We have just received this update from Paul Williams, volunteering with VSO in Bwindi with his partner Vicky:

June has been an exciting month at Bwindi Community Hospital. Power has finally arrived, and although it will eventually be fuelled by a hydroelectric system, that project has yet to be completed so generators currently power the Hospital. We have 60 large batteries that are charged by the generators during the day and then power the Hospital at night. The arrival of power at Bwindi Community Hospital means that we will be able to keep newborns warm at night, our midwives will not have to deliver babies by the light of lanterns, and our doctors will not have to stitch up wounds using headlamps.

During May, Bwindi Community Hospital welcomed its' newest team member- a brand new Toyota Landcruiser ambulance for our HIV outreach team, modified to be able to navigate the rough local terrain. We can now take HIV testing and treatment services out into the villages of this remote area instead of waiting for people to walk for a day or more to get to Bwindi Community Hospital in order to receive care.

Bwindi Community Hospital will never forget that it came into existence because of the need to provide healthcare for the Batwa pygmies. In June we opened a satellite clinic, close to the Batwa settlement of Byumba, about 20 kilometres from Bwindi. If you think Bwindi is remote, then Byumba is extreme. The health centre has been opened in order to provide much needed services to the local population in this incredibly isolated area, including the Batwa community. Byumba Health Centre will focus on providing antenatal care, increasing access to family planning, and immunisations, as well as providing basic treatment. They even performed one delivery during the first month that they were open. Urgent or complex problems will be referred to us at the Hospital.

The Children’s ward is the busiest in the hospital. There are up to 90 admissions a month with conditions like pneumonia, burns and malnutrition. A large part of the work of the children’s ward is education and prevention. Mothers of malnourished children work in the demonstration garden and have cooking lessons. Family planning, immunisations and mosquito nets are offered to all families admitted to the ward.

You do not improve health by building a nice Hospital and waiting for sick patients to find you. Prevention and education are fundamental. The Hospital has a Community Health team who spend every day in the field giving education and treatment to thousands. They teach in every school - about water safety, sanitation and good nutrition, they sell mosquito nets at subsidised prices in churches and do special outreaches to Batwa pygmy settlements. This includes immunisation to ensure that we reach the very poorest children.

The last twelve months have been a time of expansion and delivery in Bwindi Community hospital. We published an ambitious strategic plan on our website in July 2008 and by the end of June 2009 had delivered 75% of it. The hospital has limited resources and is located in a remote part of Uganda where poverty abounds. Every single percent represents a huge amount of hard work from the team.

Staff at Byumba Community Health Centre

Child on children's ward

First of all, on behalf of all of us at VSO, I want to thank everyone who has given a gift for this appeal and who bought friends and family some VSO volunteer hours for Christmas. We are extremely grateful, and send you our very best wishes for the coming months.

The last update promised you news from Nurse Duncan Smith, volunteering as a trainer and tutor in Kampala. Duncan is on a 2-year placement from June 2007 to June 2009, providing care for desperately ill patients in Kampala, Uganda. He is working with students to develop their nursing skills in addition to running regular training workshops and courses. Many nurses in Uganda are extremely disempowered and consequently people in Uganda are dying because of poor nursing care. Duncan hopes the new school of nursing and the curriculum he is teaching will help increase nurse morale and lead to improved patient care. As you will see from this extract of his update below, there are difficult challenges. Duncan’s input is vital to establish and sustain a momentum to improve healthcare, starting with training the next generation of nurses and sharing good practice with them.

To see Duncan’s earlier update and to link with a VSO volunteer for just £10 a month, have a look at www.volunteerlinking.org.uk

Report from Duncan Smith, VSO Volunteer in Kampala, Uganda November 2008

“Hello everyone

Work has been eventful. The organisation where I am based has been working for the last 18 months to license, open and operate a University of Health Sciences. I am pleased that despite the University being named the International University of Health Sciences the majority of the staff are indeed African (if not Ugandan then Kenyan).

The organisation hopes to develop a more modern learning institution promoting student centred learning and trying to challenge the talk and chalk culture that exists in Uganda from primary schools right through to higher education institutions. This all sounds great of course, but this aim in itself is going to require a massive level of commitment, dedication and hard work from all parties. The power gap between lecturers and students in Uganda is massive and this fuels the image that academics are inaccessible to students and just to be obeyed rather than questioned or, heaven forbid, challenged. All of these deep seated expectations will need to be turned on their head.

I have been allocated to teach the whole of the Anatomy module to the BSc (nursing) students which equates to about 120 hours of teaching. I am hoping to use the anatomy CD ROMS I have collected to make this a little more interesting and 3D, rather than students staring at labelled diagrams in books for 3 hours a day.

Aside from all of the hustle and bustle, it has been business as usual. Our 3rd years sat their final examinations which was quite an ordeal for them. The papers (set by tutors from neighbouring nursing schools) had questions relating to everything they should have learnt over the past two years. True to form, the papers were full of spelling mistakes and grammatical errors, and the standard was tough.

Following their written papers the students were required to complete 10 OSCE or clinical examination stations. This ordeal (and it is literally that) involves the students moving around 10 different sets where they must carry out a nursing procedure within a short time period. A bell rings and then they move onto the next station. During this assessment they were required to complete everything from administering an intra-muscular injection to teaching a mother how to prepare oral rehydration solution for a child with diarrhoea. The process is made more terrifying by the presence of possibly the scariest, most miserable nurse tutors Uganda has to offer, who descend as the external examiners. They seem to take great pleasure in the students fear and spend long periods of time cultivating the terror by peering over the top of their specs!

Despite the adversities the students performed very well and all passed their clinical with either distinction or credit!

With the exams out of the way, all the diploma students (2nd and 3rd years) went out on clinical placements again. The 3rd years undertook a short stint at Hospice Uganda to gain practical insight into Palliative care nursing, following on from the teaching that I carried out with them the previous term. After this they attended Mulago (the big Government hospital) to do Obstetrics. In Uganda there is a requirement that all health professionals are able to carry out a delivery if necessary, even if you decide not to pursue Midwifery. The labour ward at Mulago is reputed to be one of the worst in Uganda, as complicated deliveries are often referred there from rural health centres. Of course in many cases by the time the mother arrives, the baby has died and complications have already occurred.

The 2nd year students meanwhile were also carrying out a long three month placement at Mulago but not in Obstetrics. They were rotating through the different specialist areas including Ophthalmic (eyes), ENT, Cardiac, Neuro, Cancer etc. and I visited on a weekly basis.

I thought I would tell you about my experience earlier on this year. After completing their exams the students (2nd and 3rd years) started their next clinical allocation in the specialised psychiatric referral hospital for the whole of Uganda. The stigma surrounding mental illness is massive here.

On the first day we were given a tour around the hospital. Not being a psychiatric nurse by speciality, on a personal level I think I was even more shocked than I have been in the general Government hospitals. Some parts including the drug and alcohol dependence unit seemed fairly well resourced and quite un-intimidating. Other parts were very distressing. To outline the general process of admission - the patient is first sedated almost to unconsciousness, stripped naked and placed in a green gown (all patients wear the same) and locked away in either the male or female acute ward, resembling more of a cell block with rows and rows of rusty metal beds and mattresses on the ground. Here the patient waits to see one of the psychiatrists.

As well as the acute wards the hospital has several convalescent areas and an occupational therapy department, which did seem quite impressive and well co-ordinated. The hospital also has a male and female sick ward for any patients who also develop physical illness. My impression from my visits so far is it most certainly is not the place to develop physical illness as the resources for diagnosing and treating such illness are sparse. Last week my students were telling me of a young man who had been transferred from the convalescent ward to the sick ward with acute abdominal pain. He had allegedly been left writhing in agony waiting to see a doctor. It transpires he was suffering acute appendicitis; by the time the doctor put in an appearance his appendix had burst and he died of peritonitis, he was only 22.

After our tour I left the students to receive their allocations. I always leave quite reluctantly when the students are starting a new placement, particularly one as challenging as this, but they are a truly amazing bunch and seem to approach even the most challenging placements with a remarkably positive attitude.

Just over a week later I returned, under my own steam, to follow the students up on the wards. On one of the wards I found a large gaggle of my 3rd year students observing a patient receiving ECT (electro convulsive therapy). This had not been performed in any private or concealed environment, simply in the middle of a very overcrowded ward area.

I left the hospital feeling quite overwhelmed. So many young people with extremely debilitating mental illnesses living in real squalor with obviously (and perhaps understandably) apathetic nursing staff and security staff very willing to dish out a beating often just to exert their authority.”

Duncan’s update shows just what challenges there are for a sick person to receive good medical care in Uganda, and how important his input is to training the new generation of nurses. Clearly attitudes are changing at the university and he is there at just the right time to be able to make the most of that. Clearly too, his “remarkably positive” students and colleagues are increasingly rising to the challenges before them.

If you are interested in following the work of volunteers like Duncan, Paul and Unni (the last two featured in the first update on this VSO Uganda health programme), VSO’s Volunteer Linking scheme will suit you down to the ground, and you can help us keep sending these amazing individuals to share their skills and practice in places where they are needed most. You can find out how to join by going to www.volunteerlinking.org.uk Thank you again for your gift, your support and for your time.

Emma VSO

We've had two updates from volunteer doctors working in Uganda, Paul at Bwindi Community Hospital in its rural forest setting, and Unni at Mbarara University in Kampala. Nurse trainer Duncan's update is on its way too so I'll add his news when I have it as well as some overview from Sarah in the Uganda VSO office.

So, Paul's news. Firstly, if you haven't read the background document for this project, you might like to (there's a link further down our appeal page). Paul has been volunteering in Uganda with VSO for over two years, achieving extraordinary successes, and working phenomenally hard together with his colleagues at the hospital. His updates give a real flavour of achievement together with the challenges. These include problems the patients present, issues of access, damage to property etc, but also familiar human achievements and challenges amongst the staff such as taking on a new skill and responsibility and feeling a protective resistance to change.

Anyway, here he is himself:

“It is sometimes hard working in an environment like Bwindi, and also hard to convey in writing just how difficult it is. 6am to 7am is a precious time, as I’m uninterrupted and can catch up with thoughts and work. This morning I’ve used that time to write.

Yesterday a lot of things happened. I began the day at 7am with a breakfast meeting with the Project Manager to discuss all of our current construction projects, plan for the installation of power in the hospital, chase up the lack of progress on the new maternity ward, review plans for drainage and reject a design for a mortuary because it is too expensive. I learnt that the Administrator wants to be away next month, when I was planning a fundraising trip to the US. I then met with the HIV/AIDS team at 9am for the weekly get-together for the part of the hospital that I have clinical responsibility for.

I then spent several hours doing ward rounds on all of the children and the adults (although we only have about 20 inpatients at the moment, there are some complex cases), managed a complicated delivery, oversaw an HIV & AIDS clinic and supervised three medical students. In between I can remember the following things that drew me away.

I was told there was no O negative blood for a young man with a massive spleen who needs a transfusion, and our laboratory attendant said that we could not get any. I organised sending someone off on the bus to Mbarara 5 hours away to get some today.

A fuse blew on the x-ray machine, and we have a visiting radiologist and radiographer here to train some of our staff. A team is leaving at 7am this morning to travel to the Tea Factory in Butagota to try to get another fuse or to fashion something from there so that we can run the service today.

Crops were burnt in a field adjoining the Hospital and the fire got out of control, threatening the children's ward. The night watchmen and the drivers all beat the fire back with branches (or fanned the flames!)

Batwa pygmies broke through the window in the children's ward kitchen and stole all of the milk prepared for the malnourished children. Someone had been asked to put locks on the windows 8 weeks ago but had forgotten.

A support supervision visit happened from JCRC, the organisation that provides us with HIV & AIDS drugs. We discussed the sustainable funding of our HIV and TB outreach programme. They cannot help, but they reviewed a proposal to the Elton John AIDS Foundation that I have written that I am touting about to other organisations. We also discussed new guidance from WHO (World Health Organisation) on treating all babies born with HIV with antiretroviral drugs, how much support we should be giving to Government units, training opportunities for our staff and plans to develop a CD4 testing service (blood test which measures the immune system's strength after a diagnosis of an HIV infection) here in Bwindi. The clinician on duty for the night went off to a burial of a boy in his village who had been burnt to death in a lorry accident at the weekend, but he did not arrange cover. Protracted negotiations took place with another clinician who asked me to "put a request in writing" for him to cover the work. We have a cash flow crisis as our finance manager has been off looking after her sick daughter and has not left adequate information, so I have real difficulty in making any decisions about expenditure. It is 4 days to pay day and I’m uncertain if we have enough money for the staff. I think we probably don’t. The company that provides us with drugs from Kampala is not responding to email requests for an order, and our secretary is not able to get them to send us the information.

At various points during the day I gave an anaesthetic and performed a surgical toilet on a man who had the tip of his nose bitten off the night before, I talked with the family of an old man who had died in the night and worked with our IT people on introducing a computer database for our HIV service I sat with the midwife to help her with her data collection for the organisation that supports our Prevention of Mother to Child Transmission services. I reviewed a child with severe dehydration, a man admitted with a ruptured liver, saw a young girl who has juvenile rheumatoid arthritis and is suspected to have TB (although I am initially managing her for pneumonia) and tried to work out if the scan really showed an ovarian tumour in the lady in bed 3 with abdominal pain.

After dark I sat with the clinician who agreed to cover, and tried to review some of the cases that he had admitted in the last 3-4 days, giving him constructive criticism. I finished work at 9pm and had some food whilst opening and responding to some of my emails (another 43 today...) before reading the paper online and going to sleep.

Best wishes

Paul”

You see how Paul refers to fundraising in the US. He is looking for large donations from wealthy individuals for the Hospital, and you will see below Unni is doing something similar for his placement. Your and my donations to send the volunteers go a long way, as these specialist doctors/trainers double up as managers and project fundraisers. Costing about £5 a day - how about a really imaginative Christmas present! I’m certainly buying my friends some Uganda healthcare volunteer days each.

Over to Unni, or to give him his full title – you should understand the calibre of the VSO volunteer! – Dr Unni Wariyar OBE, Senior Paediatrician:

“Uganda is a great country but the health care system is well behind the progress made in this field in developed countries. It is even worse for the sick and very small and vulnerable babies. There are no specialists here and no specially trained nurses either. I am trying to start a facility to care for the newborn ill babies at a basic level in the "regional referral hospital" and "Medical school". I am looking for some resources to buy equipment to warm the area to care for them and some basic monitoring and treatment facilities.

The University is committed to this development and will work in partnership with the local community and Voluntary Service Overseas (VSO) and the donor to ensure a successful outcome.

The hospital was set up as a regional referral hospital in 1950. It became a teaching hospital and was incorporated into Mbarara University of Science and Technology in 1989. The hospital serves a large rural area of south western Uganda comprising of the districts of Mbarara, Isingiro and Kiruhura.

The University management team are committed to developing the hospital to meet the needs of the very deprived communities served by the hospital but lack funding for any development. There is a large paediatric patient turnover – approximately 7000 patients per year – and the majority of admissions are newborns or toddlers. The paediatric unit accounts for 53% of hospital admissions but has only 15% of the beds. The admission room is not adequately set up for its purpose. The space and basic equipment are inadequate. Babies are kept with other patients with communicable diseases increasing the risk of mortality and morbidity and this needs to change.

The hospital serves a population of 1.4 million people. The largest community served by the hospital is the town of Mbarara with a population of 80,000. The remaining population live in small rural villages where subsistence farming is the main occupation. Some of the villages with good infrastructure are relatively prosperous but the majority lack basic water and electricity and people live in extreme hardship. Half the population are children.

The infant mortality rate is around 15% with the main diseases of malaria, bacterial infections, HIV and malnutrition placing a heavy burden on the children. Ignorance is a major factor in these diseases. In this region many children in the villages suffer malnutrition because of the lack of essential nutrients in their diet.

Cultural practices have led to small farm plots of around a few acres. If current trends continue the land use will de-fragment further leading to problems. The average family has around 7 children with about half surviving to adulthood. There is an urgent need for basic equipment for the care of newborns. It is currently not possible to administer oxygen appropriately to babies, protect them from hospital infections and to keep them warm.”

There is no room here for the end of Unni’s report, but it can be accessed in full via www.volunteerlinking.org.uk

I hope this has been helpful in giving you a VSO volunteer’s-eye-view of the nuts and bolts of development work in health and in Uganda. The next update will give quite a different view, so do please come and visit us again, and don’t forget to make a Christmas present of some VSO valuable time.

Thank you very much for your time too!

Emma VSO