The operation hadn’t exactly been going well anyway.

“These officers….” Anthony, my fellow ‘observer’ of the operation raised an eyebrow and sighed as we watched 20 police and 15 municipal enforcement officers wander, aimlessly and timidly along the busy wholesale street they were supposed to be raiding to impound illegal alcohol. The head of the operation was no where to be seen.

“Come on, they aren’t really checking these shops.” I led the way into a dimly lit, densely packed store. Armed with a cell-phone torch, a quick peep behind the counter revealed a jackpot. Somewhat relieved to be given a clear instruction, officers removed the illegal products. Having instigated at least a little action, we headed off to target another shop.

What felt like just moments later, I heard shouting and looked over my shoulder to see a growing crowd swarming. We rushed back over to find an irate shop owner standing over the pile of confiscated products yelling into his cell phone. At his feet were boxes of plastic sachets of spirits. There were also some plastic bottles and small glass bottles of spirits. The head of the operation and other officers stood nearby, looking uncertain and nervously requesting the shop keeper to calm down.

Then the Mayor arrived. Obviously at the shop keepers summons. He proudly strutted in, crowd parting to allow him to take center stage to start pontificating. Struggling to get close enough to hear what he was saying, I caught phrases like “unfair targeting of municipal businessmen,” and “now they want to take your glass bottles,” and “defend Gulu’s economic interests.” Each sentence got cheers from the surrounding shop owners, presumably his new private supporters. On my phone, I tried in vein to convince a higher power (i.e. the District chairman) to come and intervene. Then the rain started, and the police officers cowered further under the shop eaves. Operation aborted. The officers scuttled back into the vehicle, the shopkeeper packed his goods back inside, and everyone left.

As unjust and illegal as the Mayor’s actions had been, I realize we had made a critical mistake. The target of the law was the cheapest, nastiest spirits in plastic sachets and bottles. There are, however, some glass bottles of 200ml, which are also now technically against the law, which has a minimum packaging size limit of 250ml. The police weren’t wrong to try to impound the smaller glass bottles. But the language of our movement has focused on plastic packaging, and so the Mayor felt justified to come running to “defend” the business owners. Had we made it clear to the police that they should stick to confiscating plastic bottles and sachets, we might not have been thwarted.

I kicked myself. The worst news came some time later. Indignant, and possibly also receiving financial inducements, the Mayor decided to completely block the municipal enforcement officers from taking part in operations. Because the police required the presence of local government (because, they say it’s a local government ordinance), I was sure this would block all further enforcement. Eventually, it was decided between all parties that we would collectively “overlook” the glass bottle issue and focus 100% on plastics. I visited the Mayor personally to try and smooth things over, assure him that glass bottles would no longer be targeted. Let me just say that his response was such that for the first time, I lost my temper to a ‘VIP’ official and walked out of his office.

Next time I saw him, there was plenty of media with us.

P.S  For those confused about these different products:

(Above left): different brands of sachet alcohol, 40% spirits, 100ml, 20 NZ cents
(Above right): the 200ml of spirits in glass bottle- 40% spirits 200ml, about 3.50 NZ dollars…technically illegal, but not really a problem.

I can’t believe I’m doing a political blog post! Apologies to non New Zealanders who don’t care about the political tides in a few tiny meaningless islands somewhere near the bottom of the world.

Here are 3 policies I like, and 3 I don’t from the Labour Party. Don’t get me wrong, I love the increased support Labour are getting and I think Jacinda is great, but the policies? Mixed feelings. I also don’t think either the good or the bad ones are very significant.. Tinkering around the edges, nothing more. What do you think?

Like

• $25 Tourist tax. Awesome. Should be even higher, should have been done long ago. Levy tourists, who by definition are Rich from a Global perspective. Done, Next. Most other touristy countries do it – here in Uganda its $65 dollars!
• Irrigation and bottled water tax. Using our water has an enormous environmental cost, and whoever is using it should start to actually pay some of that tax. My only problem with this policy is the tax should be even higher than they’ve stated!
• 8 billion extra spent on healthcare. Great. Healthcare needs more and more money, it’s the nature of the beast. Throw the money at it. I don’t mind if you don’t specify where it goes, the health policy bean counters can sort that out

Don’t Like

• Free Tertiary education for 3 years. Lolly throwing policy. Favours the rich, as a disproportionate number of rich people go to university rather than other forms of tertiary education. If you are a blue collar worker who doesn’t study, no benefit for you. Obviously baby boomers and young people love this $^#&, but that doesn’t make it the best use of money.
• Lower GP fees for all. I actually like Nationals policy better here. Fees should be free or super cheap for poor people. Others can afford 35-50 bucks. Under 2 hours work for a GP visit? That’s 100 years away here in Uganda. 10 bucks cheaper for everyone smacks of meaningless populism rather than sensible policy. “They have literally copied National’s announcement from last week targeting low income New Zealanders, and tacked on a $10 universal subsidy over the top,” – As much as I dislike Steven Joyce, hard to Argue with.
• No Capital gains tax or raising taxes on the mega rich. I wonder how Labour will afford all their lollies, without raising taxes. It doesn’t make sense. I know they are swinging a bit to the center to get votes and its working, but that doesn’t mean I have to like it!

Phase 1 – Great hope
In March, we rode a trusty-rusty pickup with enthusiastic nurse Walter to the frontier town of Elegu on the South Sudanese border. High population, no health center, traders with a bit of money. What location could be better? The place even came with our Bishop’s recommendation.

Optimism, Hope and an Amazing nurse Walter

Phase 2 – Bewilderingly slow
Things started surprisingly slowly. Only 60 patients came the first month. 97 the second. Walter was bored. The patients who came appreciated the service greatly, but we were bewildered by how few there were. After an amateur advertising campaign where we shouted through a megaphone, smeared A4 notices around town, and gained the trust of the local Maadi tribe, things started to pick up.

Phase 3 – Maybe yes?
In July, the clinic broke even for the first time, with a bunch of sick patients coming for IV treatment, in addition to more minor conditions. 175 patients for the month. Walter called excitedly with the statistics, sharing that the word had spread, that people were appreciating him, the health center, and the care- the only high quality care available in the area.

Some parts of Elegu flooded even worse than our healht center

FLOODED OUT  – We’ll never know
On Tuesday 22^nd August, at around 4:00pm the banks of the Unyama River burst. The flooding was swift and violent. The scale is huge – as of now at least 3 people have been found dead, and over 2000 are displaced. Our nurse Walter Ran 50 meters to the clinic from his hut in an attempt save the drugs, but only managed to gather half before the water reached waist deep. By the time he filled a bag with drugs, his own home was flooded. He lost all his rice and beans, but him and his wife made it safely up to the safety of the raised main road. I thought he exaggerated when he said the water level reached over a meter, until I saw the water line on our drug cupboard today. Around 1.2 meters high. Today, a week later the water is still ankle deep, and Fiona from our Health office went to Elegu to retrieve the Cupboard, desks and other equipment that were covered in mud. Amazingly the clinic hadn’t been looted. We spent this afternoon washing them up, so we can use them in another health center soon. It hurts to lose Elegu clinic. something that could have done so much good. Time to mourn and move on.

Ruined Drugs

The crew cleans up back at the office

There’s a great song, “Flood Waters” by Josh Garrells (do listen) which discusses a deep love which can’t be washed away. A love which can’t fail no matter what. Our love for this place, and Walther’s love for the people he treats won’t be washed away by this flood. We’ll all find new ways to put it into action.

Tuesday evening are special. Every week we’ve been in Gulu for the last 4 years, we’ve run an evening class for kids in the neighbourhood. They live within 200 meters of our house, and we’re really close with them. We focus on catching up kids who have missed large chunks of school because their parents couldn’t afford the fees. We also have a library of story books which kids can borrow from – if they can prove they’ve read their current book! In the last year we’ve exchanged over 200 books with the kids. While yesterday Tessa arranged the whole library, lazy me just made the kids laugh for the photo.

We have 3 classes based on ability. Tessa takes the lower two, and I take the older kids. This is the middle class. Why so serious?

Our visitors have been a great help with the class, and many have run their own programmes during the week to help give the kids an extra boost. Some of the results have been remarkable. Phoebe helped one girl to improve her reading and math by over 2 year levels in just 3 months. Six of the kids are sponsored to school through generous friends and churches, and will now finish primary school without missing another day. Thank you!

Lydia was always ready to drop whatever she was doing to read with the kids.  Lydia designed a star system where kids get a sticker for every book they read. Three kids have read over 10 books already! Sharon (below) is keen and focused, but over 5 years behind due to missing school and poor teaching.

Ira re-invigorated math for the older kids, and helped pitch the work more at the individual levels of the kids. (Nearly) all of these kids are from our class.

Mum is the biggest contributor to the  library, which now includes classics like The Very Hungry Caterpillar, Where the Wild things are and Dr. Seuss. While she was here she did class every day for a week, which was extremely popular. She may or may not have given out a few more stickers than we usually do ;).

And a huge thanks to our resident education expert Jody for making this all possible by showing us how to teach her wonderful phonics program.

We’re 5 months into the trial of the 4 new clinics, with a total of 12 operational months between the health centers – the halfway point in the trial. Cetkana has been running for 5 months, and our most recent Obanga pe Wany. only 1 month. We’re aiming for ‘operationally sustainability’, which means the patient fees cover running costs. The new clinics have already treated 2293 patients combined which is impressive. YAY STATS here goes…

The patients

Here’s the graph of the number of patients seen by each clinic every month. Note Obanga Pe wany only has 1 dot – the clinic has only been running for a month. I’m not currently collating the data for conditions seen (its available at the health cetners), but over 60% of these patients had malaria.

Two Thirds of our patients are kids under 12, which is great from a saving lives perspective, but not so good for our sustainability as they pay less money.

The money

Patients pay a flat fee which covers Consultation + Test + drugs. This means someone knows before they walk 2 hours to the health center exactly how much money they need. Patients 0-4 years old pay USD 0.70. 5-12 pay US 1$, 13+ pay $1.50. Even in Uganda where people have very little, this is a relatively small amount of money, and always less than transport to the nearest other health facility. You won’t find cheaper healthcare in Northern Uganda outside the hopeless government system.

Over 90% of our running cost are drugs + the nurse’s salary + rent, and from our current experience it takes around 235 patients a month to raise the money required to pay for this. Here’s the graph showing how much money our health centers are losing/gaining each month. The line in the middle is the “sustainability line”, which the health center has to stay above on average to be viable. Keep in mind a couple of really good months can offset 4-6 not so good ones (see Ocim) If you’re wondering why its US rather than NZ dollars, its because the New Zealand Dollar is a backwater currency and we want to be taken seriously. A beautiful backwater though…

As a side note We also give some stuff out for free, like condoms, family planning and mama kits for pregnant mothers. Nurse Naume at Ocim gave out 300 free condoms one month. Awesome.

Take away points

• Around 235 patients a month is what’s needed for sustainability
• Even after only 4 months, Ocim is doing well enough for us to say they can continue indefinitely. Sustainability win and compounded good!
• Obanga Pe wany had a fantastic first month, if this continues it should also become sustainable.
• Cetkana is doing a great job, but Is unlikely to become sustainable,.
• Elegu has started very slowly and is losing a lot of money, but its early days.
• Stats alone don’t show the good these places are doing. Stay tuned for the non evidence based stories to pull the heartstrings and give the majority of people who didn’t read this blog a warped view of how awesome these health centers are :p.
• 2/3 of our patients are kids, which is great for their health and their future

PS: Since starting writing this we’ve decided to extend Cetkana’s trial another 3 months to 9 months, Despite their currently unsustainably low number of patients, they’ve actually lost very little money. Unfortunately I doubt they will reach the magical 235 number to be able to continue, but we wanted to give them every chance. Their deficit is only USD 40 a month. You might say, why don’t we just fund that shortfall? That’s so little money to help provide healthcare for 150-200 really poor people a month. People have already offered. Maybe in future we will run centers with small subsidies. For now though lets shoot for the moon and go for 100% local sustainability. It may hurt to shut places down, but we can always go back and through this approach we’ll find the areas which desperately need quality health care, rather than just a lot.

If you got to the end my respect for you is immense. More exciting and inspiring stories coming soon :D.

Today was EPIC at St. Philip Health Center. Our Visionary In-Charge Moses typified his Go Big attitude by advertising on the radio and churches on the same day…

1. Free HIV testing  (tested 90 people for HIV)
2. Free drop-in Cervical Cancer screening (screened 40 women)
3. The opening of our Inpatient service

And all that in addition to seeing 70 patients as part of regular outpatients. Crazy town.

You heard it right, we’ve opened our Inpatient, 24 hour service. St. Philip is now a mini hospital – sort of. Complete with beds, night staff and everything. We had our first 4 admissions today, 3 with severe malaria and one with bad epilepsy 4 seizures in one day. Great work moses and the team!