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On the way home

Sat 30th Sept 2023.

I started yesterday with a visit to the Benedict Medical Centre, a small hospital in a poor suburb of Kampala.   They are continuing to find funding a bit of a struggle.  It was worse in Covid but there are 3 government health centres in the locality who give free medication when they have it, and three or four private-for-profit ones.  Also Butabika Hospital, the main psychiatric hospital, is only about 3 miles away, so many people with a mental illness go straight there. The public perception of mental illness is that it means 'Butabika'. It takes quite a shift to imagine that mental illness can be treated at the level of a small hospital like Benedict Medical Centre.

They are hoping that having a psychiatric clinical officer will enable them to develop a good reputation for mental health care.    JF has sponsored Robin to train as a psychiatric clinical officer.  He has finished the course but has still to get a project approved.  We are helping them to raise the awareness of mental illness and its care in their community and to present the hospital as an alternative to Butabika.

Meanwhile, Joshua and I had agreed to look at the experiences of people with mental illness or epilepsy who have been confined at home, usually by their families. They may be chained, tied with ropes, or left in shackles and sometimes leg shackles as well, then locked in the room and dependent on someone else to prepare their food and attend to their personal hygiene. I would be really interested to know how they think of it all. Are they troubled by traumatic memories? Angry with their families? Resentful about the lost years? Or do they just accept that this is how it is during times when they are ill and troubled or overactive and moveous?

Some of you will remember James, who was kept locked in a dark room, chained by his ankle, from his late 20’s to age 42, about 15 years. When we saw him 6 months after our first meeting, he was being cared for by the team and on treatment, and was totally transformed. James taught me a little of what it can be like for our patients, and his story comes with me whenever I teach on international mental health. 

Joshua and I thought it would be interesting to interview some of the  patients we know who have been in similar situations. He’s made a good start, but the majority of the cases so far come just from Bwindi Hospital. Apparently the research journals get suspicious when that appears to be the case; you may have been making up the details!

I’ve asked our young colleagues to scout around to find us some more, as several thought there were some in their districts. Village health workers from the Village Health Teams (VHT), church leaders and local councillors often know their communities very well and will be aware if there are some individuals hidden in the darkness.

The VHTs remind me of the old wise women of the villages in earlier times in our English landscapes. I can remember some from the villages near where my grandmother lived in Somerset. ‘Aunt Em’ and ‘Aunt Cis’, for example. They knew all the local remedies, the herbs and potions that could help with everyday ailments. I’d quite like to talk with them again now, but they have long gone.

When Joshua and I talk, we find our conversation ranges far and wide beyond clinical matters. He’s not short of opinion on some of the political shenanigans that go on in Uganda and from his stories I learnt some fascinating details. He’s interested in English politics too though even he, who has long experience of goings on in Africa, was a bit surprised at the thinking and impact of Liz Truss. And indeed her very short tenure as our prime minister. Uganda’s current president has been in charge for 37 years. Just imagine….

Joshua is a great friend to Jamie’s Fund. He has years of experience in mental health research, and trained as an mhGAP Master Trainer in Geneva (and Italy!) directly under the auspices of the World Health Organisation. We have been very fortunate to have him and his support in our training programmes which have been making such a difference across Uganda. 

Market day at the roadside.

Hassan later drove us down to Entebbe where we had a late lunch in a café we have known for some years.  It has a lush green garden.

A metal baboon in the garden.

We were then dropped at Guinea Fowl guest house, where we spent time catching up on our computers. They were doing major road works on the residential road outside and I enjoyed watching the machines at work – as I used to do 60 years ago.  Not sure why they have selected this road for such major works – the fact that a number of military officers apparently live on it may not be a coincidence.

A grader at work, even after dark.

We went to the airport late evening and  all went smoothly.  In Brussels I was fascinated to make the acquaintance of a Ugandan dentist who has lived in London for a long time but still comes back to Uganda to see family. Her father is a doctor and her sister is a psychiatrist in UK! 

We changed planes in Brussels and got home late morning today, Saturday.

It has been a very encouraging visit.  Hugh, Linda and Avril have found the same encouragements visiting the hospitals in the west as well.  Although JF is stopping we will continue to visit and have tentative plans to return early next year when six of the PCOs JF sponsored will be graduating.

Thank you for reading our blogs and we hope you have found them of interest.  We have aimed to give you a flavour of what we have been doing.

If you would like to drop us an email, please do using the email [email protected]

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Back into city life

Thursday 28th September 2023

Here in Uganda’s capital city it’s almost impossible to guarantee that you will be able to make more than two meetings in one day if they are in different venues.

Plastic waste being collected for some sort of recycling.

Rush hour traffic peaks are office traffic and the school run, which follow on each other and blend into one gigantic jam. Mostly the peaks are dead slow and stop, often quite a lot of stop! Journey times are highly unpredictable

How do you get a pig to market?

This morning we allowed plenty of time to get in from Bushbaby Lodge to the city centre, where we had an appointment to meet our old friend James Mwesigwa at the Uganda Protestant Medical Bureau. It took us two and three-quarter hours to travel about 18 miles.  

Road side clothes shopping; did you spot the Barbie mention?

We had planned to drop off our katundu (our ‘stuff’) at the hotel beforehand, but as time marched slowly on, Ewan said, let’s just go to an early lunch and on to the meeting, which we did. 

As always, James was very cordial; he worked as a social worker in UK in another life. We had to tell him about the closure of JF. He wondered if he should make a video of the work that JF has done in the last 10 years.

With James, who has always been supportive.

Our second assignment of the day was our important meeting with Dr Hafsa, who is the lead for mental health at the Ministry of Health. She has always been very supportive of us, and keenly interested in what we do. We need to be working within Ministry policy so we like to check that out. 

Had she been able to come to open the CPD workshop, we would have broken the news of JF closing to her then. 

She wasn’t able to do that, so today we did the deed. 

To be honest, she was more shocked and upset than we expected at the news of our winding down the funds. She needed considerable reassurance that we are ‘only’ ending the money; relationships, friendships and support will continue. I was relieved when she gave me the customary very warm hug as we said goodbye.

some babies sleep anywhere.

We are staying in the Duomo hotel where we have stayed quite a few times before as we like it. Though the surroundings are getting a bit louder. I had a swim after a shower of rain.

During our visits we heard more about the challenges of running a PNFP hospital.  You are dependent on getting enough money in to pay the salaries.  In one place they are only now paying the August salaries.  The take home pay of an enrolled nurse is around 300,000 shillings a month which is about £80.  The government put salaries up for health staff and science teachers a couple of years ago so if the nurses and PCOs move to government they get a two or three fold pay rise immediately.

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Under the mango tree

Wednesday 27th September 2023

My favourite clinics are held under a mango tree. This morning we joined Amuron to do just such a clinic. But it was a little bit complicated to get there..

Amuron was our first Jamie’s Fund graduate. When we first met her we were struck by her warm compassion and her heart for people with mental illness. She is now a fully qualified Psychiatric Clinical Officer, and with her colleague Joseph, leads the mental health service at Kumi Hospital, a former leprosy hospital, way out of town and usually very peaceful.

Our driver Hassan picked us up at 8.15 and we called first at the hospital for the customary meeting, chaired on this occasion by the in-charge of Human Resources. Warm appreciation on both sides was definitely part of it. Once again we are struck by their expressions of thanks:

“Thank you for loving us”. 

“Thank you for loving Uganda and for coming to us”.

We believe it matters that we do come, to express what someone has called the ministry of presence.

Out then to the clinic, a fair way away. We are out in rural Uganda here, and in some senses traditional Africa, with the old thatched roofs, even though the walls are brick. 

Our route led us down smaller and smaller roads, until we were joined by a local man, who cheerfully ran ahead of the vehicle to show the way down the ever tinier paths to the mango tree where the patients were waiting. 

One older lady raised her arms in the air with a great chorus of ululations to welcome us, and the others joined in as we shook hands with everyone. 

They had come! Always the first challenge. And they had brought their records, in an exercise book, many pretty dog-eared but still functioning. Amuron gave some health education and the clinic proceeded. 

Quite a mix: mostly epilepsy but with some mental illness, including new patients. Older and younger, including some toddlers, male and female. Shy quiet ones, and some great characters. All of human life is here under the mango tree.

One lady appeared very low and tearful, but was reluctant to talk. I watched Amuron deal so kindly and gently with her and begin to form the relationship that will be the beginning of healing. 

I hope you have gathered that everyone is sitting around together. They listened to each other’s stories – or not, if they were attending to babies or going to the toilet or other necessities. But no one thinks twice about the confidentiality that is so important to us. 

This is a collectivist society, different from our own individualistic one. People belong together, share each other’s concerns, pray for each other, understand each other. It is of no great importance if they hear each other’s consultations; they need each other in order to get through their lives with so many challenges. 

The person who clearly did not want others to be involved was the quiet tearful lady. We think there is more to her story than we yet know, and Amuron will continue to talk gently with her for as long as needed.  

This was one of the bikes used to get to the clinic – old and tough, no gears and not much in the way of brakes either. It will have carried all kinds of things over the years.  Some welding on the frame, but it is still very useful.

These are flip flops made from old car tyres.  Called “thousand milers” by some

After the clinic we had a four hour drive back to Bushbaby lodge, which was a pleasantly easy one.  It is cooler here.  Kampala tomorrow.  We just heard this afternoon we can meet the lead for Mental Health in the ministry tomorrow afternoon.  Glad that that has fallen into place.

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Another hospital rising to the challenge.

Tuesday 26th September 2023

Sleeping at the Benedictine retreat house meant we didn’t need to get up too early – the hospital is just up the road. However, the cockerels hadn’t been given our schedule, seemingly, because they were crowing their wake-up call from about 4.30am.

Mo catching up with e-mails before our meeting.

Our meeting at the Benedictine Eye Hospital was a little eccentric but delightful. Psychiatric nurse Brenda you have already met – she is the mother of delicious baby Zion. She came in from her maternity leave to be at the meeting and give us her report. She was going on to run a community clinic afterwards. 

It took a while before everyone was gathered, including Julius, leader of the community rehab programme in Tororo, and Moses, the programme manager. (Please don’t ask me the difference between these two!). They summoned an accountant, Sam, to respond to JF’s treasurer’s questions, and eventually we gathered in an IT guy as well.

That was when Ewan began the discussion about data and spreadsheets. Part of his mission is to encourage our colleagues to collect good data and then to use it – you can certainly use it to persuade potential donors into generosity. You can show them how many people’s lives have been transformed by treatment for their mental illness. 

At some point a tall and striking figure in a white monastic robe strode in: the Executive Director, Father Peter. I hadn’t met him before but he’s clearly a supporter of mental health service development, and also someone who insists on proper accounting and reporting. I was delighted to hear from him that he was late because their monastic order was being audited!

At a slightly later point we decided to start the meeting, and Julius drafted an agenda, with the usual rather formal structure, including opening and closing prayers. 

Our colleagues at Benedictine have been very keen to establish mental health services alongside the epilepsy service they run – 11 clinics across the district.  As always, there has been a funding problem for their drugs. They are compassionate carers and long for patients to have the treatment they need.  We have been able to find a donor who is funding the drugs for the moment.  We will see how that proceeds.

We arrived at our hotel here in Mbale at about 2.30pm. That was a fun morning!

View of part of Mt Elgon from our room.

Afterwards Ewan had a sleep and we both went for a walk in the pleasant evening sunshine. Teenagers passed us on both sides of the road on their way home from school. And there were mysterious goings on in the construction of storm drains. Or possibly deconstruction, it was difficult to tell. When African rains come down so heavily, you need a way of dealing with the potential floods.  Ewan enjoyed a swim once we were back at the hotel.

Brenda is a very committed and enthusiastic psychiatric nurse. She met her husband when they were both at nursing school. He has since switched to medicine. I was very pleased indeed to learn that he is hoping to specialise in psychiatry. 

Our workshop last week was well balanced in terms of female-male delegates. I am impressed that so many young women in particular have not only had a good general education (you cannot take that for granted in a country like Uganda) but have chosen to specialise in mental health, knowing that professionals carry the stigma as well as our patients. You are unlikely to acquire fame or fortune in our specialty. The women who do opt for such a career have a big heart for people with mental illness, and clearly show their dedication.

Prima was just one such; she was both delegate and presenter last week. She had always been interested in psychiatry but thought it was a challenging subject and you had to be a (probably middle-aged) strong man who wouldn’t be easily approachable. 

Mo and Prima

She was working as a general nurse when Sister Nancy, who ran the mental health service at Kisiizi, told the nurses to get the ward in good order because the consultant psychiatrist was visiting. As it happened, the visiting psychiatrist was me!

Prima was astonished to find that you could have a lady psychiatrist. And someone who wasn’t a strong silent type of middle-aged man. That was it: she told herself that she could go into psychiatry. She is now in charge of the psych ward at Kisiizi and is a qualified specialist nurse in Child and Adolescent Mental Health. Isn’t that a great story?

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Off East

Monday 25th Sept 2023

We woke to a warm sunny day and enjoyed the trill of the kingfishers.  I was sorry we hadn’t had much chance to bird watch here, as we had seen quite few just as we moved around. – turacos, hornbills, kingfishers, weaver birds etc.

A woodland kingfisher, taken on a previous trip.

A short drive to Mukono hospital where we were warmly greeted by Dr Simon – one of our favourite medical directors.  He invited in his senior team – and then got involved in a clinical emergency, so we had a very interesting discussion with his team about cremation, cemeteries, the ancestors and post mortems!

Mukono hospital is doing well with mental health, having started from nothing. It’s one of the hospitals where JF has nudged them into taking mental health seriously.  

A view of Mukono hospital

Eseza, one of the brightest of the PCO’s we have sponsored as she trained, is based here. Transport for her and her colleagues to get out to clinics and home visits is an issue. The vehicle we used yesterday is much needed during the week, which is partly why the community clinics are on a Sunday. We said to the team if they come up with a reasonable proposal we will see if we can raise the £4000 or so to buy a motor cycle with protective gear and get them properly trained.  The main road outside the hospital would be awful to ride on but once you are off that most of the roads are fairly quiet dirt roads.

Although they are sad JF is closing, they are already planning how to continue things.  We were able to reassure them that JF will support them for the 12 months we have committed to, and possibly longer.   Where there are specific projects being funded by JF that are showing promise, us two as individuals, with some other supporters may be able to continue the support for a bit longer, provided there is a good management team as well.

Dr Simon and Moses, the administrator, then took us over the road for a light lunch before we set off to Tororo, 4 hours drive away.  We had a clear run, with occasional showers, including seeing some baboons on the road.

Street traders selling roasted maize cobs and drinks to those trapped in over-crowded minibuses.

We arrived at the Benedictine Fathers retreat centre before 5 and enjoyed the peacefulness, with a cup of tea in the grounds.

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Out to a clinic.

Sunday 24th September 

We woke to a grey morning that looked as though it might turn into rain, which, sure enough, it did. I started out with a top and trousers, added a cardi, then added a rather warm fleece. At one stage I thought maybe I should have worn my tights.

Our driver appeared promptly at 8.15 am, pretty much as the rain was starting. It quickly became quite heavy, and the dirt track down to the main road took some negotiating. We were on our way to Namakwa Clinic run by Mukono Hospital, one of our mental health teams that is really flying. We then spent a wee while waiting for the team, who had an equally challenging drive to the health centre and church at Namakwa.

How to succeed at a Sunday morning mental health clinic without really trying? Look for where the people are – they are at church of course. So the clinic is held at a time when they can both come to church and keep their appointment. 

The clinic with the road in the foreground.

Lamet, Emmanuel and newly qualified PCO Eseza are three clinical officers for whom I have the greatest affection and admiration. I sat in on the clinic run by Emmanuel and Eseza, while Ewan and Lamet got together over spreadsheets in the back of the vehicle. 

In keeping with the teaching session we held last week, many of the patients have epilepsy. Straightforward enough if you do the minimum (check number of seizures, adjust the meds, say goodbye) but so much more interesting and useful if you get to know the patient a little better and find out about their lives. And check on the relative who has come with them, perhaps? 

Many of the children who came have intellectual disability as well as seizures, and some have genetic syndromes. The teaching delivered last week by our friends from Cheshire & Wirral was spot on! One of the Namakwa children needed referral to specialist paediatrics; the relevant specialist also works at the big mental hospital. Emmanuel was confident the child would be properly assessed. I know we have long waiting lists in the NHS now, but sometimes there aren’t even the specialists available in this country.

A few of the epilepsy patients have mental illness as well. Very few neurologists here, and very limited access to investigations. In the UK we have sizeable neurology departments to look after this group of patients. Here, a significant proportion of the population have epilepsy and many have no access to treatment at all. 

Emmanuel smiled broadly to see one young lady. Last time he saw her she was very excitable, talkative, irritable: now she is calm and contented. Sometimes the medicine is just the thing!  

We had one new patient. You might have almost ‘recognised’ her – she was unkempt but had on a few strings of small beads and bracelets, and a dress that had clearly been almost a party frock but was now grubby and torn. She was carrying in bags what Emmanuel described as her ‘treasures’ – such an appropriate word for the things people might carry around with them.  She said her father had told her to come because she was hearing voices, then later told us her parents were dead. The father she referred to turned out to be the village headman, who was, thankfully, keeping an eye on her. 

Waiting to be seen.

One attractive young woman was wearing a very pretty dress, like many of the women. Not sure whether they had dressed up for church or clinic, but either would be characteristic. This lass had had an illness like schizophrenia from early on in her life. She grew into a teenage beauty and got pregnant, almost certainly unintentionally. It’s a common outcome when girls aren’t in education, and there were many such pregnancies during Covid, when no children were in school.

Our young lady told the clinic staff about the baby, then disappeared for 2 months. This was the next review: no pregnancy. We don’t know what really happened. I was so impressed today by how our clinical officers were serenely dealing not only mental illness epilepsy and paediatrics, but also assorted medical and surgical conditions, including obs and gynae. 

Several of the patients told me how grateful they were for the clinic and the medicines that made their lives to be more normal including this lady and her son.

On the veranda I found this small charcoal stove with a pan on top and a bag of charcoal behind.  It is a widely used fuel in towns but not very ecologically friendly.

After an intense but very interesting morning’s work, we took our colleagues out to lunch. On the whole, Ugandans really enjoy their food. It may be something to do with the lack of food security – if you are a subsistence farmer growing your family’s food and the rains fail, there is nothing to eat. Perhaps it’s not surprising that our young people packed away very substantial platefuls! 

a good plateful.

[ewan-mo]

Moving on

Saturday 23rd September 2023

The banner of ARU (Association of the Religious in Uganda) says its motto is “No longer strangers but friends”, and that is exactly how we felt saying goodbye to the lovely nuns who have looked after us so well and shown us so much loving kindness throughout the workshop. 

We also said farewell to our young people, with promises on both sides – they vow to continue the good work, and we promise to keep in touch, with visits where we can, and otherwise with WhatsApp or whichever technology is appropriate.

We arrived at Bushbaby Lodge for our day ‘off’ to find a lush green setting, plenty of space, and all around the colourful birds of Africa. As we arrived a little woodland kingfisher was trilling his song from a telegraph wire, and Sunday morning he was singing his heart out again at 6.

We were grateful to have time for both a walk and a siesta on Saturday afternoon. The walk simply took us down the road, but the exercise was very welcome. Contrary to my usual daily fitness regime, I’ve scarcely moved over the last week or two except to go up and down stairs at ARU. 

Dinner was out on the extensive lawn, in the smoke of the campfire, unless you positioned yourself more strategically. The food is good, well cooked and nicely presented. On the whole the restaurants here are good at serving seasonal items for dessert. 

But when you’ve had pineapple and water melon for dessert two meals a day every day, you just occasionally fancy a slice of mango. But it’s not mango season.

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The end of the first week.

Friday 22nd September 23

I woke 6ish just as dawn was breaking. Today there seemed to be a competition between the muezzins and the Christians as to who could most effectively disturb the peace using their loudspeakers.  I regret to say the Christians won – they went on a lot longer than the muezzins. 

My birthday began with a ceremonial opening of cards and presents which Ewan had brought with him, all lovely, then at breakfast Sister Lydia led a great chorus of Happy birthday to you, with our students and a grand group of nuns who were staying overnight. What a splendid beginning.

We spent much of the day at Lubaga hospital, where they have taken up the challenge of developing mental health and are running with it enthusiastically. Their service is now officially on the list of services offered by the hospital, which has become a Regional Referral Hospital. Mental Health now has a Budget! And a mental health consultation room.

The consulting room and some of the enthusiastic staff.

You might think these are par for the course, and indeed they would be in the UK. But here such developments are also symbolic: the importance of the service is recognised, and resources are set aside for its continuance. Wow. That doesn’t happen often in a low income country like Uganda.

After the meeting, which included a report on the service and all kinds of responses, we had breakfast just before 12. This consisted of sausages, potatoes, plantains and spinach. Um…Yum??!

One of the wonderful themes that came through loud and clear was the loving relationships and loving care that permeate the service. I am tempted to say that Lubaga is full of love.

The PCO is called Claire. I had a long talk with her in which we practically exchanged life stories. She is of my tribe, speaks my language; even to hear her describing her early reactions to psychiatry sounded like an echo of my own. I was moved to hear her say that discovering mentally ill people walking naked, or being abandoned in their village, her thought is “How can I help this person to know they are loved?”

After the official meeting we were taken on a tour of the hospital.  It is an impressive place and seems a happy one as well.  In three years, of the 46 trained in mhGAP only one person has left.  Other places it is ¾ of those trained have left.  They are waiting approval to become the first hospital in Uganda to be approved to do organ transplants.  This can be life saving for those who need it as long-term dialysis gets way too expensive.  Up till now people have gone to India if they need it.  It emphasises the disparities.

I was pleased to see that a tree that Mo and I planted last time is still growing.  

Hugh, Avril and Linda went off to visit another smaller hospital the other side of town.

I spent a while teaching a pair of the mental health staff how to use Excel to get better data after which we got a lift back to ARU, where I agreed the final bill with ARU.  Very reasonable considering what they have provided for us.

In the evening we went out for a meal together to celebrate Mo’s birthday and a good week of work.

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"Sweet things end while still tasty."

Thursday 21st September 2023. 

Yesterday our proceedings were accompanied by the sound of falling rain: very heavy and very noisy on the tin roof immediately above us. You can imagine that that disrupted the teaching somewhat as we kept on reminding people to shout at each other!

Today was happily quieter and we got on a bit faster. Hugh and I are the ones with the hearing aids, so we still like people to shout(!) and I’m the one with the walking stick while going up and down stairs and corridors here. We hope we are gradually getting our colleagues used to the truth of the fact that JF Trustees and consultants are definitely getting older. We haven’t got quite the energy of youth, which is one of the reasons that it’s become harder to do the necessary fundraising. 

Be that as it may, we had another good workshop day, our final one. 

There have been renewed questions from our students about counselling suicidal patients when the law says attempted suicide is a criminal offence. We invited back Freddy, who ran some suicide workshops for us earlier in the year. These were very well received, so we asked him to revisit the legal ramifications and safety planning, as the first session of the day.

Prima describing an incident.

One of the tutors from the PCO School joined us to revise risk assessment and management. You might see a sort of theme developing here. We asked Mathias because he was highly rated by some of our own trainee PCOs when we asked them who the best teachers were. 

Africa being Africa, you may not be surprised to hear that we came back from lunch to find no electricity! All kinds of techy contrivances were attempted, but in the end it came back by itself. That didn’t prevent the occasional strange colour transformations of our powerpoint slides on a couple of occasions to a lurid pink-green scenario. Eek! Ewan and I now recognize the yellow tones of a poor connection but this was a new one. However, we pressed on..

Uganda National TV produced a short film about depression in Uganda, and how you can train local women as counsellors and therapists – in this case in an organisation called Strong Minds. It’s very local to where we are here in Kampala and we thought our students might like a film for a change.

Hugh led a session on leadership which was well received. In the feedback several of the students appeared to be taking this up with enthusiasm. 

Moses the senior hospital administrator from Kisiizi came in the afternoon to officially close the workshop.  He was at Kisiizi when Jamie died so has been part of the story.  He presented all the certificates to the participants (the certificates only arrived about 15 minutes before they were needed, on a boda-boda). 

We value Mose's friendship.

After the official closing Linda ran an extra workshop for those who could stay. Hugh and I went for a short walk before supper. We stopped and admired the wood work being done at this small workshop.  I admired the hard woods they were using. Some of the pieces were 4 inch thick and 20+ inches wide.  You would pay a small fortune for that in UK.  He said they were offcuts from timber coming from Congo for export – all part of the international trade and the loss of ancient forest.  No easy answers.

Oiling the newly sanded wood

We were a smaller group for supper as some people had left to start their journeys home. Discussions contiued over the dinner table.

[ewan-mo]

Mo had a dream

20th September 2023

The youngest student at the workshop; 2 months old. Son of Brenda, Community MH nurse, he is just 2 months old. He’s called Zion. And very advanced, of course.

At breakfast today I decided to have avocado. Because I could, because it’s good for me, and because we normally eat quite a bit of it at home.

Our menu here tends to be based on common Ugandan everyday foods, hence yesterday’s liver and cooking banana and today’s avocado.

Ewan began the day’s programme with a snowball exercise. 2-3 people discuss first, then they join another group to become 6 and so on. Each time the group has to decide on its ‘top 3’ – in this case, their top three things learnt as a result of the partnership with Jamie’s Fund. Great to read their results. I was not surprised, but I was moved, to hear mention of loving our patients, and other similar sentiments 

Long ago in Malawi, I was surprised and upset to find that the PrivateNotForProfit hospitals, which were mostly faith based, wouldn’t care for any patients with mental illness. While in government service we were developing community mental health care and reducing the population of the mental hospital, the mission hospitals were saying “We don’t do this.”

We asked a question of the Christian Medical Fellowship in UK as to why should this be? That led to a consultation: “Should faith based health institutions provide mental health services?”

An international conference followed in 1998: Developing Mental Health: a Challenge to the Churches. We brought participants from five continents - mental health workers, their managers and their bishops, and had a wonderful week in a conference centre in England. 

By then I had a dream: that faith-based hospitals, especially in low-income countries, would develop community mental health services, and offer love and commitment to this group of people who are so often stigmatised, rejected and outcast.

Working in Jamie’s Fund in Uganda, my dream has come true. Our young colleagues here have a shining vision to make things better in mental health, and they are transforming lives. They also love to learn and we are having such a good week with them.

Second on today’s agenda I presented Trauma Matters, prepared by our good friend Helen, a Liverpool psychiatrist. We were all looking forward to her first visit to Uganda – and so was she, but late in the day illness stopped that happening. Interesting presenting other people’s powerpoint! But I already knew that she and I had were of the same tribe, had concerns and values in common, and that it was a privilege to present her work. 

After lunch our colleague Sudaat told us about a new syndrome “Shake Shake”. Every so often these slightly odd presentations crop up, often in boarding schools, looking like some weird neurological disease. As far as I know, they never are, but are usually due to underlying stress and the girls ‘catch’ it from each other. You won’t be surprised to hear that in ShakeShake the girls’ legs shake.

Some of our colleagues had asked for screening tools to give them a straightforward and speedy way to assess those patients in medical clinics who come with physical symptoms but appear to have nothing wrong with them. So we talked about screening principles and got them doing translations of one such tool into local languages. Much hilarity ensued. Keeping control was like herding cats.  

We took a group photo with the banner of the the Diversity Foundation behind the group.  Diversity Travel have been very generous in their support to Jamie’s Fund and have paid about half the cost of this work shop for which we are very grateful..

Ewan enjoys data. Don’t drown in data, turn it into information!  Kuule from Bwindi and Lamet from Mukono, both very able and visionary mental health clinicians, joined Ewan to show how it could be done. Kuule and Ewan have recently spent a considerable time preparing a research paper on this very subject, which shows how the number of patients attending mental health clinics around Bwindi has increased as more clinics have been opened as a result of training of clnical staff  in basic mental health care, sponsored by JF.  The only officially required figures are for the clinic attendances rather than how an individual attends.  Just looking at the number of attendances doesn't tell you about the size of pool of patients or if individuals are attending regularly for follow up. You need this to be able to manage your service effectively.

Supper as usual and early bed.

[ewan-mo]

A good day’s work and a celebration dinner

Tuesday 19th September

Breakfast here has different food on offer.  Mo started the day with liver and plantain....

Our conference day began with lingering anxiety over the technology, then a breath of relief. 

Our good friends Mahesh and Sujeet - both professors at Chester University and Cheshire & Wirral Partnership where I used to work - had kindly agreed to give us some teaching on Intellectual Disability and Neurodevelopmental Disorder. ID and NDD! This meant them getting up rather early to allow for the time difference between our two countries, and both ends needing faultless technology to make it happen, despite it being a two hour session over the internet.

Learning from the professors.

ID and NDD are common around the world, and probably neglected more than any other mental health condition.

Happily all went well, and we had a very comprehensive learning session with two international experts. At one point Mahesh was helping us to think about the difficulty some people with NDD have in understanding what others are saying. His illustration was to talk to our students in a foreign language – his native language from a remote part of India, which no one had even heard of. The students were quite entertained as they listened; he turned out to be asking them what they’d had for breakfast.

Our session on epilepsy later in the morning was one of joint learning. 

I challenged the students to discuss how we can do better – rather than just running huge clinics with a minute or two for each patient to review medication and little more, can we do better to help this person in their situation? How are their families managing the stigma? How much do community leaders know? How could we help to change attitudes amongst teachers, employers and the general public? How can we prevent epilepsy from even happening?

Meanwhile I learnt a whole lot more about traditional knowledge of epilepsy and its effects, and the perpetuation of the stigma surrounding the disease.

In April Uganda hosted a national conference on epilepsy. I didn’t know that until I was well on the way thinking about our teaching session! There are 770,000 individuals living with epilepsy in Uganda. Many others are not known to services. There are very few neurologists in the country (hence mental health teams manage people with the condition), and very limited access to investigations such as EEG, which would be routine in the UK. 

Children with epilepsy are often denied education. If they do go to school they are frequently traumatised by the way they are treated – bullied, shamed and stigmatised. Many drop out. Getting employment is a big challenge, and if the seizures are not well controlled, then usually that means dismissal. On our last visit here we met a teacher and her daughter, both of whom have epilepsy. They have been unable to get work. You don’t have to look far to begin to understand some of the causes of poverty in a country like Uganda.

Hugh and Avril arrived just before lunch. It was good to see them and have a more complete team

Supper being cooked outside.

Linda spent the afternoon helping our students to understand psychological ways of working with serious mental conditions like psychosis. 

Workshop Celebration Dinner and an important announcement

Our lovely nuns had prepared a special celebration dinner which as always included several different carbohydrates, and on this occasion, several proteins as well, including goat, chicken, and beef.  In our experience goat can sometimes be a bit chewy, but this was very well cooked. Avril had never had goat before but she really enjoyed it.

They had also commissioned a beautiful cake:

As the meal ended, Hugh (Chair of Jamie’s Fund) gave a moving resume of all that has been achieved in partnership over the last 10 years: 

Working with 25 hospitals across Uganda

Running professional development workshops in mental health

Training of seven new Psych Clinical Officers who will lead services for the future at their facilities

Over 1000 general health workers trained in mental health knowledge and skills

Over 1000 Community Leaders sensitized on mental health

Provision of new equipment – motor cycles, lap tops etc

He then made the difficult announcement that JF would be closing at the end of the year. As Hugh explained, we have not reached the decision easily. We promised that although the Fund would finish, our relationships would not. The trustees are all getting older as JF has been running for 10 years and the next generation of leaders has unfortunately not emerged. (Those of you on the JF supporters mailing list will receive the letter we have prepared in the near future, but  we felt it was important to tell those who are most affected here in Uganda first.)

Ewan and I are certainly likely to return from time to time to see our friends. 

Our wonderful young people received the news quietly but with great grace and appreciation. They promised that they would continue the great work they had been doing, and would indeed continue community mental health service development. 

[ewan-mo]

Getting started.

Monday 18th September 2023.

Yesterday it was good to have breakfast with Linda, who had arrived safely.  We were collected by Abdu and his minibus midmorning and came to Kampala.  We were warned that the roads around Kampala would usually be busy on Sunday and Monday morning as it was the start of the new school term so parents would be taking children to school.  We were early enough to avoid the worst of it but others later said the roads were very busy.

We had lunch at one of the cafes we know before going to the ARU (The Association of the Religious in Uganda) conference centre.  The nuns, led by sister Lydia, gave us a warm and genuine welcome.  Nothing was too much trouble for them.  We have comfortable ensuite rooms.  The participants trickled in during the evening, some having travelled overnight by bus, others all day. We have known some of our delegates for ten years.

The two accommodation blocks.

Ewan and I had visited the conference centre and met the nuns in February. We thought our young delegates would like this setting, with lovely bedrooms and excellent conference facilities. As they arrived in the evening they were very impressed by the specially warm welcome and careful attention to detail by the nuns.

I was bowled over as we two came into the meeting room first thing this morning. The tables had been set out with beautiful soft blue pleated table cloths, and there were little pots of colourful artificial flowers on each. It all looked so pretty.

When I thanked Sister Lydia (with yet another hug), she waved lightly at her head and said “It all helps with mental health!”

Sister Lydia opened our proceedings with prayer, including a beautiful soft musical prayer.

Our programme today began with getting our students together to catch up and share news of the challenges they have faced and solutions they’ve come up with. They love being together and there is a lot of laughter and affection for each other. Many of them work in relative isolation in rural areas or in the midst of big cities.

As with our patients, our mental health tribe of professionals face stigma from so many sources, and it’s great for them to join again with their colleagues and share their love for working in mental health.

The morning programme continued with reflections on a research paper which illustrated how many patients default from treatment, and the reasons for that. Often it’s because they want the treatment that will heal them completely. Like many conditions, major mental illnesses need long term treatment.

Two of the delegates with the JF bags they have just been given

This afternoon we were on drugs and alcohol!

We’ve had some changes in the programme, for example with the other two psychiatrists who were originally coming having to drop out. I’ve had a bit of extra work to do, both presenting material devised by others and also drastically pruning powerpoints so that my local colleagues could share in the presenting bit  - they haven’t had the many years of practice I’ve had in ‘winging it’.

The programme includes subjects requested by the local teams and other items suggested by us from our observations. It’s a fun mix. We have a mix of presenters too.

[ewan-mo]

A day to collect ourselves

Saturday 16th September 2023

It is good to be back in Uganda again. We like this guest house.  It in one of the back streets of Entebbe, and the road reflects the state of some of the infrastructure. Once you leave the main road the surface deteriorates as the tar has fragmented such that after a while, it is better not even to try and drive on the tar.

The sides of the road in a residential area are too good to waste; they become potential grazing for cattle, sheep and goats.

We took a taxi up to the shopping mall, which emphasises the enormous disparities. It is a modern shopping area where we have to go to buy local Sim cards – all very efficient and high tech, including a disability desk where Mo could go and sit to do the waiting bits.  A delightful young person spotted the walking stick and looked after us. 

Elsewhere in the mall there is a supermarket belonging to the Carrefour French chain where you can buy anything and everything, including all kinds of chocolate (even liquorice-covered white chocolate), single malt Scotch whisky, high cost imported foods and many other things that only the affluent can afford.  

Javas is a café, part of a chain we know and trust where we enjoyed having lunch.  But last year when we took our driver, John. to have lunch in one of these cafés when we were travelling, he was so discomfited at the price of chicken and chips that thereafter I gave him some money so he could buy food where he was more comfortable.

This afternoon I walked down to the local shops.  They vary from good sized shops to small shacks.  With the latter, people scrape a living.  

Shops across the road from each other

Within about a 50 metre circle there were about 30 men with motorcycles – the local motor bike taxis.  All waiting for fares.  Again just scraping along.

Just waiting

We had an interesting discussion with our taxi driver.  He did a business administration degree at university, but was not able to get a relevant job.  Graduate unemployment is all too common here and at least some of the time you need to be of the right tribe and possibly able to pay a “joining fee“ or know the right people, to get a job.  He worked at the airport for a bit but has been a taxi driver for the last four years – like his father: “You need to find a way to make enough money to live and to be in harmony with the government requirements.”

We have enjoyed having today as a less pressurised time.  We had planned it to give our friend Helen time to orientate as it would have been her first time in Uganda, but it has in the event given us a bit more time to catch up.  Mo is having to pick up even more of the presentations as Sudaat, one of the presenters, suffered a crashed computer, losing all her work. She has borrowed a friend’s laptop but is now desperately trying to get her material back on the screen again. 

Linda arrives later tonight.

[ewan-mo]

Back in the warmth of Uganda.

Friday 15th Sept 2023

This last week was meant to be quiet and relaxed as we made our preparations for our Uganda trip, which includes running a 4 day workshop for 30 people next week. You know that quote about best-laid plans of mice and men -? 

Our geriatric summer cycle tour is one of our year’s highlights. Ewan devises a wonderful route, this year in Burgundy, around Dijon, and through the glorious rolling Morvan landscape. Each day the four couples set out, taking it in turns to drive the support car or accompany the driver.

On this occasion my left knee was too painful to allow for cycling, so I was in the car every day. But then you get the fun of stopping for coffee and people watching, and shopping for a French picnic lunch and finding a happy spot on the cycle route, by a river or somewhere else agreeably scenic, and often complete with picnic table on the village green.

On the way up to Calais on Saturday 9th to take the shuttle, our dear old campervan came to a slow stop with flashing lights to match and we had to be taken off the autoroute by a big truck. (For the interested car technos, it was the fuel filter spraying fuel.) Saturdays and Sundays not best days to obtain Parts! 

Insurance came up trumps, thankfully, and we were accommodated in a small hotel where we could get on with the work needed for Uganda – thank you, Internet – and after a final night in St Omer we left early on Tuesday morning to catch the shuttle and drive home.

 

Working to music en-route and once we have arrived

This left us with two days instead of that quiet and relaxed week to get ready for Uganda! But here we are, sitting in the peaceful garden of the Guinea Fowl Guest House, a favourite of ours in Entebbe. We are glad to be here after the long day flight from Manchester.

Though it was fun taking advantage of Special Assistance and being wheelchaired over those long airport walks. The young people doing the pushing and other ferrying were charming. 

#uganda #mental health in africa

[ewan-mo]

We made it

15th March 2023

This has been quite a trip. So good to sense the improved mood compared with last year, the renewal of optimism and cheerful responsivity. But it’s clear that the economic challenges are very difficult indeed, and most of our partner hospitals are struggling financially.

The knock-on effects include a national shortage of prescribed drugs which is only just beginning to recover, and in any case many of our patients can’t afford the fees. A new and rapidly developing problem is the use and abuse of pethidine and tramadol, both strong painkillers. 

As you will have gathered, we’ve been here for the beginning of the rains; sorely needed in many dry areas, but sometimes carrying the risk of flooding, which we saw in miniature at the community clinic with Lubaga.

It was a bit damp

Many of our partners have grasped the challenge of developing mental health services, and some of our days out with them have been brilliant. There are still some among the church hospitals who haven’t quite caught the vision, though. 

In all cases, there is a great deal to do in encouraging local communities to believe that there is a modern treatment for the behaviour that they assume is due to evil spirits or witchcraft, and which I would describe as mental illness or in some cases epilepsy.

Our colleagues here suffer the same stigma as our patients. I have the highest regard for them as they faithfully ‘serve their patients with love’ as the Lubaga logo has it. 

You can see that there are many contrasts in the day to day world of Uganda and its development. We came from Kampala to Entebbe this morning ready for our flight tonight. We came through some highly deprived city areas but also along the superb Kampala-Entebbe Highway, beautifully constructed, smooth and free flowing, lined with palm trees. Such a contrast to the very muddy and potholed dirt roads, found over much of the country.

Here and there in the city are some quite desirable dwellings (sorry to sound like an estate agent) but for the majority in rural Uganda, many people still live in traditional mud or fired brick houses. Mostly with corrugated iron roofs, which is great, but we have seen many examples of grass roofs, used to make thatched houses in Africa from time immemorial.  

A line of duka's

Most of the shops we see are the dukas, small and almost always fronting on to the road – at risk of flooding in the heavy rain, as well as dusty when it’s dry. What puzzles us is that in these shops and in the big sprawling markets, so many units sell exactly the same things, often arranged in exactly the same way too. How do they ever sell enough to make a difference?

Big but not splendid - our vehicle, a 4x4 van.

There are many big, shining and splendid vehicles large and small on the crowded roads. Some vehicles are not so splendid though! Like the vehicle which has been transporting us around Uganda these last days. It has done us fine, but it is 25 years old and covered over 360,000 km.  I was wondering if it is down on power but the owner assures me it just may need a service and new air-filter!

You now know all about the boda-bodas! So pity the poor cyclists, who are at the mercy of all the rest on the road. 

Time on the road and evening time in the guest houses and hotels where we’ve stayed have often been occupied with writing. I try to write a blog each evening, to give you a window into our world here. Ewan is always on the lookout for good snapshots to illustrate the written account, then makes the selection for the blog and edits it into place. He also writes a report for the Jamie’s Fund trustees on each of our visits, which I then check and review. 

Using the time

Often the apparent gaps in our timetable are filled up by these activities, so sometimes the days are tiring. We do hope you have found the blog interesting and helpful, especially if you are a JF supporter. You have been helping to make the transformations we’ve described as beginning to happen.   

We are going to need to raise funds for the professional development workshop we are planning in September (£9000) and probably for a motor bike and rider training for Eseza to get out to do her work in the community (around £5000). Do let us know if you would like to help or donate through the Just giving site https://www.justgiving.com/jamiedevaney-memorial and say which you would like your donation to go to.

Having reflected to a limited extent on this country which has come to mean a great deal to us, I have to return to one of its great characteristics, and that is the welcome we receive. Everywhere you go they will ask you how you are, then tell you that you are welcome. In the JF meetings they add how very much they appreciate us.

Over the last ten years we have gradually built relationships with the teams supported by JF. The welcome now feels very genuine, rather  than traditionally formulaic. And in many different ways our friends have made it clear that they do appreciate us coming so that we meet face to face: a deeply rooted part of African culture. 

I have a very special memory of a community leader in a small village high in the hills above Bwindi Community Hospital. Having waited there 5 hours because they knew we would come that day, when we arrived after quite a precarious journey, he told us in his welcome speech that they were a small people of no account, but we came on our long journey, and we talked with them. How they valued that encounter.

We assured them that they were people of worth and importance.  We value our meetings with them very much and continue to learn a great deal from them. Our overwhelming response to all that we experience is how privileged we are. Thank you for being part of it with us.

[ewan-mo]

Rain didn’t stop play!

14th  March 2023

Kampala, like Rome, is built on several hills. So far I haven’t discovered any other similarities. The hills add interest to all the other complexities of travelling the city. The rivers between the hills have limited crossing points, particularly as you get nearer to Lake Victoria, which is partly why traffic gets so congested.

We are currently sitting in our vehicle in the rain, having left so much time for our journey through the Kampala traffic that we arrived half an hour early for a community clinic.

It’s hard to convey the full effect of the city traffic, as the cars segue casually on to roundabouts,  boda-bodas weave in and out in every direction, https://youtu.be/vaw2RRKP-Iw and the occasional vehicle forms a third (or fourth) lane to overtake a long queue. Sometimes you can sit for an hour or more in a traffic jam.

Then there are the pedestrians: some just getting across the traffic to the other side, some opportunistically selling oranges, apples, tyres, garden windmills, grapes (grapes?), pens,  cushions – you name it, someone somewhere will be wandering up and down the lines of stationary cars offering it for sale. 

The drivers  are really very skilful but do get so close to each other it’s hard to see why they don’t end up at least touching. But they don’t, most of the time. On a day like today the potential for accidents is magnified by the heavy rain, and the road surfaces are even worse than usual – you can’t tell how deep the hole is under the puddle. And it’s very difficult to predict how long any journey will take. 

Not so much fun in the rain.

We have come to St Joseph’s centre where Lubaga Hospital hold a community clinic. We had lots of interesting conversations about data, research projects, clinical conundrums and finding hidden patients – the ones locked away by their families because of the stigma of their illness.

Discussing data with Clare and Mathius

I talked with a village health worker and heard how well she knows her community; she will be a great resource for finding such hidden potential patients. Meanwhile the rain continued to beat down on the tin roofs, and splashed up from the cement floors while a river formed and rushed down the central road of the compound. 

Mo with village heath volunteer and Clare the PCO

When there was a momentary easing of the downpour, we walked up the hill to meet the parish priest for a short and quite quiet conversation with him, followed of course by the obligatory group photograph. 

No patients had arrived by the time we left for our next meeting. In general I like patients to come to their appointments, but in this rain I can’t say I blame them for staying home! The staff thought that quite a few would come later in the afternoon.

Francesca with a hospital umbrella complete with logo

Meanwhile we had a happy and stimulating meeting at the Uganda Protestant Medical Bureau. This is the coordinating body for all the Protestant church hospitals, and, like the Catholic equivalent, they set the direction for the next few years. When they can they also try to get funding for service development. 

And that was the last official appointment of our programme. Though of course, we did have to get back to our guest house in that Kampala traffic. It took quite a while. 

[ewan-mo]

Two special hospitals

13th March 2023

Monday we began by meeting the Mukono Hospital senior management team, and hearing their reflections on the year in mental health, and their ideas for the next developments. It is a great team.

One of the JF-sponsored PCO’s will be returning to take up her work as lead for the team in June. They already have some very keen clinicians at work in mental health, so they have begun to sort out how things will change and develop when Eseza returns. 

Eseza is a capable PCO in her final semester.

As previously we were impressed by the line-up of senior managers, led by the Medical Director (MD). (You have met the MD – he is Simon Peter with whom we had dinner the previous night!)  We look forward to hearing how the plans evolve.

At Lubaga in the afternoon, a considerable number of staff were there to reflect on the year’s work, the current challenges and plans for the future. 

We were pleased to meet a number of senior folk, some of whom were new to us. I love it that the Medical Director is a religious sister - she is Sister Doctor Grace. We very much enjoyed conversation with her and other colleagues who have become friends, like the lovely Sister Lilian. She’s a nurse-type sister, not a nun.

Sister Lilian, Mo, Sister Dr Grace and Ewan

This mental health team have wonderful enthusiasm, and also have a great capacity for celebration, so of course we had cake as well. And a first – Ewan planted a celebratory tree which it is hoped will give shade to people waiting in years to come.

Our day concluded with a meal to which we’d invited the other three PCO’s in training, Gloria, Bazirio and Simon. Good to discuss with them how their studies are going, how they are feeling about graduating in June, and their plans for return to their home hospitals and their new roles. We were pleased to find them in better spirits than last year.