Tuesday, September 20, 2011

What price compassion in Uganda?

The headline said it all. For lack of Shs300,000 teacher bleeds to death in labour ward. (Sunday Monitor 18 September 2011)

There is, of course, a second story here: about the capacity of members of the teaching profession to afford even the most basic of health services. However, teachers' salaries and the current on-off teachers' strike are not the topics for today's post.

No today, I thought we'd look at the implications of this story, a family tragedy and a national disgrace, a story which didn't even make the front page news when it first broke.

The woman concerned, Cecilia Nambozo, checked into Mbale Regional Referral Hospital (the main hospital in the east of Uganda) at 6 o'clock in the morning. She died at 8 o'clock at night. Her family and neighbours had already spent all their money on buying the surgical equipment necessary for delivery: the usual - razor blade, cotton wool, birth sheets and surgical gloves. Let's just get this straight: Mbale is a government hospital. Cecilia had already paid for this equipment through her taxes. The government abolished user fees for government hospitals and public health facilities in 2001. Health care is supposed to be free at the point of delivery. Nevertheless, pregnant women often bear the cost of maternity care.

The baby was too large to be born without medical intervention. This had been predicted well in advance, as Cecilia had sensibly been attending ante-natal check-ups and a caesarian had been recommended. A neighbour who had accompanied Cecilia, allegedly asked both a midwife and a doctor to help. She is quoted as saying, ' ...I found her in pain, crying, there was no help. The medical workers looked on as they asked for money.' They allegedly demanded Shs300,000 (£75) to attend to her. Cecilia's husband ran to the local village to sell property to raise the money.

When Cecilia fell to the floor bleeding, the doctor eventually responded by taking her into the theatre, but too late. Her womb had already ruptured. She and her baby died 10 minutes later. The head of Mbale Hospital is later quoted as saying that Cecilia already knew she should have a C section, the implication, perhaps, being that she should have come to hospital ready prepared with the necessary bribe. He uttered the following mystifying words, she 'should not have asked doctors to take her to theatre.'

The story gets even worse, if that is possible. Her naked body was left in the open labour ward and it was left up to hospital cleaners to remove the foetus, which they did, in public and, one would assume, in sight of all the other mothers waiting to deliver.

The police surgeon who carried out the post-mortem said, 'This is not the first case at this hospital; many women have died in labour out of neglect.'

Why did hospital staff ask for money? It was not a fee for medical treatment. No, it was a bribe, straightforward and blatant corruption, money intended to go straight into staff pockets.

It is not an unusual story. Like Cecilia, many women may have no money left over from paying for surgical resources to pay the bribes required for actual treatment. Corruption is rife; so is carelessness and incompetence. Other recent news stories have included the following:

  • When Nalubowa, a peasant farmer and mother of seven, recently arrived at Mityana Hospital, nurses demanded a bribe of Shs62,000 (£15) and the money to buy airtime to call a doctor. She only had Shs6,000 as she had already bought the necessary razor blade and gloves. She was left unattended in the maternity ward. In terrible pain and bleeding to death she screamed that she would sell all her pigs, chickens and goats if the nurses would come and help her. She died. President Museveni's response on hearing of the case? He paid her family Shs500,000 (£125), what he considered her life to be worth.
  • This month, an elected official, an educated woman with three young children - not that that makes any difference - died after bleeding to death in the maternity ward at Arua Hospital, a 400-bed public hospital. A lawsuit following her death may be the first legal test of an African government's obligation to provide basic maternal care. She had arrived in time to be saved, together with the necessary supplies which she knew the hospital didn't have - latex gloves, cotton wool and a razor blade to cut the cord. However, only one midwife was on duty and no doctor examined her for 12 hours. An hour later she was taken into the theatre but she and her baby died. . Her husband, a teacher, provided her only care, frantically changing her blood-soaked bedclothes.
  • In May, a woman booked into a private bed at Jinja Regional Referral Hospital, arrived on a Sunday well prepared with all the medical equipment needed for delivery. The doctor who was supposed to be attending her didn't answer his phone. After two days' labour, during which other medical staff refused to attend to her, the baby died. Rough treatment and inappropriate language from hospital staff are quite often quoted in cases such as this. The bereaved couple have to pay transport for the pathologist if they want a post-mortem. 
  • A new born baby in Gulu Regional Hospital bled to death in its cot as staff allegedly forgot to tie the umbilical cord and did not check on it at any point during the night. 
  • Mbarara MP Emma Boona recently asked medical staff at Mbarara Referral Hospital why some of them were selling delivery kits. A nurse responded by saying they are 'forced to do business with patients as an alternative income owing to their low pay.' Medical staff angrily challenged the MP's right to question their actions, pointing to the recently inflated MPs' salaries and the lack of resourcing for hospitals.

Of course, there are far more medical emergencies in Uganda than in the West, for obvious reasons.  Three quarters of all maternal mortalities result from obstructed labour, haemorrhage and infections. Many of the survivors suffer from fistulas or other injuries as a result. Stunted growth caused by malnutrition during childhood is a major cause of fistulas; the impact of labour on the exhausted bodies of older women with too many children already cause many other problems. Long term, dangerous childbirth can be dealt with through better nutrition, improved education and delaying childbirth until young women's bodies are physically mature. In the meantime, to reduce the high rates of maternal and child mortality in Uganda (at 435 deaths per 100,000 or 16 each day, one of the highest rates in the world) one might expect hospital staff to carry out the jobs which they were employed to do.

Admittedly, inadequate resourcing is also a major factor in endangering the lives of both mothers and their children. 

  • In June, three deaths, two of mothers and one of a baby, occurred in the maternity ward at Lira Hospital. Emergency blood transfusions were required but the hospital did not have any blood supplies. All hospitals in Uganda use one machine in Kampala (five hours away by road) for screening.
  • For the last four months or so, 27 of the 28 incubators at Mulago National Referral Hospital in Kampala, which handles 1,000 premature babies every month, have been out of commission.  The situation was discovered by 20 MPs who were visiting the hospital for other reasons. At the time of their visit, 59 babies were waiting for the only available machine. Every day, 30 to 40 babies are born prematurely at Mulago and are currently being kept warm by being wrapped in cotton. The paediatric ward has one doctor and one nurse. There is no doctor on duty at night. 
  • Arua Hospital has no sutures to sew up women after Caesarian sections: patients must buy these. On the day on which the incident referred to above occurred, the hospital also dealt with ruptured uteruses, a still birth, an incomplete abortion and a bleeding cancer of the cervix.

However, the problems of maternal death are not just caused by inadequate finance. The issue is also about medical ethics and the principles and values of individual medical staff. 

Many Ugandans do not even bother going to government hospitals or health clinics because of the bribes they are expected to pay. You bribe the askari to get into the queue. You bribe the nurse to see the doctor. You bribe the doctor for a consultation. You bribe the pharmacist to collect a prescription. None of these are legitimate costs. Ordinary Ugandans often find it easier to go to private health clinics and pharmacies because at least you pay an all-in up-front fee. The problem is that the majority of these health facilities operate illegally. A recent joint operation by the Ministry of Health, the Joint Health Professionals Councils and the Pharmaceutical Society of Uganda found that as many as 70% of all health service providers in Kampala are illegal: some are not registered and others employ unqualified staff.

However, this still leaves the issue of what those medical staff at Mbale Hospital were thinking of when they refused to help Cecilia Nambozo. What was in their heads? What was in their hearts?

Stuart and I often struggle with the issue of what we see as callousness and lack of compassion in Uganda. We try to rationalise it. We recall Uganda's terrible history: hundreds of thousands killed under Amin, during the bush war, as a result of the AIDs epidemic, and of violence, malnutrition and disease during the Northern Insurgency. We ask ourselves if there is a hardening of the heart which comes from seeing so much death and experiencing so much suffering. Research by clinical psychologists across the world has identified post-traumatic stress disorder as a major issue in mental health. So many survivors have suffered bereavement and family dislocation.

Uganda is a poor country. Most people spend most of their time just trying to survive and trying to feed, educate and support their children. The constant struggle must wear them down. They must have little time, energy or empathy left for the troubles of other people. However, these medical staff chose their profession and applied for their jobs. They signed codes of practice. They have undergone at least some training and, most of the time, they receive a salary, inadequate though it may be.

Uganda prides itself on being a 'Christian' country, one of the earliest conversion stories in nineteenth century missionary history. Whereas Ugandan Islam is low key and discreet, with Muslims quietly following the tenets of their religious faith without making a big deal about it in public, Ugandan Christianity is extrovert. It shouts its presence from every street corner and every hoarding. Prayers are said before - and often during - every work-related meeting, even in the public sector. Money is poured into lavish church buildings. Ordinary people tithe their incomes, in order to provide their pastor with an appropriately prestigious 4x4 vehicle. Evangelists imported from the USA shriek about salvation, promise miracles and then go away with people's hard-earned cash. Sunday peace is disrupted by mad-sounding Pentacostalists gibbering away in gimcrack halls.

All very similar to aspects of religion in mediaeval Europe, in fact, but very very different from the Christianity we are familiar with from our orderly, reflective 21st century British church services. In fact, very different, I guess, from the faith the missionaries brought with them from Europe all that time ago. The nineteenth century was the age of the great social reformers, many of them Christian. They campaigned against slavery, they set up up schools and established hospitals at home and abroad. Admittedly, they did other less creditable things as well, were often complicit in the nineteenth century colonial land grab and insensitive towards, and unappreciative of the cultures and histories of the people they served. They interfered and they caused problems, but, in essence, they meant well towards those in whose lives they meddled. And, yes, they did save lives.

Ugandan Christianity seems to offer salvation, a place in heaven, compensation for the sufferings of this world and an escape from hell. It also offers forgiveness - sins wiped out and a clean slate the next day. What it doesn't seem to offer is compassion for other people. Stuart and I can scarcely recall ever hearing a prayer which was concerned with the plight or needs of others. 

The medical staff in the hospitals mentioned above will almost certainly have been 'Christians'. Just as in nineteenth century Britain, in Uganda it is unheard of not to be affiliated to a church. There are few enough Muslims in Uganda and the concept of agnosticism or atheism is virtually unknown. The assumption is that everyone is Christian, with a few Muslim exceptions. Churches are packed. People can quote scriptural texts at the drop of a hat. They offer to pray for you at the slightest opportunity. However, the faith itself appears to make absolutely no difference to the way people live their lives.

Except that some of them are able to stand and watch another human being die with complete equanimity.

What is the price of compassion in Uganda?

You may also be interested in the following posts.

Caring for the sick in Uganda
Is the word 'corruption' synonymous with the word 'Uganda'?

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