite interesting how one’s perspective of cost and value adjusts to local standards. What is initially a great deal becomes highway robbery as soon as you know you can get it for much less at the shops for locals. When a taxi driver asks for 5,000 when a trip should cost 4,000, one argues, though it’s not about the difference, of course: it’s about being accepted, being ‘in’.

Other things have changed too. I haven’t worn black and my thighs have not seen the light of day since I arrived. Ugandan women do not bare their legs from the knees up, so neither do I, though in the hospital they will strip to the waist without a second thought. Yesterday in clinic I saw a Sudanese refugee with von Recklinghausen’s disease. In a small room with three physicians and at least as many patients, she removed her blouse without a moment’s hesitation to show me the lesions. I was the only one uncomfortable. Imagine what they would think of our huge preoccupation with the mammary glands, which I guess we’d get over if we made as much use of them as the women here do.

And I haven’t danced once, had a drop of tequila, coffee or tea – a holdover from the British, who also left very English manners. People are very cordial. They don’t say ‘Hi’. It’s ‘Good morning madam,’ or ‘Good evening’. When you present yourself at an office they say, “You are welcome.” It’s nice, genteel.

Despite the poverty, people dress up. Many women wear a traditional Ugandan blouse with peaked sleeves over an ankle length full skirt in colorful patterned cloth, often with a brocade sash. Nothing seems too dressy for daytime. Or Muslim women wear long flowing scarves. Men are in shirt and tie, or a long straight white muslin gown over slacks. I have seen no begging.

Being a physician allows one a more intimate view of a society. Many male patients are polygamous. I saw a man with a stroke who was presented to me by the resident as “Mr. ___ from _____ of the ____ tribe who has 11 wives and 35 children was admitted with ____,” etc. Not a beat was skipped. None of the 11 was at his bedside whenever I performed rounds, but that was unusual. At times there were two or three wives tending to a patient, and sharing the chores amicably, it seemed.
In pediatric neurology clinic one might see a beautiful baby all dressed in a frilly dress and hat, and only discover on doing a thorough exam that it’s a boy baby. They just like dressing up their babies till they’re two or so. Speaking of gender matters, men walk hand in hand here. Just because they are friends. It’s nice to see.

A different view of society is gleaned through the newspapers. There are two here, most of the time: the government-run New Vision and the independent, The Monitor. The latter was closed for a week and its offices ransacked by the government because they reported that rebels in the north shot down a government military helicopter. The government didn’t say exactly that it didn’t happen, but that the report undermined national security. The Monitor is back open. Someone reported that helicopter parts were seen being trucked off in a pickup truck, but the government said that was ridiculous. Those parts wouldn’t fit in a pickup truck.

The war is presented as a conflict among thugs called the Lord’s Resistance Army, led by a madman. They are said to have no political or religious platform, and have no uniforms, making it hard to identify, kill or capture them. The daily front page reads like the sports page – how many of which side were killed by the other. Often the killings, by the LRA at least, seem random or retaliatory, and the victims just village people. It’s senseless, and everyone seems to think so.

There’s also lots of coverage about graft: millions of shillings missing from this account or that. Today it was 396 million missing from the coffers of the hospital where I teach, where patients who can’t afford medicines die, and many would not be ill if there was money for medicine and immunizations. One of my patients last week was going home to sell his farm so he could get an MRI in hopes of recovering the use of his legs.

The ‘jungle junk cyber café’ is closing and I am off to see the gorillas in the morning, so more on my return.

Elizabeth

Hello my good friends and relations,
I started out this afternoon to attend three African movies at the National Theatre downtown. I arrived to find the electricity down, so I walked toward the British Embassy to drop in on a friend. But the sky opened up without much warning, and finding myself between the Web City Cafe and the Catholic Cathedral, I chose the former, and here we are, dry and cozy. Things here rarely happen just when and how they are planned. It is called ‘African time’.

It has been another eventful week for me. I went off for the weekend to see the mountain gorillas, and see them I did. There are a few groups in the mountains in the southwest of Uganda and neighboring Rwanda. Three groups in Uganda have been ‘habituated,’ which means they have spent sufficient time with the trackers that they are no longer threatened by their upright brethren, and don’t charge. As a matter of fact, they don’t pay us any mind at all. We trekked for about 3 hours up the mountains of the Bwindi Impenetrable Rain Forest and found two females and a five-month old lounging in the bushes.

The trip there, a long nine hours, half of which on winding and potholed dirt roads, is through beautiful countryside. The hills are terraced and every inch is planted in patches of millet, tea, sweet potatoes, and banana and spotted with small mud one-room houses with thatched roofs. At night candle light glows in the windows, and it seems so serene. Everyone totes something: water, firewood, bananas, and furniture on heads, backs, and back seats of bicycles. Children barely three carry littler ones. And all along the route the children notice the Muzungus, or Caucasians, in the van and run along waving and smiling with such happiness with what seems a great novelty. I felt a bit like the queen waving from her carriage.

Second excitement has been the arrival of The Twins. Perhaps you heard. Last October a peasant woman from a small village in the north delivered a set of conjoined twins there. They were transferred here to Mulago Hospital, and after some considerable arranging, were taken to the States by one of the other HVO volunteer physicians here at the time. They were successfully separated and have thrived. They returned this week with the doctor, their physical therapist, and a crew of news folks from Dateline and NBC who recorded their every squeal. They are healthy and absolutely charming. After a week of making the rounds of the Ministry of Health, and performing at press conferences and dinner parties, they are safely back in their village, and life here is hum-drum again.

Work at the hospital remains challenging, intellectually and emotionally. I have learned a great deal, and find myself becoming a better teacher and enjoying it more.

My love to you all,
Elizabeth

20-11-02, a palindrome
Greetings from Khartoum, The Sudan. And as flat and dry and brown as it is, I am happier to be here than anywhere I have ever been in my life. I left Kampala for London this morning with a book to finish, my knitting, stories and reflections to compose to you, and, serendipitously, a woman I had met in Bwindi trekking the gorillas was my seatmate. We bonded, and had quite a lively chat going when the chief steward interrupted all conversation and deflated everyone’s mood, except the children who kept up their cheery play, by announcing ‘We are having a mechanical problem and will be landing in Khartoum. Please put on your seat belts...’ Nothing more. I thought I heard a nervous quake in his voice.

The next twenty minutes were each one’s personal hell. The Ugandan woman to my left prayed. I left the praying to those more practiced than I, figuring no god would be happy to hear from me only when in dire straits. The view, port and starboard, was only sand, and the Nile. I looked to the faces of the stewards for confidence, and found none. With nothing more to do I wished only for the miles to fly literally and figuratively by. And they did. It was a tipsy ride: too-fast descent, depressurization, the heat off the desert, and the jangled nerves of the pilot, but we landed safely.

There had been ‘acrid smoke’ in the cockpit, the captain told us later, and they had had to use oxygen masks, dump fuel, and land as quickly as possible. Luckily we were just at the edge of the Sahara. If we had been farther along we might have found out how 767s land on sand dunes. We were five hours on the ground, stuck on the plane looking at the Khartoum skyline, and putting our hearts back in our chests and quietly rejoicing at still being whole, while the engine was repaired.

So now, a day later, I return to the States a bit more affected by my trip to Uganda than I expected to be.

Love, Elizabeth

1 December 2002
As whenever I have been away for sometime, I had forgotten how beautiful Laguna and the canyon are. And the winds have blown the smog out to sea leaving the sky as blue as it is meant to be, and the clouds as white and billowy as in Africa. Friends welcomed me back with an equal measure of “Oh, I missed you so much” and “Back so soon?” with lots of affection and curiosity. As anticipated, the mending, the rickety second step on the front porch and the loose doorknobs were just as I left them.

It took me a few days to get into my car and drive, the flat tire and dead battery notwithstanding, opting to walk to town and back. Though there were no monkeys, roosters, nor long horn cattle en route, I did finally meet the old woman who lives behind the boarded up, tarpaulin-roofed antique store that I have passed for years wondering who lived there. She was sweeping the walkway out front and paused for a chat we never would have had had I driven. Maybe I will meet some more of my neighbors I have missed over the past 20 years if they will walk too.

In telling the stories of my Uganda adventure, I focus on the beauty of the lush green hills, cultivated to the peaks; the elegant, handsome faces with coal black skin and bright smiles; the pleasures of teaching, and studying; the wonderful fruits and vegetables, and great Indian restaurant food. I edit out the tragedies that were, and are, on the wards at Mulago Hospital everyday, year in and out. They are more stark and painful from a distance. When you are in the midst of a calamity and have a job to do you steel yourself, accept limitations, do what can be done. But from a distance, from the comfort of home, the immensity of the impact of the AIDS epidemic is undeniable, and you even wonder if your efforts made any difference at all.

Today happens to be World AIDS Day. I am not sure what or who to commemorate. The scientists striving to develop therapies and perhaps a cure, the philanthropists who try to right the wrong of inequitable access to treatment; the educators trying to stem the spread of a disease caught when making love, giving birth, breast feeding; or those who have died with AIDS or who have been left behind infected, in poverty, orphaned, or all three. It is
not a day for celebration, and if there is a protest I
haven’t heard about it.

Several friends have asked me for information on opportunities to contribute to the care of the people of Uganda. Here are a couple I think are very worthwhile because 100% of the funds go directly to life saving efforts. There is a fund at the Mulago Hospital, which is used entirely by house officers to pay for medicines or imaging studies for inpatients who cannot afford them. There is also a non-profit organization, “The Meeting Point Kampala,” which helps to educate, feed, and support orphans in a day program, or arrange for their care in boarding schools.
The routine of the past 28 years begins again tomorrow morning at 9 a.m. – three consults, three returns, lunch, repeat as above; repeat daily times 5; weekly times years. Don’t pass ‘go’. Get a gold watch. I am looking forward to the home stretch.

I wish you all good fortune, good health, the love of friends and family, and very happy holidays. And I thank you from the bottom of my heart for all your kindnesses and encouragement.

With much love, Elizabeth

Epilogue
It is now a nearly a year later, and I have retired from my first world job. After a few months dedicated to those chores and pleasures, I have been too busy for too long: with the garden, books, and friends neglected, I will head back to Uganda. I’ll be better prepared this time with the right books, paper for copying, laptop, lectures prepared. But I don’t think I will ever be prepared for the tragedy that has befallen the men, women and children of Africa, and the stark contrast between their daily struggles and ours.