Thursday, March 29, 2007

Half-Baked Study Skills

Abdul, our project driver asked me if I knew someone who could give him some study tips. He says for the amount of time he is spending studying, he doesn’t seem to be able to remember as much as he would like to recall. He is a bright, dedicated, enterprising chap and a valuable resource for our project. He often has to wait for people. His work life in fact involves a lot of hanging around waiting. He has begun studying for his O levels. (The equivalent of Grade 12 in Canada). This is done generally in the back of the van with the windows open. But in the African sun, it is very hot and stuffy, so it is no wonder he has trouble retaining what he reads.

I suggest he ask the wife of the pediatrician who is here working on the project, who is a retired school teacher. He seemed reluctant so I agreed to ask her for him. Daily over the next couple of days, Abdul asks if I have asked her. Finally, I get that having some study skills is very important to him. When Ido finally ask the retired teacher she says she has never done any study skills courses. Neither have I. When I check on the internet, I find nothing. I try a couple of different prompts but still no luck. Are study skills a recent phenomenum? Beats me.

When I relay this to him, he is crestfallen. Abdul clearly thinks some short written instruction on study skills is going to help him. So I think, how hard can it be? As a medical educator, I have a couple of ideas. So I tell him I will have a go and try to pull something together.

Finally pen in hand, I come up with a couple of tips. Five to be exact. I press the retired school teacher into service and she has a couple of good ideas and edits. The five tips we settle on are: summarize, paraphrase, repeat, study in short periods and build your vocabulary. Examples of each are provided.

For paraphrase, I lift a paragraph out of a Ruth Rendall murder mystery I am reading.

eg. “Things were getting too much for Norman Smith. He also was snowbound with a fellow being who was uncongenial to him, only the fellow being was his wife.”

Paraphrase: “Norman Smith was getting upset. Because of snow, he was stuck in the house with his wife.”

Only I fail to notice at the time that the word “snowbound” would be completely foreign to Abdul.

Regarding repetition,I give the example of 4 ways to sterilize water, a useful consideration around here.

e.g. 4 ways to sterilize water: boiling, UV radiation, use of disinfecting tablets and ionization.

A couple of days after I have given him the sheet of Study Skills, Abdul and I were out visiting one of our remote communities and he asks me what snowbound means. I am both chagrined and pleased. Chagrined, that the word had slipped by me, but pleased because I recognized immediately that he was actually reading the study skills. Later that day, he asks me where one would get disinfecting tablets. Well, my day was complete. I tell him that I have some but thankfully never had to use them but I carried them with me in case I couldn't get boiled water.

"You get these pills for water in Canada?" he inquired.

"Yah", I reply, realizing it does sound strange from his vantage point to have pills for water. 'But I think they would be available here, maybe at the pharmacy."

I think I am finally talking to someone who has, word by word, devoured what I have written. How wonderful is this? It seems as if almost daily I encounter volunteers and trainers who don't seem to know the most basic details in the manuals I wrote specifically for them. Maybe, I think, I should give up writing manuals and write study skills.

So here it is, my contribution to remedy this lack of Study Skills on the internet, the complete five tips in its entirity. Edits will be kindly and gratefully received.

Study Skills

Dedicated to Abdul

Study skills assist you in making more effective use of the time spent studying. They help you to understand what you have read or heard. New skills will take a while to master, especially in a language other than your mother tongue. So start slowly and don’t give up easily. Everyone is different in how he learn. You will need to try different skills to determine which ones work best for you.

The five skills below can assist you to ensure you have understood what has been said or written and remember it. a) Paraphrasing -- repeating in different words what something means. b) Summarizing -- picking out the main points of an idea and putting them in a shortened form. c) Repeating – saying out loud, to yourself or in writing what you want to remember. d) Study in short periods. e) Build your vocabulary

Begin by paraphrasing, or repeating in other words, what each sentence means after you have read it. As it becomes easier for you, paraphrase after two, then three sentences and finally after a whole paragraph. With practice it becomes easier. It will be easiest if you are reading something you know a bit about and more difficult with a topic that is new to you. Remember that many textbooks are written in jargon, or words specific to that topic, and may not be familiar to others. The important thing is to get the idea behind what is written and put it into simple words so you understand. In the beginning it will take time but as you get used to doing it, it becomes easier. Once you have trained your brain to do, it will happen on its own.

eg. “Things were getting too much for Norman Smith. He also was snowbound with a fellow being who was uncongenial to him, only the fellow being was his wife.”

Paraphrase: “Norman Smith was getting upset. Because of snow, he was stuck in the house with his wife.”
b) Summarizing

Summarizing means taking out the main points or ideas in something you have read and repeating them in fewer words. Include the important parts of what you have learned. You can summarize after each paragraph to start, then after each page and then after each chapter. When you summarize a whole course, you are identifying what you think is important and therefore likely to be tested or examined. This kind of course summary can help you to focus on what you need to study. But first you need to start with each paragraph.

To summarize after you read a paragraph, close the book or your eyes and review what you think are the main ideas or points in the paragraph. When you have done that, check the paragraph to see if you got them. At first doing this will slow your reading down, but as you practice your brain is being trained to do it. With time and practice you will only have to do this when you are reading something very difficult or new.

The next two skills help you to remember or recall items. Remembering is always easier if you have understood but sometimes you need to recall a list of items. Repeating can help with this.

c) Repeating

Repeating means saying the same or similar thing many times. Many people begin repeating before they have understood what they have read. By understanding first, using paraphrasing and summarizing, you will be able to make better use of repetition. Repetition is used best when you have to recall or remember a number of specific steps or items.

E.g. 4 ways to sterilize water: boiling, UV radiation, use of disinfecting tablets and ionization.

It helps to understand what each process is. Then say them several times. Repeat them through out the day. Say them again before you go to bed and repeat them in the morning when you wake. Make a list of such items for yourself and repeat them at different times in the day. This alone is often enough to help you remember them. You can practice with a list of things you need to get at the store. It also helps with lists to put them to a tune and sing them. It can help to put them in a mnemonic. A mnemonic is a short word or phrase which reminds you of each item in a list.

E.g. New MEDICINE is a mnemonic for the 8 elements of Primary Health Care:, Maternal and child care, Education about Health, essential Drugs, Immunization, Clean water & sanitation, Injury & common disease treatment, Nutrition, and Endemic disease prevention.

d) Study in short periods

Start a new topic in small amounts. Take frequent breaks. Stretch and move around at least every 20 minutes. Memory is lodged in all our muscles, not just our brains, so if you want to learn to remember something, keep your body healthy and happy. When you are learning something new, the brain works best in short periods with small bites of information. As you become more familiar with a topic, the brain can add larger bits to what you know more easily. Break a reading assignment into smaller bites. Set do-able goals. Eg. Read this page, make that list, complete this exercise and summarize this chapter.

e) Build your vocabulary

Enlarging your vocabulary gives you an important tool in your education and in life. A large vocabulary will improve your ability to discuss new ideas. It can also help in learning, summarizing and remembering. Set a goal to learn at least one new word each day. Start with the new words you are learning in your study. Write them down. Note down their meaning. Later you can check them in a dictionary. Keep a pocket-sized dictionary handy. You want to be able to use your new words so find out how they are pronounced. Use each new word 5 times in the next couple of days. Find ways to insert it into the conversation. Powerful words are not necessarily long words. Keep the list of new words with you. Each week review all the words you have learned that week. Within a couple of months you will notice that the new words are cropping up in your conversation readily.

Good Luck!

OK so this may be an excuse to show off the Abdim's Stork I saw which is a bit out of its usual nesting grounds in the Sudan and I should consider a day job.

Photos: Abdim's stork, coffee in flower

Monday, March 26, 2007

Pediatric Grand Rounds Vol 1:14

Pediatric Grand Rounds is up at Musings of a Distractible Mind. Rob has created a huge assortment of delectibles around the Tom and Jerry theme, a wonderful tour de force. I am pleased to be included. If you make it to the end you will see that I have been rated highly indeed and with such a lovely comment.

Finally, what I consider the best submission this week comes from Uganda. Travelingdoc of the blog Borneo Breezes gives us all perspective in her post Sad News. This tells of the death of a child she cared for in Uganda. While we are all doing our best in our own situation, we need to stay aware that there are those whose needs we could not fathom. The work is great, but the workers are few."

Pediatric Grand Rounds in the Blogosphere is a collection of posts from bloggers about issues related to children's health. It occurs every two weeks and is a great place to check out new-to-you bloggers. Just click on Tom and Jerry and you will get there.


Saturday, March 17, 2007

Sad News

Festus, the clinical officer who is facilitating the Integrated Management of Childhood Illness course, manages to link all twelve nurses up with suitable clients for their practicals within a few minutes. Most of them are sitting outside the OPD under the shade of a tree. A couple of them are in the nearby pediatric ward. I move around taking pictures as they take temperatures, gather histories and follow their flow charts to arrive at a diagnosis.

Several of the children have significant findings so Festus has us gather round to observe. A young boy suffers from acute painful mastoiditis. One of a set of twins has the high temperature, rapid breathing and indrawing of pneumonia. Then we come to Immaculata, one of the nurses, who is examining the most severely malnourished infant I have seen in Uganda. Gently Festus reviews the history and demonstrates the signs. The child is 5 months old and weighs only 2 kg. The skin on his buttocks hangs down to produce what is called the “baggy pants” sign. He has been breast feed and mother says he is sucking eagerly but when asked to demonstrate, her breasts are dry. His palms are almost white. Festus quietly points out that the mother too is malnourished with the silky thin hair of chronic malnutrition. Signs of severe dehydration are confirmed in addition to severe anemia, so the child is taken immediately to the clinical officer.

We return to the classroom. During the break, I go with Immaculata to visit the child on the ward next door to the classroom. Immaculata has obtained a detailed history so we know that the family has no land and are unable to produce their own food. In this place, at this time, HIV is also a real possibility. We realize treatment of this child and family is not going to be easy.

But when we get to the ward, the child and his mother are not there. I look around the compound outside while Immaculata tries to find out where they have gone. Nobody on the ward seems to know. Immaculata goes back to the clinic, locates a hemoglobin result and finds out that the child has been referred to the nearest hospital for a blood transfusion.

As the mother was unable to afford the transport, she has taken him home. It is that simple. She didn’t really have any other option.

“Oh, no,” I think, “We didn’t even start him on ORS. We could have done that much.

I am consumed with remorse. Immaculata is as distressed as I am. We had determined the mother had no money. How could I have trusted the system to look after them? Others suggest, kindly, that it was clearly such a desperate situation, maybe the mother took him home to die.

As we are sorting out what has happened, the high keening sound made by a mother when a child dies, rises from the health center. It is still a hard sound for me to hear, but one that Africans seem better able to take in their stride. It is heard much too frequently but one never gets used to it.

It is a terrible sound, this immediate, bottomless grief of a mother. It clutches at soft places inside you, holding you in its thrall. Later, the mother will be consoled, but at this time, it seems, she needs to physically exorcize the grief with howls of pain. Today, I am so distressed by our inability to assist the severely malnourished child, that only later do I realize that I don’t even know what else was happening in the health center.

Immaculata offers to send a message to the mother in the village to come back. I think at the time she is just placating me, but I thank her.

The next morning, Immaculata comes to tell me that the mother and the father have returned. I am amazed she has managed to get the message to them so quickly. I can see them standing over by the OPD with the baby wrapped in a clean white shawl. This time the mother has brought a plastic basin and a other few things wrapped in a cloth that she will need to care for the child on the ward.

“They just arrived and as I was examining him, he passed away in my arms,” she sighs.

Together we talk to the mother, finding out she has three others under five at home. The three year old, she tells us, is also malnourished. Immaculata and I think that, given her own state, probably all of them are in a bad way. I notice there is no keening for this child, more like a quiet resignation but maybe we are seeing the impact of depression or the hopelessness of chronic starvation.

Festus announces the death to the class. He is a good teacher and avoids judging the situation or people but wants the students to understand the importance of their work.

Later that evening, I am watching CNN, beer in hand, in a darkened shack all by myself. The TV is powered by a generator which is operated by an energetic business woman who also provides my breakfast of milk tea and chapatti each morning. The CNN news clip has to do with a Druze wedding on the Syria-Israel border. When a Druze woman marries someone on the other side of the border, she can no longer visit her family. CNN seem to have lifted their story in its entirety from an evocative documentary I have recently seen. It is sad alright, but when the tears start to tunnel silently down my cheeks, I know it is not just for the Druzes I am grieving.

Photos: Interviews under the tree; Interview in OPD; SevereMarasmus; SeverMarasmus2; Coffins


Thursday, March 15, 2007

The Naming of Things

The Integrated Management of Childhood Illness (IMCI) workshop is on in Rugazi. Twelve nurses who work at health centers in the areas where the Healthy Child project operates are attending. IMCI training was introduced in the developing world by the World Health Organization (WHO) a couple of years ago. It was a successful program and has improved the management of children’s health by nurses and clinical officers who handle the vast majority of health care in rural areas. Members of our team assisted with the implementation when it first began and were impressed by how useful it was. For our program to be successful we need the health centers attached to the communities to be able to handle the clinical cases appropriately, so we have supported having the staff trained effectively.

IMCI was rolled out across Uganda, facilitators were trained and then, I suppose, the money ran out. Now our project is one of the few that has continued to run the course. We run it twice a year because there is such high turnover of staff in rural health units. I am enjoying getting to know the nurses and it has occurred to me that this would be a good place to recruit future trainers for our project.

Enroute to Rugazi, my driver began telling me an interesting story about how this area got its name.

“Which name?” I inquire, not sure if we are talking about the parish, the town or the subdistrict.

“The whole area, Bunyaruguru,” he responds. “It means the people who walked on their own legs this far.”

“From where?” I ask.

”They came from the western edge of Buganda."

Buganda is the largest of the five kingdoms in Uganda. It is composed of the Baganda tribe and located in the area around Kampala in the center of the country.

“How come? I ask.

“I am not sure,” he says, “But some of their group only got as far as the area around Ibanda, got tired and stopped there. They called their place Batagenda, which means we stopped before we got there. They were families who were related to the people here.”

Later I try out my new found knowledge on the nurses who are from this area.

“Yes”, they affirm, “It is a true story.”

I have borrowed a map from a local tourist brochure to show you some of these places. Mbarara is marked in pink; Ibanda, the place where those who sto
pped before they got there settled is also marked with a pink dot; and Rugazi is the most westerly pink dot in Bunyruguru, not a big enough place to be named on the map but located just before you get to Queen Elizabeth National Park and the Kazinga Channel. The approximate area in Buganda from where people walked is in the vicinity of the large pink patch. So it is qute a long walk, a couple of hundred kilometers at least and you could be forgiven if you failed to make the full journey.

For me it explains why I see more basute, the long dress of the Baganda women with their high puffed sleeves hereabouts. When you cross the border between Buganda and Ankole along the main highway, the kiganda dress and kiganda baskets of the Baganda are found no more. Then you notice the Ankole baskets and the women wearing two skirt layers with the upper one ¾ length and the lower one of usually horizontal stripes of red in the manner of the Banyankole. I mention this to my driver and he tells me that over time the Ankole and Baganda have intermarried in this area but I could be right about there being more Baganda influence.

There are other interesting names around these parts. When foreigners first arrived in Uganda, people wanted to protect their local resources so they named one of the well stocked rivers , Semuliki, meaning "river without fish". When the train tracks were built from Mombasa to Kampala, Namagasali was so named because it meant “I am greeting the train”.

The palace of the Baganda king or Kabaka is high on a hill and his subjects often crawl up the hill on their knees as a form of reverence, often bearing gifts. The site was named, Kubendabenda, meaning climbing while bending over double, an evocative use of repetition, onomatopoeia and simile all at once. It has an impact similar to the phrase "mpola mpola" which translates as "slowly by slowly" and works on you whenever you hear it, to slow you right down.

There is some speculation about the derivation of the term "muzungu" for a "white person"--the plural form is "bazungu". Some say it means "traveller "or "wanderer". It seems to be limited to whites as there is a separate word for an "East Indian" -- "muhindi". "Kizunguzungu", which means dizzy, may have been in use before Ugandans met whites and after observing us they may have applied the term or it may have been a new word coined for dizzy after they got to know us and our behaviour a bit.

Although "ba" is the prefix used for the plural form of people in most of Uganda, in Kenya and Tanzania where Swahili is used more, the prefix would be "wa" as in "wazungu". In Uganda however they do use the term "WaBenzi" for the newly rich capturing nicely their penchance for Mercedes Benzs.

There are equally fascinating stories about people’s names.

I met a fellow called Mwesigwe and said to him, "You must be trustworthy."

“Maybe not,” he replied. “I got my name because my mother had twin girls and prayed for a boy. So when God gave her a boy, she said, God is trustworthy, and it became my name."

Photos: Woman Pounding millet; children in Rugazi; Eye Map of Uganda; Tea Plantation & dugout boat.


Monday, March 12, 2007


Our volunteers have always included men, about one male to every three women. When there aren’t enough men in the groups, the women complain because it becomes more difficult to have a significant impact if men are not involved. Having men also sends the message that this is an important activity.

Lately we have been attracting more older men, or rather the communities have been selecting more older men as their volunteers. At our most recent training course for volunteers, 8 of the 24 new volunteers were men, and six of the men were over 60.

Their contributions have been spirited and thoughtful. The most engaged, revered, funny and thoughtful fellow is 78 and addressed by everyone as Mzee. Mzee is a form of respect in East Africa. Julius Nyerere, the former President of Tanzania is called Mzee. It is that kind of respect that the honorific carries.

In one drama, Mzee played a woman with a breast abscess. With his shirt stuffed with newsprint, cradling the painful, swollen area, he created such an accurate depiction that he had the whole group transfixed in astonishment as he discussed his problem with the man playing the volunteer. People were riveted by the role play, waiting in earnest anticipation to see if he was going to get the advice he needed and there were whoops of delight at the end.

Mzee exhibits all the characteristics that are said to be necessary for a healthy old age. At the beginning and end of each day, he has been chosen by his peers to say prayers. He has many friends among the volunteers, young and old, often staying afterwards to talk with others. Along with all the other men, he rides a bike to and from the training each day, a winding, up and down ride of more than ten miles. He comes from a home with a child under five, that being one of the few requirements the project makes. From his responses in groups, he appears fully involved in child care for his great grandchildren as well as in the running of the home. He teaches others informally and in the small groups. And he volunteered for this job which requires as a minimum for him to visit all the homes of children under five in his village at least once a month in addition to other activities, and this is a very hilly area.

He is slight, of medium height and carries himself erect with a closely cropped head of white hair and alert, inquiring eyes. When I talked to him about why he had volunteered, I noticed he had marked dimple-like depressions equidistant from his nose in about the mid point of his cheeks. I had seen this before in the Keewatin region of the North West Territories, or what is now called Nunavut.

Dr. Otto Schaeffer, an Austrian-Canadian internist who devoted his professional life to the Inuit, first identified this rather distinctive loss of facial fat in the Inuit who had survived the great famine that occurred in the early 1950s in the Canadian Arctic. For some reason both seals and caribou, which provided the staple food of these northern nomadic hunters, did not appear in the usual places or numbers for a couple of years running in the 1950s and many Inuit died.

Canada was slow to respond to the famine in the Arctic but eventually a decision was made to relocate what were at the time a nomadic people, into a few, scattered, small hamlets around the shores of Hudson’s Bay so food could be provided more conveniently and the children who survived could attend school. The houses built were inadequate for the arctic winter and crowded and the services were poor or non-existent. This is the simplified version, but simple or complex the story is not a pretty one.

Farley Mowat has written evocative fictional versions of some of what happened at the time. People of the Deer and The Desperate People. His work isn’t appreciated by the Inuit partly because in fictionalizing events he was not seen as “telling the truth”. Hamlets such as Rankin Inlet, Whale Cove, Chesterfield, Eskimo Point, Belcher Islands, Coral Harbour and Baker Lake, as they were called for a number of years later, were established as settlements at that time.

Dr. Schaeffer wrote about a number of his observations, becoming an expert on childhood nutrition, bottle caries, breast feeding, severe cold and respiratory disease. He wrote a number of papers that spanned a whole range of topics but I don’t think he ever wrote about the facial results of starvation.

However, he often showed slide shows to physicians and nurse practitioners who worked in the north and was instrumental in educating us about northern health. When I did my MPH at Johns Hopkins, a nutritionist who mentioned something similar in South Americans was so interested when I told him about Dr. Schaeffer’s observations that I obtained copies of some of Otto’s pictures for him. But I don’t recall anything coming of it. A curious observation, a strange finding it has remained.

Now here I am looking at something similar twenty years later in Africa. So I get someone to translate for me, although Mzee appears to understand English somewhat.

I ask, “Was there was ever a time when you were starving, not just hungry but starving.”

The translator asks, “You mean like famine?”

“Yes,” I respond, recognizing that with the banana wilt, many people are hungry a lot of the time here right now, “a long time when there was no food.”

Mzee appears to be following this exchange carefully and replies unequivocally in Runyankole as soon as the translator is finished, “1940”.

“What happened in 1940?” I inquire.

“The locusts destroyed everything.”

I work out that he was 11 at the time and want to ask more but I can see he is affected by just telling me this much. If it was anything comparable to what happened in the Arctic, many died and no one there at the time was unscathed.

The devastating impact of such starvation hits me full force. Working thru a translator, with the extra pauses that result before I can fire off another question, often has that effect on me. It is as if the pause ensures that I absorb the message with my whole body.

Mzee watches my face carefully, his eyes questioning. So I explain that I have seen the same thing in Canada in the north where people had really starved. He nods, interested, and we seem to be back on comfortable ground.

Later I share the story with George, a pediatrician and Ernest, a Ugandan public health specialist who have come on the last day of the workshop. George worked with Otto in the Arctic and knows about even more amazing observations that Otto made during his remarkable career.

I sigh, “Sometimes it feels like we are long past the time when it matters if we, as physicians, are close observers of our world”

“Not so”, protests Ernest and tells us how patients with HIV/AIDS in Uganda are noting that they have both unusual loss of and different accumulation of fat.

“Really?” says George and the three of us are off on another tangent.

Photos: Men Group; Role play; Men's bicycles under the tree; Placenta Pit becomes a project, Herb garden


Friday, March 09, 2007

Traditions and Orange Yams

The sub-district where we are now training has a strong attachment to traditional medicine. So strong, in fact, that I have been seriously considering the need for a module on traditional medicine. Outside the health center there is a large, well-tended herb garden, something I would have overlooked or called a flower garden except that one of my trainers, who is aware of all the ways plants are used, pointed it out to me.

I have asked the trainers to note down some of the stories we are hearing, some of which are peculiar to this place. One entity, on which there seems consensus, is something called Horn Disease.

“It is as real as cough or diarrhea or fever”, said one trainee, “And sometimes it looks like all three.”

It is a result, we are told, of someone bewitching your child and can only be healed by a traditional healer. After the healing has been done, the parent is instructed to take the child to the health center if the symptoms require further treatment.

The people in this area are mainly Bahima, a cultural group of traditional cattle herders, who for reasons that aren't imediately obvious, have no cattle and are attempting to establish themselves as agricultural workers. At this time it doesn’t appear to be much of a success. The matooke (cooking banana) plantations, which are the beloved staple food in the area are not in good shape. People from the central part of the district note that the matooke stems here are short, stunted and the bunches are few and small. And if that weren't enough, this district is also experiencing a menacing banana wilt which has severely decreased crops and continues to do so. There isn’t much need here for the long forked poles which support overweight bunches in other more fertile regions.

I don’t mean to suggest that I can spot this difference in crops myself. Not by a long shot. There are exclamations in the car about how poor the plantations look. Finally I have to inquire, “How can you tell?”

At first they just reply, “Just look at it!”

“What do I look at?” I have to ask since it all looks like matooke to me.

Poor crops, poverty, persistence of traditional beliefs and poor adaptation to a completely different way of life seem to be related.

This weekend in Kampala I was meeting with an old friend who is working on a project to introduce an orange yam with high beta carotene into the diet in Uganda and Mozambique. The project includes establishing agricultural support, seeds, establishing markets, introducing people to this new tuber and trying to create a taste for it. Children appear to love the taste and consistency of the orange yam but the vine needs to be watered and tended somewhat more than the white and grey yams grown here. Unfortunately, for us in the south west, the areas of project implementation are in the more northerly areas of the country.

We shake our heads over the difficulty of changing people’s traditional diet. I retell the story about hosting a huge party with a groaning table full of rice, potatoes, millet, chicken, roasted beef kabobs, samosas, green salad and a fruit salad of pineapple, passion fruit, bananas and payaya. Afterwards a close friend came to thank me saying, it was a wonderful party except there was no food.

“No food!” I exclaimed, “Where were you? There was so much food, my table almost collapsed!”

“Oh, yes,” she stated, “There was lots to eat but there was no food.”

Seeing my surprised face she added, “No matooke.”

We both laughed. The attachment of the Baganda tribe in central Uganda to matooke is legendary and has even spread to other areas. Here among the Ankole, matooke has also become a staple both for local consumption and a cash crop with huge truckloads marketed in Kampala.

“Good luck with the orange yam!” I tell my friend as we hug on parting.

Trying to introduce orange yams seem a mad undertaking at first glance, but I have noticed that cucumbers, carrots, okra, cilantro and green peppers that were not grown here before are starting to appear in Mbarara markets. We could really use the beta carotene these orange yams contain especially for children. It would make a whole lot more sense than giving children Vit A capsules every six months as is now done. So I am already thinking about how it might become an income generating project. Maybe if it was started near a swamp or another source of water? One needs to take note of traditional practices but one also needs to move forward.

photos: Orange yam (AKA sweet potato); matooke market; local yams; matooke bunch


Tuesday, March 06, 2007

Grand Rounds at Grunt Doctor

Grand Rounds is up at Grunt Doctor, his fourth time to host it. He deserves a medal! He has put all 60 submission he received in and I am pleased to be among them with my post about Special Children. Medical Grand Rounds on the Blogosphere is a weekly compliation of the best of the posts based on those who submit posts to the host. It's a good way to find other writers about things medical that you would like to read.


Saturday, March 03, 2007

Special Children

In our child health project we have designated children with disabilities due to birth injury, deafness, blindness, epilepsy, HIV/AIDS and chronic conditions as Special Children. In small isolated rural communities such children may be kept indoors, regarded as bewitched and the parents shamed or blamed. One of the tasks of our community volunteers, called CORPs, is to identify such children and to work with the community to have them accepted and assisted by the community. Orphans who have lost one or both parents and severely malnourished children are also included.

The urgent field interventions such children needed often required small but necessary input such as avocados, milk and protein-rich foods f
or the severely malnourished. A donor supplied a small fund for such interventions so they aren't delayed by the elaborate procurement process required for other purchases.

On Tuesday, the project vehicle took our two research assistant up the mountain for the monthly meeting of the CORPs in one parish. The research assistants are collecting annual information about children under five. Two of the visiting pediatricians, one a pediatric neurologist from the UK who is here for two weeks and has been teaching post grads and students on the ward, went along. They ate the noon meal with the CORPs, listened to their songs, sat in on their training session and answered questions.

A 4-5 month old child
who had congenital cataracts was brought by one of the CORPs from a nearby village for their advice. The pediatricians recognized that the child was at the upper limit of age when the cataracts could be removed and sight established. Left much longer, the ability of the child’s brain to begin processing visual information would be lost and even if the cataracts were removed later, sight would never be established. When they asked how to arrange for the needed surgery, they were told that the family and community would need to raise funds, the mother had never been to Mbarara and would need to be escorted, appointments would need to be set up, the father would need to be convinced as he had accepted that the child would be blind for life etc. All were legitimate objections.

The pediatric neurologist is a mild, gentle, unprepossessing man with little experience in Africa and on his very first community visit.

“We decided to push the system”, he tells me later, adding dramatic emphasis to push the system. “We put the mom and child in the vehicle with us at the end of the day, drove down the hill and delivered them before dark to the Eye Hospital in Mbarara."

"You absconded with them?" I ask.

"Well sort of," he grins. "And the surgeon is going to operate in the next couple of days and he is going to do it for free! Luckily enough, your driver knew staff at the rehabilitation project which is attached to the Eye Hospital so we were able to talk to them and arrange for them to assist the mom with accommodation and food.”

It’s a wonderful outcome for the child, the family and the pediatricians, both of whom are leaving today. We have been dialoguing during their stay about how as expatriate physicians to best make a difference in the developing world and had reached a sort-of consensus that consultants need to have long term commitments, not necessarily staying for long periods at a time although that may be helpful, but returning again and again and setting up connections and relationships.

I don’t have the name of the child with the cataracts or her mother at this point but what is more important, our driver, Abdul, can find them for me. As well, Speciosa, one of our trainers who is the In-Charge at the referral health center and who conducts the monthly meetings with the CORPs in this parish knows the family and can follow them at home. Abdul and I are going to stop by the hospital on Sunday to check on progress. And our project now has contact with staff in a committed rehabilitation project that can help us with the Special Children that the CORPs identify in the community. It’s a Win – Win situation.

At the training of new CORPs in another corner of the district, a young child with a massive, suppurating osteomyelitis of the tibia was brought for us to see. It is the worst such case I have ever laid eyes on. It is a wonder that the child is even still alive. The parents have been spending vast amounts of money on traditional herbs and now have no funds for X-ray or antibiotics.

Our Special Children Fund has criteria to ensure it is used appropriately and not spent on all the clinical needs that abound. Our staff ask me if this condition would qualify for the Special Fund, or worded differently, does an infection qualify as a disability?

I am inclined in cases of need to beg for forgiveness after the fact rather than seek permission but what they need is a justification to put in their report so I say, “Well it is a chronic condition. It has already created disability because the child can no longer walk. It is serious and getting worse. Urgent intervention is needed to save function, the leg and maybe even the life. I say it qualifies.“ They are delighted and begin to make plans with a Ugandan surgeon who has offered recently to assist with such cases.

From a community health point of view, these anecdotal clinical successes, or soon-to-be successes, are not and should not be our main focus. While they make dramatic images, I am suspicious about the committment to development of groups which communicate and raise funds by using such anecdotes. And I worry that our project is becoming more a Special Children project than a Child Health project.

The pediatric neurologist argues, rightly enough, that a comprehensive, effective, quality program for disabled children will also be a good community program for all children. A community health specialist on the other hand needs to balance need with the available resources, which for all children
in Uganda are meager. We probably need a separate project for Special Children. Certainly more needs to be done. For now we will continue to use the opportunities that our access to the communities provides to do what we can. It will definitely help to have somewhere to refer Special Children when they are identified, so I will need to do some followup with the rehabilitation project. All children are special! And it certainly puts a spring in your step to think that you may be able to contribute, however peripherally, to a child being cured of life-long blindness or avoiding a limb amputation.

Photos: Child with trad herbs for skin condition; kids cutting up jackfruit; kids with millet baskets; kids in yard; Mom preparing millet with small child.


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