A man’s world? 

“Has your husband beaten you before?”

I wait patiently for the nurse to translate my question and her subsequent reply in Rukiga. I already know the answer, I can see it in her downcast furtive gaze.

“Yes”

“How often?”

“Every time he drinks alcohol”

“How often does he drink alcohol?”

“Every day”

This tiny woman, this child in front of me has been admitted after a horrific beating which caused her to bleed from her private parts. Fortunately the neighbours succeeded in pulling off her husband before he managed to actually follow through on his threat of ripping out her womb.

Her crime? She was not able to conceive another child. This 20 year old mother “only” has 2, one age 5 and one aged 1. You do the math…

Unfortunately there is nothing unique or unusual about this story. It is one we hear all to frequently here.

Since arriving last August, the most challenging aspect of our work has been the prevalence of Gender Based Violence (studies estimate between 60-70% of women and girls over the age of 14 are affected).

We see women and children savagely affected directly and indirectly by frequent and routine daily violence, that is accepted as not only a cultural norm, but in fact an inevitable part of a woman’s life. Often fuelled by alcohol, this has far reaching impact on a women’s health, including mental health and exposure to sexually transmitted infections. Even more worrying is the apparent impact it has on their children, who not only grow up exposed to violence, but are more likely to be orphaned or neglected leading to problems such as malnutrition, poor physical health, and lack of education access.

Most victims are not identified by the hospital staff and those that are seem to be dismissed off hand, with comments from colleagues such as

“she probably deserved it”

and

“that is what happens in marriage”

Even more disturbing is the perspective of many women in the community that

“if he doesn’t beat you he doesn’t love you”

Most women even after attending hospital for severe injuries end up returning to their partners, as they are not accepted back to their premarital homes, cannot buy land for themselves and have no viable alternatives.

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However, I am not alone in my concern, we have many local colleagues who find the situation intolerable, as well as an ever increasing incentive from NGOs and women’s advocacy groups to change the tide of cultural perception.

We felt that to truly tackle GBV we first needed a deeper understanding of the attitudinal and cultural barriers that we must overcome. Thus in conjunction with our Ugandan colleagues, we have embarked on a vital piece of research into healthcare worker attitudes and behaviours. This could help us really change health outcomes and futures for women and children not only in our immediate area, but across the region and Uganda.
genderViolence
This is the first step in what we hope will be a full and comprehensive program to tackle GBV in South West Uganda, from senstisation and screening, to care packages and lobbying for the development of third party organisations for community support.

To donate please follow this link: No GBV

Permanent link to this article: http://www.clairemariethomas.com/2016/06/a-mans-world/

Doctors in the Mist

Wanted: GPs for Remote Rural Hospital in Uganda… 

Living in Liverpool and Sheffield, never having met, we were two recently qualified GPs, already feeling jaded with clinical practice in the UK. We were both searching to find an overseas long term placement that would allow us to combine direct clinical care with capacity building for local staff and systems. We were looking for somewhere that was well supported, where we would not be forced to work in situations beyond our clinical capacity but where we would still be challenged and our specific skillsets would be valuable. In fact our whole careers had been leading up to this moment: becoming general practitioners, ensuring rotations in women’s health, paediatrics and emergency medicine, undertaking the Diploma of Tropical Medicine, previous shorter stints volunteering overseas and engaging with activities to develop our education, leadership and management capacities.

 

Separately we both began to do the circuits of global health courses and conferences, sifting through placements offered by various NGOs and scouring the back pages of journals. Then we found it: a job at Bwindi Community Hospital (BCH) in South West Uganda advertised via the Royal College of General Practitioner’s (RCGP) Junior International Committee.

 

We sent in our CVs and passionate covering letters and were shortlisted for interview via Skype, conducted by RCGP and management from BCH in Uganda. On Christmas Eve 2014 we both got the call we had been waiting for: we were going to Uganda in August 2015, for a year in the Bwindi Impenetrable Forest, home of the rare and beautiful mountain Gorilla.gorillas

Overview
Our year in Bwindi thus far has been both challenging and rewarding in equal measure. We are thrilled to report that Ceri has decided to stay on for another year which we feel will be of enormous benefit for the continuity of some of the many projects and initiatives we are working on including the THET funded USHAPE Family Planning Training Project.  She will soon be joined by Leo, who will be replacing me and who I am sure will be welcomed into the Bwindi Community warmly and fully as have I. For those who don’t know about our life and work here in Uganda here is a brief summary:
Clinical
  • Adult in patients
  • Out patient clincs
  • Emergencies
  • Paediatrics cross cover

Non-clinical

  • Audit and quality improvement
  • Research
  • Departmental management
  • Teaching and mentoring

Social

  • Hiking and exploring
  • Playing sports such as netball, football and volleyball 
  • Joining the hospital choir
  • Attending weddings and social functions
  • Hosting parties
  • Attending religious activities
  • Visiting the tourist lodges to publicise the hospital or simply relax and have a beer
 
Whilst we are here we are able to develop further our skills in:
  • Leadership
  • Mentoring
  • Teaching
  • Intercultural Communication
  • Clinical Diagnostics
  • Tropical Medicine
  • Resource Management
  • Service Development
  • Team Building
  • Research & Audit
  • Quality Improvement
  • Change Management
Activities undertaken by RCGP Volunteers at Bwindi (clinical, non-clinical and social)

Activities undertaken by RCGP Volunteers at Bwindi (clinical, non-clinical and social)

On a personal note
 
My time is coming to and end in just a few short months I have begun to reflect on the challenges and rewards and consider where best to focus my efforts in these final weeks.
 
Managing your own expectations for what is desirable, acceptable and/or feasible for providing clinical care in this remote context is always the toughest challenge. Continually evaluating your decision making process in the context of local culture, resources and skill sets is a daily reflective requirement. It is not uncommon to feel frustrated when things will not or can not proceed, either clinically or organisationally, as you would wish.  
 
Drugs or tests may not be available or may not be affordable for your patients, skills or attitudes that you would desire your team to have may be too complex or simply not culturally relevant. These frustrations can be tackled however and I think there are some key lessons I have learned (universal I think and not only unique to our specific circumstance):
 
1) Build Rapport and Team Spirit: The thing that gets me through a tough day is the strong relationships we have with our nursing team on the adult ward and outpatient department. This is fostered through making sure we spend quality social time together, by sharing food and laughter outside of our clinical working environment and creating a sense of identity and community within the department. We have a running theme on AIP that we are striving to be the best ward ever and this is emphasised through regular constructive feedback, showing appreciation for work well done and even having our ward computer passwords as various versions of the phrase “Best Ward Ever”
 

me and ceri

2) Build Trust and Respect: Not only do we have a sense of team spirit with our team, but we also work hard to earn their trust and show them respect.  They have countless knowledge and skills that we do not, particularly in the application of local context (cultural, resource, disease burden etc). After every patient review and ward round we stop and ask ” Is there anything else that you feel we should or shouldn’t be doing?” It is also important to recognise that listening should be active and take into account non-verbal cues, which are easy to misunderstand in different cultural contexts. When we see a facial expression on a team member that we do not understand the meaning of we try to explore what message and meaning they are trying to convey and how can we address their concerns or ideas. We try to practice openly and honestly with all the teams opinions taken into account.  If they feel unsure about a task or are struggling to implement a clinical objective we will explore why and how they think we can resolve the situation or adjust the plan to suit their skills and working practices.
 
3) Don’t bury your head in the sand: It is easy to feel overwhelmed and to back away from raising concerns for want of an easier life.  But this rarely leads to any improvement or development. It is important to tactfully but clearly raise issues of concern and facilitate problem solving processes with local staff.
 
4) (conversely) Don’t be confrontational: This might be the hardest one for me to follow personally, but whilst you should indeed raise concerns and tackle problems it is important to do so calmly, patiently and constructively. You are often coming up against deeply ingrained misconceptions or cultural behaviours that will not respond well to brute force.  It takes slow, subtle, integrated, gradual development for change to be sustainable and pushing the issue to hard can actually serve to produce a reflexive backlash that may only make the problem worse.
 
I have written some more reflections on the lessons I have learned here:
 

Permanent link to this article: http://www.clairemariethomas.com/2016/05/doctors-in-the-mist/

Home for just a while

Just over 24hrs til we set foot in the UK! Whilst I am absolutely loving my time in Uganda (beautiful, warm, adventurous, friendly, lovely place) there are a few things I will be looking forward to over the next 2 weeks at home. Some are specific to the UK, some just about not being deep in a remote rural area, but all quite enticing…
1) my niece and nephews! Definitely top of the list! And there is a new one I have never even met, who I am going to snuggle sooooo much! 

2) friends & family… Miss you guys! You are all blooming marvellous and I am so lucky to have you! 

3) CHEESE! Cheddar, mozzarella, Parmesan, Stilton, Gorgonzola, Boursin (oh my gosh! Boursin!)… And much much more! 

4) duvets! Snuggly, buggly, cuddly, lovely duvets! And weather that is cold enough to use one and not sweat to death!

5) things just working they way they ought to ie. Showers where water comes out consistently and it is actually hot, windows that actually shut, electronics that function, buses that don’t break down, Internet that is faster than 1KB/hour… You get the idea!

6) salad! Beautiful crisp fresh salad! Fresh lettuce and spinach! Fresh vegetables that I can eat without fear of an upset stomach or having washed in boiled water first! Let’s add to this any meal in general that has less than 3 giant portions of carbohydrates! 

7) brown bread! Mmmmmm! And brown rice! And all things nice!

8) a proper haircut! Turns out that Ugandans are a bit unsure about cutting muzungu hair and subsequently I have some random uneven bits that frankly make me look like a bit of a nutter! Not to mention the very out of hand roots I have going on right now that are almost bad enough to make it look like I have attempted a shambolic home dip dye! 

9) being clean… Like properly clean… No tint of red dust pervading every item of clothing, no permanently dirty, dusty or muddy feet! Aaaaah! It’s the simple things…

10) not being itchy! Okay it will take a few days for my most recent bites to die down, but I am already anticipating the utter joy of not feeling intense itching on various locals of my body parts! How luxurious and delightful it will be! Sigh! 

11) being totally ignored wherever I go! How wonderful! Not being the side show freak in the circus with people taking pictures and shouting at you as you walk down the street, not being singled out at every event and social function because of my skin and hair (most of the time people are very lovely and genuinely interested of course, but after a while it can be a bit tiring)… Anonymity! Fabulous!

12) ATMs… Finding one without it being a day long event, queues that are less than 20 people long, machines that actually work and dispense money and most excitingly not being guarded by a chap with an AK47 whilst you take your money out!

13) getting on public transport without genuinely fearing for your life! We have a dark joke here that when assessing suicidal risk, yes you ask all the usual questions like are you stock piling meds you could use for an overdose or keeping handy a knife or rope, but also how many times have you taken the night bus in the last month? If more than 3 you may well have a death wish! 

14) carpets! I love a good carpet! Taking off your shoes and socks and curling your toes up in it! 

15) not adding 2 hours to any scheduled or timed event ie meeting someone at 10 means they are likely to be there at 10, or taking a journey that is estimated to last 4 hours actually lasting around 4 hours! There are of course exceptions to this rule … Jennifer Moore 😉

Permanent link to this article: http://www.clairemariethomas.com/2016/04/home-for-just-a-while/

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