A Doctor's Quest

The Struggle for Mother-and-Child Health Around the Globe

Gretchen Roedde

• Publisher: Dundurn Press
• Year: 2019
• ISBN:
  9781459743342
• Edition: 2
• Topic: Medicine
• Subtopic: Medicine Biographies

A doctor grapples with the challenges of mother-and-child health in the developing world. Recounting medical missions in one-third of the forty-five countries in which she has worked for the past thirty years in Africa, Asia, and, the Caribbean, and the South Pacific, Dr. Gretchen Roedde shares the grim reality of world politics and bureaucratic red tape on the front lines as a doctor in mother-and-child health and HIV/AIDS. This second edition updates the progress in reproductive, maternal, newborn, child, and adolescent health (RMNCAH), with additional studies in Afghanistan, Laos, South Sudan, and Nigeria. It tells the stories of the hopes of village women struggling to give birth safely, of their often corrupt leaders, and of countries trying to bring evil despots to justice. Roedde analyzes the encouraging momentum in global maternal health while maintaining a focus on equity disparities within and between countries.

1

I AM POOR:

UGANDA, SUDAN, AND SOUTH SUDAN

FIRST MISSION, UGANDA, 1987

We lurched along the rutted red murram (earth) road, the dark forest gleaming green and black against the violet sky. Huge flowering trees dropped flamboyant, jacaranda, and bougainvillea blossoms, delighting me with the feel of their feather-light lavender, fuchsia, and orange petals. The noisy chatter of monkeys in the low branches of the trees melded with the calls of mysterious new birds and the strange grunts from animals I could only imagine on my first time in a jungle. When four-foot Twa pygmies ran to meet us, smoking strange pipes and offering monkey-furred objects for sale, the sight of them was straight out of a storybook. The magical quality of the moment seemed to belie the challenge of this journey.

Our young university-educated driver, Paul Mpanga, had spent hours waiting in long queues at various filling stations so we would have enough fuel for the several-day trip to the west and back. Once we were on our way with jerry cans precariously loaded on the roof, he joked, “In Uganda you can tell a drunk driver because he drives in a straight line instead of swerving to avoid potholes.” Many times we got stuck in the wet mud and had to get out and push the Jeep.

We were travelling to the west, several hours from the chaos of Kampala, Uganda’s capital. Our work was to assess the staff and supply needs in health facilities, from small rural clinics to hospitals in these isolated rural regions. The health workers — all of them unpaid — did what they could in these most difficult circumstances. But the only foods, harvested from the local shamba (family farm), were a few bananas and plantains. They were a major food source at all times, but especially in this period of war and poverty when no one could afford chicken, eggs, fish, or goat. This lack of nutrients resulted in the starving children we would see on the wards, with their grossly swollen bellies and thin, wasted arms.

I had never seen such suffering, had never fully understood that the photographs and newscasts of famine and HIV victims were of such terribly real human beings. In the first hospital, on our first day, I had to struggle with nausea and keep my face tight with control, since I felt I was shattering into small pieces. I glanced at my companions, who seemed unmoved or perfectly able to cope, and became painfully aware of my inexperience. But how could one possibly get used to this?

In the crowded outpatient department, patients in ragged clothing spilled in from the veranda, and naked children and babies cried. Mothers seemed listless and resigned. The smell of urine permeated the room. Nurses used the same needle to inject many different people, wiping the needle on their worn dresses between patients. One nurse, named Beatrice, asked me plaintively, “What else can we do? We know how bad things are here, we know we are spreading infection, but there are no supplies, and even the water we use isn’t clean.”

These hospitals in the centre of the AIDS epidemic had no gloves for health workers, no condoms, and few needles. We shuddered, remembering the well-stocked warehouses we had left behind days earlier in the capital, where our fellow jet-set development health personnel were busy joining one another at the Entebbe Sailing Club on Lake Victoria for drinks and sailing, making dates for tennis, and hiring better cooks and houseboys.

In a hospital in Fort Portal, on the pediatric ward, we saw three small children who were so pale they appeared to be white, not black. They were severely anemic, suffering from malaria, and in desperate need of blood transfusions. The families were being shouted at by the nurses, who were demanding money that the families didn’t have. Two children were turned away. One small girl, Flavia, appeared to be about four years old and was a little better dressed than the two left to die. Since there was no blood bank, once her mother was able to get enough paper Uganda shillings from the other members of the family to pay for treatment, the mother herself was strapped up to donate blood. This direct transfusion, from mother to child, was done without her being tested for HIV. There were no test kits.

I knew the facts and had read the reports. More than one in six children would die before they were five. Each mother could lose one child. The poor, because they can’t afford enough food, have higher death rates for their children. So children who die from infection are usually malnourished. But nothing had prepared me for this reality.

On the wards the listless, wasted sick crowded together, lying side by side on the floor. Many of them were children, with swollen bellies, loose, dehydrated skin, and unresponsive eyes. They were dying from diarrhea, measles, malaria, malnutrition, and AIDS. I had never seen so many people near death in one place, many with illnesses that could be inexpensively prevented and treated. One mother, Ruth, looked into my eyes with beseeching intensity. She tried to coax drops of water from a dirty rag into her baby’s dry mouth, and then tried again without success to squeeze milk from her own thin breasts. Without milk, with only filthy water, this baby would die. I looked around the ward. Ruth was one of many. Huddled on the floor, about twenty mothers all attempted to feed their starving, dehydrated babies — children who were too weak even to cry with hunger. I struggled not to weep, myself, as we made rounds through the wards. How could this be happening? How could there be so little help?

But we, too, came close to not being here to help.

After a seven-hour drive to Toronto, a long transatlantic flight to London, another ten hours to Nairobi, and a hop to Entebbe, I arrived in Uganda just before dusk. I was disoriented and exhausted but exhilarated. I had expected to be met, but no one raised a sign with my name and no one was searching for a Canadian doctor. I needed to find my way to the German Embassy in Kampala, almost an hour’s drive away, but had no idea where the embassy was and knew at this hour that it would be closed.

Surveying the boisterous sea of Ugandan taxi drivers aggressively offering their services, I struggled to stay calm and eventually chose a driver who seemed the least threatening, a slight man who had a soft smile and a gentle face. He ushered me into a beat-up cab, and we drove off toward Kampala. After passing through several army checkpoints “manned” by boy soldiers, he deposited me at a “major” hotel. Four stars adorned its shabby entrance, and a few other expatriate customers wandered the lobby. In my room I could hear the sound of sporadic gunfire in the streets, making me realize that the civil war hadn’t really ended.

When I finally met up with Katja the following morning at a whitewashed Entebbe guest house where she was staying, she informed me that our mission was in jeopardy. The German government was trying to cancel the project because of the current political instability. We now needed to convince them otherwise.

I cringed inwardly. The gunfire had frightened me into weeping and praying the night before, so I found no encouragement in the fact that the Germans had withdrawn support for our work and intended to cancel our mission because it was considered too dangerous.

Katja assembled everyone to plan a strategy for our meeting with the German Embassy. In Uganda for a month on another assignment for the World Bank, she had travelled upcountry already and thought the Germans were overreacting. David Porter, a Scot who had been working with her in the inland area, agreed. He seemed fearless and had extensive experience in harsh developing countries. Friedrich and Gerhardt, both Germans, completed the team. Their job as architect-builders was to plan any physical rehabilitation of the clinics and hospitals we would support.

At the embassy we met with the German chargé d’affaires. Katja took command. Softening her forceful personality with a flirtatious smile, she insisted they permit us to go ahead, since we were already here. She asserted that if the German Embassy was too frightened to let the two German nationals help, we — an Austrian, a Canadian, and a Scot — would go on our own. The embassy conceded, somewhat horrified that two women and a short Scot were contemplating travel without the two obviously more capable Germans to accompany us.

In charge of the Fort Portal hospital in the poor district of Kabarole was Dr. Ingrid, a German surgeon well loved by Yoweri Kaguta Museveni’s army. President Museveni had come to power after fighting a civil war in the bush using thousands of soldiers, many of them small boys.¹ Dr. Ingrid had worked tirelessly behind the lines in the war and had lost her African husband to other women somewhere along the way. She was truly a for-midable presence with her blond hair back-combed high in a beehive and her polished white shoes click-clacking over feces-stained floors.

Dr. Ingrid’s first priority for improved health care, she told us in no uncertain terms, was to obtain German funding for a neurosurgical ward. She had been treating soldiers with gunshot wounds and head injuries. Most of these men had died from post-operative infections, since they had to be nursed together with infectious cases on the crowded wards. We suggested, to Dr. Ingrid’s disgruntlement, that rainwater tanks on the roof might be more important for a hospital lacking in basic cleanliness. And a clean operating room that could provide Caesarean sections for obstructed labour would save the lives of pregnant women as well as those of soldiers.

David Porter was so angry he almost shouted, “You have no clean water! This is a filthy hospital and you can’t make your patients better in a place like this. You have to start with the basics.”

Friedrich, Gerhardt, Katja, and Dr. Ingrid took themselves off to a corner to continue the discussion in German. I caught a phrase or two and knew our team was attempting to placate the surgeon by explaining our priorities and reconciling them with her own.

David and I stood outside for a few minutes in the sunlight as I tried to regain my composure. He could tell I was having a hard time. I was a neophyte, stunned by what I was seeing and trying to stand firmly on the shifting ground of my own preconceptions of what this trip would be like. He smiled. “I’ve just what you need, lass. I’m afraid it isn’t a wee dram of a good single malt whisky, but I’ll give you a good slug of waragi [local rum] when we get back to the guest house. That will give you some perspective.”

As we accompanied Dr. Ingrid through the rest of the hospital, I clenched my jaw so I wouldn’t cry. What could I do for this emaciated young man who weighed just over ninety pounds? He was dying of tuberculosis and AIDS, and coughed quietly as he gazed at me helplessly with enormous dark eyes in a bony face that would soon be just a skull. Never had I imagined there could be so little help for such overwhelming problems, so much slow death among children and their parents. At night, back at the guest house room with its cracked and peeling floorboards and broken windows, with a bucket of water in which floated bits of bark and debris for my own basic needs, I gave in and sobbed. I held my fist against my teeth to keep from wailing, knowing my colleagues were in rooms near mine, only thin walls separating us.

For days, then weeks, we visited all the health facilities in Kabarole and Bundibugyo, two impoverished regions in western Uganda. David Porter, with his irreproducible Scottish accent, pointedly summed up the extreme challenges of the situation that confronted us daily. “That last trip I took out to that remote health centre to see what they needed was tough. Army deserters were still floating about. I was on an isolated road between villages. When we responded to the shouts we heard in the distance, we initially sped up to see what was going on. But we quickly turned around. There was a guy in a tree being lynched by shouting armed men.”

Friedrich and Gerhardt planned the physical rehabilitation of the facilities, rebuilding necessary in this impoverished area of post-conflict Uganda. They strutted importantly around, muttering in German with tape measures. Katja and I collaborated with the hospital superintendents and the midwifery school principals to outline improved in-service training for the health workers. Training had been hospital-based, but to serve the poor who lived in the rural areas, a stronger community-based approach was needed. At a local Catholic nursing school we suggested they provide midwifery training to better prepare staff to help pregnant women, since the poor usually delivered at home with an untrained birth attendant, and described how Germany could organize and fund the project.

I found Katja quite intimidating. She deftly took control, she was confrontational, and she was completely committed. I was hesitant to confide in her about how overwhelmed I sometimes felt by everything I was learning and seeing. She piled on the work, and I was sleeping only an hour or two a night. How could I ever meet her expectations? She was impatient with my inexperience, so I tried to stay out of her way. At one point she brought out her Swiss army knife. “Do you want to see how this works?”

I was curious and moved closer. She opened it up to the tweezers. “Like this,” she said, pulling hairs painfully out of my arm. I grimaced uneasily.

By the end of the mission, we had a sense of measured optimism, knowing those facilities were going to receive help. There would be no neurosurgical ward, but we had plans for rainwater tanks, medical equipment, and training for skilled birth attendants and others providing basic health care for the poor. It would be too late for Ruth and her baby, but hopefully other mothers wouldn’t have to suffer the way she had.²

SECOND MISSION, UGANDA, 1987

The second project took me to the town of Mbale, northeast of Kampala, to assess training schools for health workers and suggest changes in the curriculum and teaching methods to make them more relevant for poor mothers and children. This would involve a shift in thinking and training with more hands-on work at the community level in fundamental primary health care.

When I arrived in Mbale, the woman in charge of Canadian support for the medical assistant training school welcomed me with an offer of a hot eucalyptus-scented bubble bath. It was far more lavish than the treatment received by the Ugandan students who had arrived just before I did, escorted by the army from their previous school in the town of Gulu in northern Uganda through many miles of active fighting.

I talked to a young man named Joseph who told me, “In the morning in front of the training school we would count the dead. How many were the...