Medical doctor and medical team leader in Kitgum
I’m gonna raise an army, some tough sons-of-bitches
I’ll recruit my army from the orphanages.
Bob Dylan – Thunder on the Mountain
Twenty years of internal conflict in northern Uganda have generated an officially recognised humanitarian crisis: an acute medical emergency compounded by a lack of access to drinking water, healthcare, food, shelter etc.
But this is all history which I have not witnessed. My experience of the context was very different from what I had read in the briefing paper. Since the Lord’s Resistance Army’s departure, peace has dawned and the country is in the transition from a post-conflict context to a developing one. Kitgum town, where our project was based, is a peaceful, small municipal town surrounded by low, green, rugged, rolling hills. The town is dotted with numerous rounded, beautiful, traditional huts called tukuls, and the main central attraction – as in any other town – is a festive central market which always has loud, catchy African music playing.
© MSF
MSF’s approach in the project was constantly adjusted to the changes in context and the needs of the population. During the first few years of the mission, the tendency was to centralise the provision of basic healthcare in MSF’s facilities, both within the camps for internally displaced people and in the main towns. In the later stages of the project, with the shading down of the conflict and the consistent security improvements, services were decentralised to rural areas, MSF’s active cooperation with the Ministry of Health was strengthened, and more focus was given to secondary healthcare and long-term programmes such as HIV/AIDS, tuberculosis (TB) and multidrug-resistant tuberculosis (MDR-TB).
My objective was very clear from the start: to hand over our medical activities to the Ministry of Health and facilitate the closing down of the project. The handover of HIV, TB and sexual and gender-based violence (SGBV) programme activities in the MSF-supported health centres in two districts went as planned, but the handover of the MDR-TB component was a challenge.
MSF implemented the first MDR-TB programme in the country in 2009, adopting a home-based approach, wherein every day MSF staff visited the patients in their homes to administer the medication under directly-observed treatment (DOTS) during the intensive phase, and using a network of volunteer village health workers during the continuation phase of treatment.
© MSF
The irony is that, although the project had talked about involving the Ministry of Health, even when I arrived early in 2012, I found that the programme was still exclusively run by MSF, with no Ministry of Health involvement. Despite this, the operational decision had already been taken to hand over the programme. For the Ministry of Health, an MDR-TB programme was something totally new. There was lots of stigma attached for the diagnosed patients, and many government health staff were not keen to be a part of the programme for fear of getting the disease.
So my first task was to work with the Ministry of Health. But, in order to build their capacity in the management of MDR-TB, we first had to lobby hard for the government to assign medical staff to the programme. We arranged lots of exhausting meetings, most of our time spent searching and waiting for hours – which at times was frustrating – and running around the district health office and Kitgum district hospital.
Finally, with the support of the hospital’s medical superintendent – a fine man with a good vision, who later became my good friend – MSF rehabilitated an eight-bed isolation ward for the diagnosed MDR-TB patients – the first in the country. Though initially the ward was only manned by MSF staff, after weeks of lobbying, five Ministry of Health staff (which later became eight) were officially assigned to the MDR-TB ward. There has been no turning back since then. We worked very closely with the team assigned by the Ministry of Health, involving them in every meeting and conducting numerous trainings for them. We also succeeded in setting up an MDR-TB committee – compromising focal TB persons, social workers, clinicians and laboratory technicians – where decisions about patients’ admission and treatment were discussed and approved.
To facilitate patient referral from the peripheral health centres, I also had to travel around two districts, conducting trainings and follow ups. I also developed many documents, most notably the infection control and adherence guidelines specific to our project and adapted to our programme needs.
With Ministry of Health involvement during the later phase, we modified the programme strategy from a home-based approach in the ambulatory phase to patients receiving treatment at their nearest health centre under DOTS.
The members of the Ministry of Health MDR-TB team which we had created became the core trainers for the health centres and, with our support and training, became the country’s first MDR-TB specialists – later they were even used by the Ministry of Health to train the other districts. And, with a stroke of luck, just four months before our departure time, the second-line drugs from the Ministry of Health arrived, a result which could also be attributed to our continuous pressure at the coordination level. It was a huge success for the country’s MDR-TB programme and, with the arrival of their own supply, meant we could keep up with our scheduled handover plan.
For the purposes of sustainability after our departure, we managed to rope in a number of different partners: Mercy Corps is helping to provide nutritional support to patients, while the Transcultural Organisation – a mental health NGO – is providing counselling support, and BRAC is helping with the laboratory component.
The Kitgum MDR-TB programme grew in size and became a role model for the country. There were lots of external visitors, including many journalists and someone from the World Health Organization (WHO), while MSF’s French section also sent a team to learn from our programme.
Later, with the arrival of second-line drugs, the country opened up new MDR-TB treatment centres in more districts, with our Kitgum model of care as a role model. In this regard, the members of our trained MDR-TB team were also called on by the Ministry of Health to travel to different districts to work as TB implementers.
My proudest moment came when the WHO said that our programme was an example of the best MDR-TB programme in East Africa. And, because of the programme’s success, I was also invited to attend a meeting organised by the Ministry of Health at the capital level, where I suddenly found myself advising the Ministry of Health country coordinator on MDR-TB programme management.
During my time in the mission, as well as TB and HIV, I also had the opportunity to work with a totally different new disease, head nodding disease, so called because of the characteristic head nodding movement of affected patients, which is often accompanied with generalised fits. Head nodding disease is a new disease of an unknown aetiology, which was first described in what is now South Sudan. Typically it affects those aged between five and 15 years. We supported the government’s head nodding centres in three districts in symptomatic management and, as all the centres were managed by poorly trained staff, I suddenly found myself consulting, advising and treating paediatric cases. I had to brush up on my knowledge on the management of burns, epilepsy and malnutrition, and in turn I trained staff at the nodding disease treatment centres.
On the flipside, the hardest part of closing down the project was the periodic scaling down of the team. I had the responsibility of deciding who got to stay and whose contract had to be terminated. Some staff were particularly tough to manage, and I had to give warning letters – not a part I enjoyed.
One time I happened to find one of the clinicians clearly sleeping – and actually snoring – in the clinic while on duty. I politely asked him if he was sick and told him not to doze off while working. He informed me that he was not sleeping. I told him I had seen him sleeping, and he again denied it. I told him I saw him closing his eyes for a while – and then my creative friend said he had closed his eyes since he was praying. So my advice was that next time he wanted to pray, he should please stand up and pray.
But most of the national staff in Kitgum were my best support, always friendly and polite. I learnt lots from them. They had worked with full motivation until the last minute, despite knowing that, with the success of the programme and the handover of the activities, they would eventually lose their jobs.
Towards the end, we were reduced to a very small team and, after handing over the entire medical component to the Ministry of Health, I thought I was free to have more time on writing my many reports. But the biggest challenge of all was getting rid of the many household items and furniture that had accumulated over the years. We organised many lotteries for the staff and donated many items to local schools, hospitals and orphanages, and yet every day more things came piling up. I became a logistician in the end, every day spending time discarding our project items. We all vowed that we would never, ever go to a project which is closing down again.
I cannot fail to mention the international staff team in the mission. There was my Congolese project coordinator who, besides many other things, taught me that there are three Congos – and that he is from the best Congo: Congo Brazzaville. With him I watched many Nigerian movies.
There was also the previous team leader, whom I knew already from my last mission. She was my best support and my friend, a strong woman with a good heart and also a great Bangla cook.
There was the Colombian nurse who was very strict with time management and who taught every person in the mission about keeping time or getting a warning letter. I will miss listening to her playing the guitar and singing songs in Spanish.
There was the outgoing Czech logistician who makes the best cakes and who always tried to make the car available for my movements. And there was the second German logisitician, my football mate, who was always available to hang out in the town. We worked together until the very end.
The melancholy part of closing down the programme was realising that many patients would no longer get the benefits of MSF OCA, and that the dedicated MSF team of Ugandan staff who had worked so hard for the realisation of our project objective will all be jobless and scatter after our departure. In my last mission, though I felt sad in leaving the project, I had the consolation that MSF’s work would still continue and the patients would continue to get the benefits. But this time there was to be no more MSF. When I went in for my last patients’ round, many of them cried and begged us to stay – and although we had tried to build up Ministry of Health capacity as much as we could, of course they were not naive enough not to realise that the programme capacity will fall after our departure.
The consolation here is realising that MSF has created access to treatment for MDR-TB patients in Uganda and, come what may, at least patients will continue to get the treatment – and this is something which we can be proud of.
The gratitude for MSF OCA’s work was reflected in the last farewell meeting, attended by key officials from the district and many partners, and where we were highly praised for our contribution and many native songs were sung and speeches were said in MSF’s honour. I would like to remind all the previous international staff who have worked in the Kitgum programme that your contributions to northern Uganda were all remembered.
I thoroughly enjoyed my first African mission down to the last minute. Uganda is a pearl of Africa, a country with fantastic natural scenery and a rich mosaic of tribes and cultures. Travelling through the country, I was captivated by its beauty, overwhelmed by the friendliness of its people and intrigued by all that Uganda has to offer. It was not easy to say goodbye.
But let’s move on! Aphowo Matek!
– Mitchell Sangma
