Guest Report: Uganda, Part II
Southwestern Uganda. Image courtesy of the University of Texas.
Megan McIntosh Frenzen writes:
In Uganda, every single day is astounding, in both good and bad ways. The morning commute to Bwindi Community Hospital (BCH) is very short but very interesting. It’s a bumpy dirt road with enormous ruts, loose baseball sized stones and the occasional gigantic puddle after storms pass through. Our fellow commuters are mostly women clad in brightly colored fabrics and dirty children, all with baskets on their heads in which they are carrying bananas, sugar cane or tea. Should you happen to catch a their eye, your gaze will be met with a big white-toothed smile. These smiles are intermittently accompanied by “Hello? How are you?” which is incredibly charming. On most mornings, a haunting, rhythmic drumming echoes down the jungle-covered hillside above the hospital. There has yet to be a morning that it hasn’t stopped me in my tracks and made my heart skip a beat. Just in case crapping in a bucket wasn’t enough of a reminder that we’re in “rural” Africa…
It stormed on Wednesday morning. I haven’t described much about the operating theater at BCH, but let me start and finish by saying that the ceiling is plastic. It’s a kind of plastic that looks a lot like corrugated metal; it slants downward from the apex of the roof and it has ridges running its entire length. There are several non-plastic ceilings in the hospital, so I assume this design was intended to allow maximum light into the room – which is a good thing, given how much the theater light sucks. Yes, that’s right: one light. Singular, not plural. One light that raises the temperature in the room from uncomfortable to intolerable within minutes of being switched on. When the storm passed that morning, the thunder shook the walls and the rain sounded like mortar on the plastic roof. It was both a beautiful and a sad sound.
For some reason, on that particular morning, it humbly reminded me of the resilience of these people.
That day, we’d put a split thickness skin graft on the toe we’d (bloodily) excised a mass from earlier in the week. I must admit, I’m a little obsessed with skin grafting. It’s an endeavor well suited for someone who is borderline OCD, an excellent procedure to do with neurotic precision: measure, cut, trim, remove fat (on full thickness grafts), size perfectly, suture, repeat as necessary.
In addition to the grafting, a few more extra pinky toes were removed and Seth lengthened the Achilles tendon on a boy who couldn’t walk on the plantar surface of his foot because of how contracted his tendon was. All in all, it was a good day in the hospital and it even ended “early,” around 5:30 p.m.
I was starving, so after work we headed down the road, around the post-storm mud puddles and straight to the Good Shed. I asked Maria, the striking young woman who tends “bar” there what they might have to eat. There isn’t a menu for miles, literally, which is fine–but when her response was “rice and meat of goat,” I opted for a warm 50¢ beer and headed for a plastic chair on the 5×10 cement slab “porch” in front of the Good Shed.
It seems like the entire southwestern Ugandan world could pass you by in front of the Good Shed at that hour. There is no better reminder of Uganda’s explosive population growth, or that more than half of their population is younger than 30, than an hour spent sitting in a patio chair on the Good Shed porch. Dozens and dozens of barefoot school children dressed in tattered and filthy school uniforms, some carrying books on their heads, a few with machetes (a concept I am not yet comfortable with). Young men zip by on circa 1985 motorcycles and the occasional dark green Ugandan Wildlife Authority Land Cruiser speeds past at altogether unsafe speeds.
Darkness fell quickly that night and it was time to brave dinner and head to bed. There were big plans in the works for the following day: we were eighteen surgeries into our stay and it was time for a day off.
Most of you know that I don’t really do days off per se, so in the interest of avoiding sitting still, I’d procured two of the forty day-permits issued by the Ugandan government to go tracking mountain gorillas in the jungle. Seemed like a perfectly good plan to me. However, this “day off” would now require a 5 a.m. start. I would have to do my morning spider reconnaissance in the pitch black, and stumble around between my bed, the shower, my pillow, my hair, my clothing, and the bucket we call our toilet.
It was still dark out when we climbed into one of the BCH “ambulances” and set off for the Bwindi Impenetrable Forest. I’m not kidding: it’s really called the Impenetrable Forest and we really were taking one of the two ambulances. I was to find out exactly why the forest was given such a name in a few short hours….
The drive to Ruhija (roo-he-ja), the area of the forest where we would be tracking the Bikuru (bee-coo-roo) family of mountain gorillas, was absolutely terrifying. It could be some kind of emotional block, but I can’t even remember our driver’s name. I now call him the Chicken Killer. I almost asked him to slow down. Seriously. This, coming from someone who spent a number of years on a first-name basis with several State Troopers, in large part due to my speed-related performances on interstate 89.
Not only was I mortified that I was very close to sounding exactly like my mother, I also was forced to take stock of my own decision-making history. I have spent the vast majority of my life warmly welcoming any activity or experience that might result is serious injury or death. I’ve jumped out of a plane and off a giant crane in the middle of the night, I’ve gleefully hopped into a flimsy cage surrounded by chum and Great White sharks, I’ve come far too close to wild lions, I’ve wandered (alone) through China and a few less-than-desirable regions of Africa, I’ve paddled big rivers and skied plenty of things I shouldn’t have. In other words, I’d be hard pressed to feel justified complaining about my safety. So I shut my mouth and held on for dear life.
The Chicken Killer sped around corners on the one lane road to the forest so quickly that the rear tires would skid across the red dirt and send stones flying. Should we have met another vehicle on its way to the Thursday Market back in Kabale, we wouldn’t have fared very well at all. In Uganda, there is only one clear rule of the road: you snooze, you lose. Goats, children and cows scurry out of the way of oncoming trucks and motorcycles. Chickens too–all except for the one that passed under our tires with a dull thud (hence the origin of the Chicken Killer’s title). I was a bit perplexed as to the hurry, but I had decided I was not, under any circumstance, going to ask the Chicken Killer to slow down. Many kilometers of road we covered that day would have been a challenge to mountain bike, even for a reasonably skilled mountain biker. Those of you who know me well (especially those of you who have had the misfortune of playing the 7thhole of the Burlington Country Club golf course with me), know that my repertoire of colorful language is not, well… particularly limited. Even with an arsenal like mine, I am still at a loss for words to describe how petrifying those 90 minutes were.
By the time we arrived at Ruhija, my neck hurt and my knees were sore. I’d been sitting in the back of the ambulance, which was really just an old box-style Land Cruiser, using oppositional force to keep myself upright, bracing my feet on the jump seat that ran along the opposite side of the vehicle from the jump seat in which I sat. The seats were poorly padded and easily folded up and out of the way for when the rear was used to transport patients on army-style stretchers. There was no oxygen, no gurney and no supplies, just a metal floor. The medical cross emblazoned on the front hood of the truck was the only actual indicator that it was an ambulance.
I couldn’t help but wonder how many good people had left this world, having that dusty ceiling in the rear of that dingy truck be the last thing they ever saw. Thankfully, I didn’t have too much time to ponder the thought as the vehicle approached the Rihuja gate and I noticed several men lingering nearby, all carrying machetes and rifles.
We share something like 98% of our DNA with the (approximately) 700 mountain gorillas remaining on the planet. Half of the population lives in Uganda, the other half across the Rwandan border in this sprawling protected jungle that the countries’ borders share. I assumed the likelihood of us actually seeing them was somewhere between slim and zero. Boy, was I in for a surprise. We were given a quick briefing on tracking. Apparently there were already Ugandans out doing the real tracking, and they would find the family of gorillas and radio in the location to our guide. Evidently, we’d be taking the lazy route, and I wasn’t too thrilled about it. No point in making something simple when you can make it really, really challenging, right?
With that, we headed off into the jungle. There were three men in front of me, all dressed in dark green uniforms. One was wielding a machete, another a rifle, and the third was Benson, our guide. I don’t think I’ve ever been more grateful for a machete. I very quickly came to understand the “impenetrable” part of the region’s name. We were about 45 minutes into the jungle, scampering down muddy slopes, pulling our feet through dense vines and climbing over downed trees covered in tangled messes of green when it dawned on me, if this was the easy way, I was okay with missing out on the hard way.
“Sometime you will not know what is in the gorilla brain, so he may charge at you for something you do not understand,” Benson casually explained as we clamored our way over increasingly dense vegetation, approaching the Bikuru family. “Do not move. Do not look at gorilla eyes. Just grunt like this, grrrrr. That is gorilla friendly noise. Maybe take leaf, pretend to eat like gorilla.”
Are you kidding me? Okay, I’m oh-so-sure I won’t move an inch and I’ll remember to pretend eat a leaf if a 600lb. gorilla charges at me….
Then, mid-thought about charging-gorilla-induced panic, above the cacophony of the other jungle sounds, I heard it: the absolutely unmistakable sound of a gorilla beating his fists on his chest. The hollow, drum-like sound echoed through the trees, not as loud as I had imagined it might be, but more distinctive than anything I’ve ever heard. The grunting friendly-gorilla noise soon followed and seconds later we came upon three members of the Bikuru family; one of the silverbacks, a blackblack (a young male) and a juvenile, the latter swinging off branches 20 feet above the ground. The silverback’s hand was significantly larger than my head. It was curled under his chin. There he sat, deep in the Ugandan jungle, posed like The Thinker.
It took me more than a minute to catch my breath. I felt small. I felt humbled. I felt sad and surprisingly helpless. Not because the silverback lazing on the jungle floor just in front of me could crush my skull between two of his fingers, but because there was nothing on earth I could ever do to protect him. I wondered what the future would look like for this family of miraculous creatures. If the population of an animal so huge, so beautiful, so strong and so able could be reduced to a fraction of its size, was there anything on earth that we couldn’t completely destroy?
We followed the Bikuru family for an hour, down to the edge of the Bwindi swamp. I stood there, in the relative open, up to my ankles in mud, watching a female gorilla doze in the shade 15 feet in front of me. I was transfixed by her for several minutes, until I suddenly realized that I was almost completely encircled by butterflies. I counted more than a dozen species, not one of which I could name if my life depended on it. They darted around me like brightly colored tropical fish in an aquarium. It was a moment that I am fairly certain will make the list of the flashes of your life that people say get played back to you right before you die.
The trudge uphill and out of the jungle seemed incredibly fast. I was deep in thought, processing the whole experience and still feeling amazed that I was wandering through the Ugandan jungle, that I’d just come face-to-face with eight mountain gorillas and that I still had several days of crapping in a bucket ahead of me.
We made one stop on the death-defying drive home. I had asked the Chicken Killer if we could visit a Batwa settlement. The Batwa are a people indigenous to this region of Uganda. They used to live in the forest, but when the government figured out how much money they could make by protecting the mountain gorillas (instead of passively allowing the poaching of them), they kicked all of the Batwa out of the forest and dumped them into “settlements.” It’s sad, the way we all seem to treat indigenous people. It’s one thing we manage to royally fuck up the whole world over.
The Batwa are pygmies. They’re totally proportional, just very, very short–and that’s rich, coming from me. A number of children approached me as we walked nearer to the settlement. I crouched in front of them. As they grabbed for my sunglasses, I was fairly certain the little buggers were trying to jack my Ray Bans. They successfully pulled my sunglasses to the very end of my nose and laughed. And laughed. And laughed. Then, all at together, they pointed at my eyes, up to the sky, back to my eyes and up to the sky again. The only word I understood was Mzungu, but I knew exactly what they were saying. My blue eyes were hysterically funny looking. Next came my hands, my fingernails, the skin on my arms and my ponytail. I was pet by each one of them in turn and they spent the rest of our time at the settlement attached to my legs like barnacles.
We returned to the hospital in time for some afternoon work. Clinic was just depressing. The only alcoholic we’d seen over the course of our stay was a 70-year-old man with central cord syndrome. He walked using two tall sticks as crutches and poked his way along painfully slowly. There was nothing to do but give him steroids and hope for the best; and for once, the same treatment would be the only option at home too. The two-year-old girl who followed was another story–congenital scoliosis with a hemi vertebra in her thoracic spine. If she had been blessed with Burlington as her birthplace, she’d have a posterior spine fusion and have a pretty normal life. Here, in Bwindi, we can do nothing. Nobody can.
Friday morning came quickly. The BCH community starts every day with a prayer meeting, and as you can probably imagine this news was initially met with a good deal of skepticism on my part until I actually attended my first prayer meeting.
We sit on cement benches and each meeting begins with this awesome performance of rhythmic drumming and clapping and singing (in one of Uganda’s 32 languages, although I have no idea which) and about 60 seconds of praying, which is plenty for me. Then it’s basically a staff meeting. If Champlain College started every meeting with drumming like that, I might actually go to a few. It’s a beautiful sound and it’s a beautiful sight.
On that Friday morning, I had the honor of standing up to address the hospital staff. I thanked them all for making us feel so welcome and at home. I thanked Peter and Julius for finding all the patients we saw, and for visiting church services and the radio station to let the community know we were coming. I told them that we had seen more than 60 patients, that we had performed 21 surgeries (including those scheduled for that day) and that there were 7 patients on whom we would like to operate on when, if welcome, we returned the next year. I thanked the operating theater staff who had worked very long and hard hours for us. The staff cheered and asked us to return. We were sold.
Friday started so easy and ended so hard. The first case was an infant with clubfeet. Seth did a bilateral tenotomy (a release of the Achilles tendon) to let the child’s feet rotate into a more aligned position. The second case was yet another bilateral polydactyly, extra pinky fingers on the hands. I know it sounds like there are loads of extra digits in Uganda, but there really aren’t. It’s just that in the U.S., these things are fixed before children turn one. This patient was three–not bad, considering some of the congenital deformities we’d seen were on patients well into their 20s. Julius, the Chief Medical Officer of the hospital, and I did the case together. Removing “bonus” digits really is turning out to be my orthopedic strong suit. For those of you who are worried about the thought of yours truly doing anything with a scalpel and suture, trust me – it’s impossible to screw up this procedure.
The last case of the day broke my heart, again. Chrispus is 15 years old. His x-ray showed an osteolytic mass on his right femur but he is at the age where osteosarcoma is mostly likely to rear its ugly head, regardless of your country of origin. He’s had an uncomfortable lump on his leg for only six weeks. Based on the way his bone looked eaten away on the x-ray, it was going to be a tumor or an infection. The only problem was that he didn’t present any other symptoms of infection, which meant the odds weren’t good that it’d be an easy fix. It felt like Shaban all over again. Again, I found myself somewhere close to praying as Seth made an incision down the lateral (outer) side of his distal femur (the part closest to your knee). I steadily held retractors and scissors as he tied off vessels on his way to the mass is Chrispus’s leg.
The mass in Chrispus’s leg was much different than Shaban’s. The mass didn’t feel like soft and rotten bone, but viscous, mucoid. Seth used rongeurs (kind of like pliers, but wider and rounder at the end) to pull out pieces of the mass; I cleaned the end of his rongeurs into pieces of sterile gauze each time he pulled them from the incision. I stared at tissue coming out of Chrispus’s leg. It looked like raw chicken that had been sitting on a countertop for a couple of days. It was a brownish yellow with streaks of blood and something white in it. My heart leapt; maybe it was an infection after all. The problem was, this ‘rotten’ tissue kept coming and coming and coming–and it had destroyed a significant part of Chrispus’s femur.
I looked down at the piles of revolting material, wondering how so much crap could come out of one boy’s bone and I wondered if I was (literally) holding cancer in my hands. I wished I could kill it, far more than I’d wished I could kill all the tennis ball-sized spiders in Uganda, far more than I’ve ever wanted to kill anything in my entire life. I wished so desperately that I’d had the secret, the answer, the cure.
There was no point in trying to remove any more. If it were to be cancer, he would be dead so soon that it didn’t matter anyway. If it was infection, the best we could do was pump him full of antibiotics and take him in for another surgery to try to pull it all out and wash the bone clean with a disinfectant.
Chrispus was sedated. He looked so peaceful: his wide eyes were closed and his long eyelashes stretched down to the top of his prominent cheekbones, his dark skin was flawless. If he had only been born into our lives, he’d be getting chemo. He would have his learner’s permit and be scaring the shit out of his parents as he slid behind the wheel of a Volvo. He’d be thinking about prom, sneaking beers and trying to make it to third base with the girls in his class. I put my hand on his chest and, for the first time ever I did the closest thing to actually praying that I can think of. I silently asked for help. I don’t even know whom I asked, but I know I asked someone. The truth is, I actually begged. I begged for Chrispus to have just one small fraction of the good fortune that I’ve had (but never earned) for my entire life. I still know it will do nothing.
The mass in Chrispus’s leg is not an infection, it’s either a chondrosarcoma or a giant cell tumor – both of which suck, both of which will kill him in short order. There is nothing to do but wait for the biopsy to come back from the lab in Kampala. Trying to amputate Chrispus’s leg (with no general anesthesia, no cautery, no Gigli saw and no real tourniquet) would very likely kill him – but so will the cancer in his leg. It sounds so selfish, so shortsighted and so cowardly, but I am quietly grateful to not be at the hospital when the lab results arrive. How do you make that choice? You know death is imminent, but how could you choose to have someone die on your table, as a result of your decision to operate – even if it is the best and/or only shot you have?
According to Seth, there is no class in medical school (and I am certain there isn’t one in an MBA or business PhD program) that helps position you to make decisions like that. I spoke to my parents for the first time later that day. I was still replaying Chrispus’s lousy options in my head, feeling weak, frustrated and gutless when, ironically, my father told me that he was proud of me… for the second time in my entire life. Don’t get me wrong, my father is an amazing Dad and great man, but he’s just not one for many words. When I hung up the phone, I stared at the sky and wondered if I was worth being proud of. I certainly wasn’t a Julius or a Peter and in three weeks time I’d be tucking tail, heading back to Burlington and right back onto the golf course, clad almost entirely in pink.
Ghana was playing a World Cup match later and we were going to have a late night at the Good Shed. By 9 p.m., we were parked in the plastic patio chairs, packed into the Good Shed, completely surrounded by dozens of excited dark faces, all eyes fixed on the 12” television in the corner. The hospital staff we’d been working such long hours with was seated all around us. I felt exhausted, incredibly proud and the most content I’ve felt in months. The score was 0-0 in the first half when the power went out. We sat there in dark for several minutes, laughing and talking. Someone on the porch had a transistor radio and they shouted loudly when Ghana scored their goal in that first half. The Good Shed erupted with shouts and clapping in the pitch black as the Ugandans drank their Guinness and Coke (yes, in the same glass) and celebrated so loudly that the walls shook.
Oddly enough, despite the insomnia that plagues me nearly every night of my life, I fell sound asleep sitting upright in the Good Shed that night. I made it to overtime but couldn’t have kept my eyes open with toothpicks. I said my goodbyes and shuffled back to the tent, the sounds of cheering reverberating through the forest. Tomorrow, in the darkness of the early morning, I would have to leave this incredible place behind me.
Friends have asked me how I deal with these experiences and then come home and live the way I do–skiing at Stowe, playing golf dressed in sporty plaids (or worse, in argyle sweater vests), drinking expensive beer and even more expensive scotch, living so comfortably and so cleanly.
The best way I can describe how I deal is a technique I will refer to as the Box Method. Being so anal retentive, I have a box for just about everything in my life. All of the good things and the bad things, the great things and the terrible things, the painful heartaches and the incredible joys, the successes and the failures, they all have their own boxes. They’re alphabetized and color-coded, just like my spice cabinet and my closet.
Cambodia has a box, Haiti has a box, the South African townships have a box, Uganda now has a box, and soon Ethiopia will as well. These boxes are larger than many of the others I have stored away and they have a fair amount of padding; they’re padded with humor, laughter, new friendships and pleasant memories. Without that padding, the boxes would be unbearable, impossible to keep with me but impossible to be rid of. They would ruin my heart.
Shaban is in the Uganda box, so is Chrispus, and the mountain gorillas and the filthy, barefoot school children dressed in tattered rags. The Uganda box also includes the hillsides of dense jungle, eating around the bugs, the Good Shed, more butterflies than you could imagine, extraordinary sunrises, dark faces with white smiles, Nile beer, pygmies, giant spiders, bucket toilets, and the most beautiful drumming I’ve ever heard. There is also hopelessness, frustration and incredible heartache in the Uganda box.
Those, however, are common elements, shared by many of the boxes in the International Aid section of my internal shelving where these boxes are stored. When I’m good and ready to deal with those emotions, I put away my golf clubs or skis, pull the lid off the box of interest, have a few shots of Jack Daniels and head to a couple hours of therapy. I am not worried about any of those things.
There is only one thing different about the Uganda box, and it scares me. I have this sneaking suspicion that there will be something else eagerly waiting just under the lid of that box, like my golden retrievers at the end of every workday when I’m home. I’m afraid that when I open the lid of the this box, that the first thing I’m likely to find might just be the beginning of a love affair. A very passionate love affair with this breathtaking land, these incredibly kind and astonishing people and their rugged way of existence, with the limitless room for improving the quality of their lives in this tiny corner of the world and with the beckoning opportunity to help decrease the number of motherless children living in these rural mud huts. I don’t know what this affair will mean for me or my future, I’m sure that’s why it scares me, but I guess I’ll cross that bridge when I get there.
For now, I’ll throw my bags into the back of that truck in the 6 a.m. darkness tomorrow and I’ll very tightly position the lid on top of the Uganda box. I might even reinforce it with a bit of emotional duct tape, just to be sure. The ride will certainly be bumpy. I’ll leave the hopelessness and hurt behind for now and I will look forward to the undeniable hope that follows on the coattails of watching 20 year olds, with far more promising futures than Shaban and Chrispus, experience the real world for the first time. My students will fly into Addis Ababa in a week.
I will meet them at the airport – they will be exhausted and appropriately intimidated by the task in from of them; to interview children at the HIV/AIDS orphanage where they will be living for 10 days. For every bit of faith I lose and every piece of my heart that breaks on these trips I am regenerated ten-fold when I see my students, growing up behind me in years but so far ahead of me in terms of energy, curiosity, passion and promise.
They will look at the filthy streets of Addis; they will see hungry children and desperation. Their eyes will give them away; I will know, beyond a shadow of a doubt, when the moment comes, when they are changed for life, when they see the world for what it is–full of men, women and children who have done nothing but be born into far less fortunate circumstances, left clinging to the edge of life. I’m grateful for being able to witness that moment of change in my students because it is all of those moments, collectively, that make me feel like someday, the world might actually become a better place for every one.
From here to Ethiopia…
Meg
Megan McIntosh Frenzen is an MBA and a PhD in Marketing. She specializes in Consumer Behavior with minor areas of study in Social Psychology and Statistics, but her primary interest is in health related behaviors. In December, Megan is attending London School of Economics to start an MSC in Health Policy. Seth Frenzen is an orthopedic surgeon who specializes in hand and upper extremity surgery – he is a partner at Associates in Orthopedic Surgery in South Burlington. He completed his residency at UVM and fellowship at the University of Utah. During 2006 they took a trip to a hospital Cambodia during the worst hemorrhagic dengue fever season ever recorded. When she heard about the earthquake in Haiti, Megan said “well, how do you NOT do something when you know you can? So we went.” After an impromptu meeting with a founding board member of TOUCH Uganda, Kris Owens, Megan and Seth made their way to Uganda.