The clinic teeters on chaos half the time; dozens of people are waiting outside in a quiet crowd, waiting all day. The single room sometimes has thirty people in it, most talking at once in two languages. There is always at least one crying baby. But I rise before dawn to sit in the soft dark that is wrapped like a shawl around the resting world. The air is cool and fresh, and the sky has a billion stars, thick as fog; they are turned sideways from what I know. The birds wake before the light: chee-chee-chee, gurgle, coo, awk-awk, mew and squeak and twitter and gulp and hoot, a muted and sibilant choir. A cock crows, the cicadas begin to buzz, a truck rattles down the main road in the distance. The sky slowly pinks. I hear the crunch of pebbles, and a dark face goes by, head-lamp bobbing up the gravel trail to the latrine. “Mornin’!” says a quiet silky voice.
Ours was the first team at Engeye that was primarily seasoned physicians and nurses rather than students. We were also the first to attempt a working laboratory, as well as the first to test the new electricity. The mix of skills on the team worked well. There were two physicians, an internist and a hematology oncologist; one family nurse practitioner with experience in refugee medicine; a medical-surgical (ICU) nurse; a pediatric nurse; a mother/baby nurse; a palliative care nurse; a laboratory technician, and two unlicensed personnel who helped with the pharmacy, money, and general support. David, who has extensive travel experience but no health care background, was a huge help – he arrived early and did much of the shopping, and throughout the trip handled the budget and the photography. He quickly learned how to run the pharmacy and fill prescriptions from our motley cabinets of donated drugs.
Villagers arrived before dawn on the first day we opened the clinic, and came in large numbers throughout the week. We ultimately saw about 650-700 patients. It was a constant struggle to manage clinic flow: intake, triage, record-keeping and follow-up were never smooth, but eventually we fell into a pattern that worked as well as the environment allowed.
We practiced a lot of ordinary primary care. The doctors diagnosed carpal tunnel syndrome, hypertension, arthritis, heartburn, and headaches, as well as more serious febrile illnesses: respiratory and bladder infections, fungal skin infections, sexually transmitted diseases, and a few people with major illnesses such as AIDS. We saw a number of people with wounds, many of them children, including staph abscesses and burns. Most adults and children were affected by malnutrition to some degree. The nurses fashioned braces out of tongue depressors and cleaned ears with the sterile oil from the microscope. who set up a lab and spent the week studying blood work and slides and figuring out how and what lab work was possible in this environment. Due to the work and the diet, there was a significant amount of several musculoskeletal problems and gastric complaints. We all learned on the first day not to rely on changing a patient’s diet or physical work: these are not options for most people in Ddegeya. We ran out of pain medication twice, as there was little else to do for many of these issues. We were surprised by the amount of hypertension, as there are no risk factors for it other than genetics.
The day in Ddegeya follows the sun; we rose around 6:30 each day. We generally opened the clinic from about 8 am until 6 pm, with an hour closed for lunch. The entire team and staff worked this schedule every day with few exceptions. We decided to open the clinic late on Sunday (it is usually closed all that day). Instead we went to the children’s service at the big Catholic church on a hill outside town. There, we predictably “caused a commotion,” in John’s words.
I do a lot of intake in the clinic. Ugandans love to talk, and no one has asked these people how they feel for a long time. They are reluctant to yield the floor. I hear through their words a bit of the stress and struggle of their lives. They are hungry most of the time; they work so hard; they never retire. Some of the women and children kneel and bow their heads when we meet. I start to love this place of lushness and poverty, and these maddening, charming people: wrinkled men with a few rotten teeth and old women with rheumy eyes who complain of “locomotion under the skin” and “paralyzed limbs” which they demonstrate by swinging said limbs and slapping themselves. I love the beautiful young adults, many of whom have “private” complaints and tell sad stories, and the babies, who are scared of the strange people and look around with big eyes.
“As for her,” my interpreter says of the bent grandmother showing me her hugely swollen knee, “her joints pain her.”
In the evenings, most of us stayed at the dinner table and played Hearts or the local version of Parcheesi, or read. Every day, most of us took walks in the village, a winding net of connected red clay paths. The villagers were overtly welcoming and positive in all our interactions (even when we baffled them), and a walk through the farms meant being repeatedly thanked by various people simply for our presence.
This kind of health care requires both a tender heart and a tough skin. We knew going in that our pharmacy and diagnostic tests were limited, and that many of the complaints we would be seeing were chronic and based as much in lifestyle and endemic economic injustice as in organic problems. We went there knowing we would be able to do only so much, and that there were few problems that could be truly "fixed" for good. But our relatively small interventions – cleaning out ear wax, draining an abscess – can in fact make a huge difference in quality of life. For myself, I felt that being open-hearted with the wide variety of people who came to the clinic, simply holding a hand and listening, was my most significant contribution. Suffering can be comforted by the act of witnessing, and many of the patients we saw had never been truly listened to in this way before.
When the clinic is closed, wherever we turn, the children find us, shy and persistent, sidling up, skipping in excitement, staring, and soon enough leaning, holding hands, clapping, talking all at once. “Hello, Madam, how are you?” a girl asks me in carefully enunciated English. Many are barefoot, others are wearing the glorious shoes they chose from the piles donated by clinic supporters: skinny little girls in high-top Chuck Taylors and clod-hopper boots, boys in pink Crocs. We introduced them to Frisbee, drummed on water cans, played soccer, tic-tac-toe and shared National Geographic magazines. When I try to dance, several of the older girls fall to the ground, laughing.
One day we take a long lunch hour and walk up to the village school, a small compound of cement rooms open to the air. There are 534 students here, many orphaned by AIDS or drugs or parents who left to work in the city and never returned. But there is hope – many are learning English and are dedicated to study. The rates of HIV have declined throughout Uganda, and the message of safe sex is blunt and universal in Uganda. There is hope that the next generation will be healthier and better educated than their parents, and that the extended family culture will remain intact.
At the school, all the children wear bright blue uniforms; some are neat, others tattered and dusty. They line up and we give each student a brightly decorated pencil. Then we are led to a classroom and crouch onto the little wooden benches. The younger children crowd in behind us, and the older children dance and sing, a girl singing a shy solo, the boys drumming. The room is packed, the air redolent with sweat and high shiny voices.
“Weel-kum to orr vee-zee-tors, we are glad you are here,” they sing, lilting, simple. “Oh, merry day!”
