Mbarara’s limping health care puzzles Canadian doctors

By Matthew Stein

There is a road full of pebbles and dust that winds through an endless stretch of green; up one side and down the other, interrupted only by a cluster of indistinct homes with papyrus roofs or the well defined figure of a labourer pushing a bicycle strapped with bundles of unripe plantains to the next village.

In the distance there are children; as the youngest country in the world, there are children everywhere in Uganda and when they see a foreign face or vehicle approach they run in its direction waving hands and shouting with wide smiles.

At the end of the road, perched on top of a tall hill, is the Kibaare health centre. The bright pictures of healthy children playing football, bathing and selling fruit, painted along the walls, compliment the breathtaking scenery in this south-western region.

More children are sitting outside the centre, far less curious and energetic than the others, and a plump man in a white coat standing by the entrance door.

After the initial greetings and a short tour of the facility, a shriek emanates from the clinics sole observation room and the urgency of their visit and why they came all the way from Canada resumes focus.

On the bed, by the window, next to a crowded desk of papers and unopened boxes of malaria medication is a boy with wavy brown hair, barely three weeks old, in his mother, Enids, hands. Dressed in a bright yellow dress and a green headscarf, Enid claims shes 39 but she must be confused because she doesnt look older than 25.

Her baby, Tukamwesiga, has not stopped vomiting. His body is rejecting the milk she is eager to share and Enid is worried and scared but has no money to reach the one place that can help her son.

The man in the white coat, Kenneth Kanyima, is not a doctor; at a level two clinic, like this one in Kibaare, Mbarara district, there are only assistant nurses and their assistants. Their medical capacity amounts to little more than common vaccinations and family planning services, but Kanyima, proudly points out the charts posted along the walls detailing dates of malaria vaccinations and malnutrition statistics.

The Canadian doctors, working with the Centre for International Child Health in Vancouver, British Columbia, are impressed, but as specialists in acute child care, they are drawn to the boy.

One of doctors begins to run his fingers down Tukamwesiga’s stomach, pausing in certain areas to apply pressure. “Pyloric stenosis,” he says solemnly after a moment. “Is this your first child?” he asks Enid. Someone translates and she nods. “Tell her if her son does not reach the district hospital in Mbarara soon he can become dehydrated and die.”

Kanyima suspected as much, but in a country where 31 per cent of the population lives below the poverty line, referrals to other clinics are too often suppressed with visits to traditional healers or to one’s home where prayer and time are asked to cure.

But to the Canadian doctors, the objective is to find ways around these challenges and for three days, racing from one appointment to the next, they have attempted to do just that.

A  day earlier, they sat in the cramped office of Dr. Martin Buhamizo at the Kinoni clinic in Mbarara as he outlined the many issues plaguing his level four health centre: his staff of 17 doesn’t approach the 46 required to run the facility; medication received from both the joint and national medical stores is never delivered in its entirety and the medication that is delivered lasts only two months when orders are placed every three months.

“Do you have any scales?”

“None that work,” says Buhamizo, confirming a common problem in Mbarara.

“So, how do you know how much medicine to give?”

“We use a formula from age,” he says almost sheepishly, realising this is the wrong procedure to use in a region plagued with stunted children, where age and weight don’t often correlate.

“Have you ever heard of colour coding?” ask the Canadians.

Buhamizo shakes his head.

In North America, they explain, when there is insufficient time or children are too sick to be weighed, hospitals use a multicoloured measuring tape that allocates the patient a colour category based on their height. For instance, a child who is 100-110 cm long fits the ‘purple’ category and when he falls sick there are already pre-calculated ‘purple’ medication and infusion quantities ready to treat him.

Buhamizo’s eyes light up. “It sounds like a genius idea.”

So smart and simple, in fact, it’s bewildering these practices are not being used. But, as the Canadian doctors are informed the next day when visiting Healthy Child Uganda, a community-based health organisation, unless there is consensus amongst the district, health facilities and communities, “it’s going to end with the idea.”

Bicycle ambulances or bambulances, another innovation proposed by the Canadians, face similar hurdles in spite of proven success in reducing infant and maternal mortality rates in Malawi, Zambia and Namibia.

The Kikoni clinic alone makes one referral a day to Mbarara district hospital but the local ambulance runs only once a week. With bambulances the Shs 30,000 ambulance fee or the Shs 3,000 taxi fee could be reduced. But, will the communities use them…Will they be stolen…mismanaged… misused…is the terrain too hilly…how much money will they cost…and what about the rainy season…?Â

Everybody nods their head in approval when the Canadians float these ideas. Even Dr. Amooti Kaguna, Mbarara’s district health official, is in agreement. “We are not impervious to any new ideas,” he says, as a handsome picture of the National Resistance Movement Chairman, peers over him on the wall.

Yet whatever changes are on the horizon, none can come soon enough for little Tukamwesiga. The boy’s father has been found in a sodden shirt and rain boots pushing his bicycle by the road, but has nothing to offer. In one week, he says, he will receive a health voucher from the government for anti-natal care, but it won’t be enough to reach Mbarara and by then it could already be too late.

The Canadians decide to take Enid and Tukamwesiga to Mbarara with their own transportation. However, like every family in such a situation, they are unsure the hospital will have the medication and facilities to treat him. If only there was the technology available to call, text or e-mail to verify the information. But for the people in this region, unreliable network coverage and costs often stand in the way.

Eventually a signal is found and Juliet Mwanga, a pediatrician at Mbarara hospital, confirms that the boy can be looked after. Moments later, the doctors, Enid and Tukamwesiga are bouncing along once again, through the plantation fields and past the papyrus homes.

The Mbarara district hospital is overrun with bodies. As the most developed health care facility in the region, “it is where everyone comes when there is a crisis,” comments one local doctor. The hospital has oxygen tanks and can perform complex surgery; they can test urine and stool for certain bacteria, but other tests, like meningitis, need to be done in labs on the outside. For those who can afford it, there is a private lab that produces results in a half hour; for those who cant, there is the public lab, but they rarely return anything.

Enid and Tukamwesiga sit down in the entrance. There are only a few spaces left on the wooden bench. All the beds in the hospital are full and a number of patients are lying on mattresses on the grass outside.

Enid looks confused, overwhelmed, alone. The Canadians say they ll be back to check on her, but a day later Enid and Tukamwesiga are nowhere to be found. The doctors check the pediatric ward, where infants covered in colourful blankets compete for the attention of a lone white jacket; they walk through the surgical ward, where the mix of urine, sweat and lanced abscesses accumulate into an intolerable wave of nausea.

We told her that her son required surgery, but she just left, a doctor familiar with the case finally admits.

The Canadians are dumbfounded. Why, after so much effort, has she left?

That night, back at the luxurious Lakeview resort, sipping cold Nile beer by the waterfront, the Canadian team cant shake the news. They run through possible explanations in their heads:

Maybe Enid was scared; the hospital offered her a dramatic solution that she couldnt understand and there was nobody there to calm her down and explain it to her in words she could; or perhaps she knew someone from her village that went under the knife in Mbarara and never made it out. Was it the potential costs? The smells? Maybe Enid just couldnt tolerate the desperate crowds of mothers, fathers and sisters, completely helpless as an overburdened staff attempted to manage chaos. Maybe she got too close to the young boy whose abscesses were being drained from behind the blue curtain, his cries audible enough for the entire room to hear, and decided no. Im going home.

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