Regulation in Uganda and an Update on the Beer

Regulation of Healthcare in Uganda

Denis (the Project Coordinator for Salem) took me to the District Offices in Mbale this morning. I asked him to arrange and introduction for me in an attempt to understand their inspection system. The building and the set up reminded me of the Temple of Peace in Cathays when it was Bro Taf Health Authority; not because they are exactly the same but there are many similarities. The district office is a single story building with several offices to either side of the board room/library. The District Health Officer is a public health doctor. I spoke at some length with the public health nurse who does a lot of in service training for health workers and is also involved in the ‘inspections’.  If I have understood it correctly inspections here are not known as such, they are visits linked to the supervision framework.

The supervision framework set out by the Ministry of Health (MoH) describes how the MoH provides supervision to the district in the way that they perform their functions. In turn the district health officials provide supervision to the clinicians in the health care providers in their performance in delivering healthcare services. When an ‘inspection’ takes place there is a visit by quite a large team of people with varying expertise and the district health officials who undertake the supervision. They identify areas of commendations and areas for improvement and then sit down and discus with the healthcare provider how they can put together a plan to address areas for action.

The framework against which performance is monitored is derived from policy and standards documents issued by the MoH. Rather than having cross cutting standards which are relevant to all areas these have been produced in relation to work streams and funding  i.e. malaria treatment, injection safety and waste management, TB & HIV management, prevention of mother to child transmission of HIV, anaemia, rabies surveillance, reproductive health and education for parents on sexuality and HIV/AIDS prevention. This means that policies are focussed on these areas rather than on generic factors such as infection control, record keeping, risk management etc etc.

I explained the 3 tier approach (patient experience, organisational, board) to inspection in Wales to the District Health Officer who was very keen to explore ways that they could use this, recognising that board members generally know very little about the performance of organisations and the need for better information at this level to inform decision making. He seemed to think I might be coming back at a later date to do some more work with him on this – I explained that is a debate to be had at another level!!

I have lots of work to do back at base now that I understand a bit better how the system works and what is meant to be in place.

Feeling grotty

I’ve got a horrible cold at the moment. It started 2 days ago and my nose is just pouring. The worst bit is the sneezing and when it runs down the back of your throat and makes you feel sick. Ugggg.  Still it should be better in a few days. It was interesting last night as I was on my over to the new path lab with the head of the lab to do a monitoring site visit – as work is progressing very well. I said not to come too close as I was ‘full of germs’; his response was ‘yes but its self limiting’. Even though I was feeling a bit sorry for myself it made me think of the other diseases around here that are dealt with on a daily basis and are much worse and put it in a perspective which made me feel quite selfish I suppose.

Update on the local brew

I gave you a description previously of the beer brewed in the local villages but had trouble with the images taken by one of my housemates. I have copied the text from before but added in the images as I have managed to save them now – I think you’ll see what I mean.

We haven’t been back for any more even though we had a few offers....

The beer story with pictures -

One of the staff here who lives on site said that he had to go back to his home town on Friday and promised to bring back some of the local beer that is brewed in the villages for us to try. When he returned he invited us all over for a taste. This sounded great so off we trotted to next door for a sample. ‘We’ is Misha and Sarah (my German housemates) and I.

The local beer is brewed from millet, a very small hard grain. The brew is ready to drink after about 7 days of fermenting. We were advised that it can be taken with either hot water or cold water, but that people who drank it with cold water get drunk very quickly.

The beer is poured from a large canister into a clay pot and this is topped up with either the hot or cold water – we all opted for hot.

Each person is then supplied with a very long drinking straw. The ones we had were about 4 – 5 feet in length, so that you can sit in your chair and sip the beer from the pot. The end of the straw is covered in a tea bag like filter so that the solids in the bottom of the pot don’t get sucked up into the straw. Traditionally the mouth piece is made from a turkey quill, but the ones we had were made from plastic (I think).

The beer was not quite what I was expecting a beer to look like. It was thick grey brown liquid (a bit like cement) and had a slightly chocolaty, gritty, sharp flavour.  We did not really drink very much and I hope we didn’t offend our host but it was very different to what we are used to as a beer. 

Our host told us that back in the villages, when a person has had enough to drink, they are not expected to say anything but to quietly remove themselves and go off on their way. He said they often look around and wonder where people have gone. He also said that once the brew has been drunk the millet in the bottom is eaten in areas where they are short of food.

We have had offers to go over and finish the container for the last couple of nights but have very politely declined. I wonder if they really like it that much – they seem very keen to give it away!

Gardens, Visitors and We and They

Working with the Agriculture Team

On Friday I spent the day with Aida and Tony from the agriculture team at Salem. Aida is in charge of the gardens where they grow vegetables that are used by the guest house, the children’s home and for the staff lunch. Some of the vegetables are also sold off.

We harvested a large bin full of aubergines (egg plants as they call them here). We also picked greens for the staff lunch.

Then we went over to the medicine garden where they grow Artemisia which is harvested and dried to make tea as a relief and preventative for malaria. They also grow aloe vera, hibiscus, lemon grass, and several others - I can’t remember all the names.

We looked at the bee hives from a distance as the bees are not particularly approachable in the heat of the day. They harvest the honey as sell locally.  

One of the things that really surprised me was the G nuts. At home I know these as money nuts or peanuts. The monkey nuts that I know of are found in beige shells that are cracked to reveal nuts in a burgundy coloured coating. Everyone laughed at me when I said I thought these grow on trees and were nuts from a kind of pod – a bit like peas I suppose. They are G nuts here because they come from the ground. The stem of the plant is pulled up to expose the nut shells as a type of tuber that grows in the ground. I don’t have a picture now but will get one. The g nuts are an important part of the harvest and diet here and most small people grow some on their small plots of land. They are not eaten straight away but are slowly roasted over a charcoal fire with a small amount of salt, and then very often ground to make a sauce that is eaten with matooke (boiled green bananas). We experimented to roast them with a small bit of sugar – really nice, especially when there are no other sweet treats around.

Welsh Visitors

A group of teachers and students from Rhondda Cynon Taf arrived on Friday evening. It’s amazing that I come all this way and meet people who live 5 minutes down the road from me in Pencoed and Llanharry. The saying ‘it's a small world’ is quite significant. They had arranged a bus tour to some ancient rock paintings on Saturday and invited me along, and I gratefully accepted. The paintings are at a place called Nyero near Kumi http://whc.unesco.org/en/tentativelists/914/  . One of the village elders acted as guide and showed us around.

He said that the rock paintings were one of the first ever rock paintings completed about 7000 years ago, but I’m not sure about this.

The concentric circles are meant to symbolise the sun god and I think they are not too dissimilar to the Egyptian icons for Ra the sun god – which is not that far from here. You can also see on the paintings a boat on the river with people in it. The paintings were reportedly done with the sap from the cactus plant whose sap is quite rubbery, and is mixed with blood to give the red colouring.

As we walked between the rocks there was a large spider and web overour heads. it was 5 - 6 inches in diameter. We didnt hang around!

It was a beautiful setting and it’s a shame that it has been vandalised and spoiled over the years.

There are also some rock paintings quite close to where we are at Salem – I’d like to cycle to see those one weekend as well http://kampala.usembassy.gov/pr_09212010.html .

I thought you might also like to see what the ‘loo’ was like – a very nicely decorated pit latrine (you have to make sure you carry a supply of your own tissues).

There is also an official visit through PONT (as mentioned in earlier blog), by officials from Welsh Assembly Government as part of the Wales for Africa agenda. The focus of the visit is tree planting and climate change. I was invited to the Mount Elgon Hotel http://www.mountelgonhotel.com/  in Mbale where they are staying to have dinner on Saturday night. It was a good opportunity to summarise what I have done at Salem to date and to explain my findings and the objectives that I am working to over the 8 week placement. I hope they think they have made a good investment in me. 

From left to right is Patrick (from the hotel) Jon Townley (Wales for Africa WAG) John Griffiths AM http://www.assemblywales.org/memhome/mem-profile/mem-newport_east.htm, Elin, Me, Sarah, and John Harrington (on placement).

This poem was in a book in the volunteers house giving tips on Ugandan culture. I thought I would share it – I like it.

We and They

Rudyard Kipling

Father, Mother and me

Sister and Aunties say

All of the people like us are We,

And everyone else is They.

And They live over the sea

While we live over the way.

But – would you believe it?

They look upon WE

As only a sort of They!

We eat pork and beef

With cow-horn-handled knives.

They who gobble Their rice off a leaf

Are horrified out of Their lives;

While They who live up a tree,

Feast on grubs and clay,

(Isn’t it scandalous?) We look upon

As a simply disgusting They!

We eat kitcheny food.

We have doors that latch.

They drink milk or blood

Under an open thatch.

We have Doctors to fee

They have Wizards to pay.

And (impudent heathen!)

They look upon We

As a quite impossible They!

All good people agree

And all good people say,

All nice people, like Us, are We

And everyone else is They:

But if you cross over the sea,

Instead of over the way,

You may end (by think of it!)

Looking on WE

As only a sort of They!

Local Beer & Our Lodgers

The ‘local brew’

One of the staff here who lives on site said that he had to go back to his home town on Friday and promised to bring back some of the local beer that is brewed in the villages for us to try. When he returned he invited us all over for a taste. This sounded great so off we trotted to next door for a sample. ‘We’ is Misha and Sarah (my German housemates) and I.

The local beer is brewed from millet, a very small hard grain. The brew is ready to drink after about 7 days of fermenting. We were advised that it can be taken with either hot water or cold water, but that people who drank it with cold water get drunk very quickly.

The beer is poured from a large canister into a clay pot and this is topped up with either the hot or cold water – we all opted for hot. Each person is then supplied with a very long drinking straw. The ones we had were about 4 – 5 feet in length, so that you can sit in your chair and sip the beer from the pot. The end of the straw is covered in a tea bag like filter so that the solids in the bottom of the pot don’t get sucked up into the straw. Traditionally the mouth piece is made from a turkey quill, but the ones we had were made from plastic (I think).

We did take some photos on Misha’s camera but unfortunately I could not load them onto my laptop.

The beer was not quite what I was expecting a beer to look like. It was thick grey brown liquid (a bit like cement) and had a slightly chocolaty, gritty, sharp flavour.  We did not really drink very much and I hope we didn’t offend our host but it was very different to what we are used to as a beer. 

Our host told us that back in the villages, when a person has had enough to drink, they are not expected to say anything but to quietly remove themselves and go off on their way. He said they often look around and wonder where people have gone. He also said that once the brew has been drunk the millet in the bottom is eaten in areas where they are short of food.

We have had offers to go over and finish the container for the last couple of nights but have very politely declined. I wonder if they really like it that much – they seem very keen to give it away!

Our Lodgers.

The volunteer’s house has a concrete base and is a construction with wood cladding. There are four bedrooms, a kitchen, shower room and sitting area. There are currently three of us living in the house but I thought I would explain that we are not alone.

We have lots of spider’s webs around the lights and in the corners of the ceilings, but we don’t attempt to get rid of these because they eventually catch the mosquitoes and other flying creatures.

In the roof above the kitchen we have some creatures that make a high pitched squeak. We think they might be bats but are really not sure. We can hear them moving around a bit but we don’t see them and they make more noise in the day time.

We have quite a lot of lizards about 4 inches long with very big bulging eyes. They are very shy and quickly disappear if you manage to see one.   We think it is these that leave a trail of droppings each morning on the worktop in the kitchen.

I haven’t seen any snakes yet but Misha keeps a blanket at the foot of her door to make sure she doesn’t get one in her room. The staff here have said that there are quite of lot of snakes in the long grass by the school of nursing. There is a better internet signal up there and we previously toyed with idea of sitting on the bench up there at night to be able to get the signal – but you won’t catch me up there now I know this. Apparently they are bright green but ‘only a bit poisonous’.  There was also one in the office the other day which caused a bit of a fuss. Having looked then up on the internet there are several green species of snake so I’m not sure exactly what it is. Most likely a green tree snake.

The green snake isn’t the only one that is seen around here; a short while ago there was a very large snake (probably a python or a boa) found in the guest house – glad I wasn’t around then.

Sunday, and having babies.

On Sunday, Vanessa and I went to meet the coordinator for PONT (www.pont.mbale.org.uk/ ) based in Mbale. His other job is to be the pastor at the First Baptist Church, so we went to the service so that we could meet him after wards.  Unfortunately he wasn’t there so I went back the next day to meet him. The service was from 9 until 11 but it actually finished at about 11.30. Over here it seems it is quite usual for people to drift into the service so that by the time it is finished the church is absolutely packed.  People were obviously dressed in their ‘Sunday best’ clothes and were very colourful. The service was very lively and the singing and dancing and responding to the preacher were loud and quite uninhibited. Maybe this is what keeps people going when they have so much difficulty to contend with in the rest of their lives.

Afterwards we went for lunch in a hotel which consisted of a Spanish omelette and a tomato and avocado salad. I’ve not really been a fan of avocado up till now, but this one was delicious it just melted in the mouth along with the rest of the meal. It must be the sunshine that makes it taste so good. The hotel had a little balcony so we sat outside.

While we were eating a marching band from one of the local schools went through the town, with all the children marching behind it. It was very colourful and provided a tremendous beat for them to march to.

If you want see where I am it can be located as follows.

On Google maps search for the town of Mbale. Once this is found follow the A104 road north from the town through Namusi to Nakaloke where there is a crossroads. You will need to have quite high definition at this stage (suggest 100m/200ft on scale at the bottom). Follow the left hand turn for about 900m to a crossroads and then on a further 600m to where the road appears to fork. Just at the fork there is a line of trees that come down approx 300m to a large light area and an area with lots of trees to the right. The large light area is the playing field outside the local primary school. The tree area is the Salem compound. If you increase the definition you can see the individual huts and departments. That's where I am.    

 When we got back to Nakaloke I had my first go on the bicycle boda to get back to Salem. As I think I described previously the bicycle boda is a bicycle that is strengthened over the rear wheel and is fitted with a cushion. You have to hop on and sit side saddle and there is a little piece of metal sticking out from the hub of the rear wheel so that you can rest one foot. The only thing to hold on to is the back of saddle – I held on to the spring on the back of the seat – it was OK was I relaxed even though the road is really bumpy.  It’s about 2 km from Nakaloke to Salem and they charge about 300 Ugandan shillings (which is about 10p). The second half of the road is a steady incline and I have to say I felt particularly sorry for the young man who was peddling the bike as I know I’m not the lightest person in the world – and he was puffing a bit – but managed it ok.  

The Ante Natal Clinic

 This morning I helped out at the ante natal clinic. this is the clinic.

I was booking ladies in, taking blood pressure, weighing and measuring height. I could not take many other details due to the language difficulties. One of the ladies this morning (aged 30) was attending for her 11th pregnancy. She had 7 children already at home as not all had survived. I was amazed at how trim and pretty and fresh she looked – I doubt I could manage to look like that in the same circumstances.

I had a great discussion with the midwife about how people give birth back in the villages – she gave me a practical demonstration of the positions which we both enjoyed. She explained that ladies either come to the health centre to give birth with the midwives or they stay in the village and are assisted by one of the locals with a bit of expertise or they manage it themselves. It occurred to me that as most people have mobile phones these days – it’s a shame that the midwives cannot go out to the village to assist. I suppose this is mostly due to the number of midwives this would need and the transport issues, but it doesn’t appear to be on the agenda here. I have heard several stories where the mother has died at home; one the other day where she delivered the baby ok at about 2am. She then appeared to become very weak so the husband walked to the nearest place to try to get help but when he got back she was dead. It’s very different to our expectations and experiences back in the UK.     

Settling In at Salem

This is my first blog for a couple of days as we have had major problems with the internet connections. Whilst the power might be on and you have paid for a connection with your 'dongle' there is no guarantee that you will make the connection, which is a bit frustrating to say the least.I’m getting used to the cold shower now; I seem to have found a way to gradually work through it. The worst bit of a cold shower is when the water hits your back between your shoulder blades and around the small of your back. Brrrr....  As the water comes directly down from the shower head, my solution is to stand out of the water stream and wash my hair so that my head gets used to the temperature. When I’ve finished with that I was the rest of my body and gradually stand further under the stream of water until I’m fully under the water - it’s not so bad – try it sometime! 

The electricity has been on most evenings. It gets dark at about 6.30 pm and the electricity comes on at about 7pm. If we are lucky it stays on until sun up in the morning, otherwise it can go off at any time.  There is a massive project underway in Uganda to replace the electrical network (poles and wiring). As this is being worked on during the day the power is shut off. There is also a rotating power share where regions of the country are shut down in turn as there is not enough power for the demand.   This makes it very difficult to use computers to support staff in the work that they do, very often if something needs to be done on a computer it will mean doing it late at night and in the workplace if people do not have facilities at home to use a computer.  

On Friday, I joined the community outreach team to go out and do vaccinations and HIV testing in the community. As there was only one vehicle available (due to breakdown) the community team shared a ride in a pickup truck with some workers on one child relocation projects. This meant we were 8 people and the driver in a pickup truck meant for 2 in the front and 3 in the back. Needless to say some of us were sitting in the back in the open air. We agreed we would swap over for the way back which is when it should have been my turn but it was raining so we all squeezed into the truck except one of the men!!! I was very glad I didn’t have to sit out in the rain.

Our location for the clinic was a house at a crossroads. The road was a mud track with very large potholes in it, and the houses were made out of baked mud bricks with a mud floor. I didn’t feel comfortable asking to take photographs at this stage – I want to be a bit more established before I ask to do this although in a discussion about  photographs afterwards I was advised that actually most people like being asked to be in a photograph, so will try to get some next time.

The session started with health promotion information which tells those present what an HIV test means and what it means to be positive or negative. There is also a lot of information about family planning and trying to encourage families to reduce the number of children that they have. This message is particularly important for the poorest families as there is not enough food for everyone. However many of the men still have the mindset that they need to have lots of children; they base this on how many children they are likely to have if half of them die. Whilst quite a lot of women are becoming more open to the use of contraception it seems to be the men, especially in the more remote areas that are more resistant to these ideas. 

We started with a handful of men from the village who listened to the talk and then a steady stream of people arrived out of what appeared to be nowhere with babies in their arms ready for vaccinations.  My job was to keep the register of who attended and what they had. As well as the usual range of injections the workers were distributing Vitamin A tablets (where indicated) and worm tablets wherever a person would accept them. In all we distributed about 400 worm tablets today.  The Vitamin A tablets are given to women and children at prescribed intervals as the diet is poor in dairy products. The worm tablets are given out for each member of the household and groups of passing school children as worms can be the cause of anaemia and malnutrition and can affect survival rates if there are other illnesses. One of the things that I noticed is generally how beautifully straight people’s teeth are, they don’t seem to have the problems with misalignment that we have at home – I can’t help wondering whether this is something to do with diet or possibly genetics.

As a white person I am known as Mzungo. The children especially follow along and clamber to hold my hand if they are feeling brave. If not they are very shy and peer around corners or hide behind each other to look at me. The children stare more in the more remote villages where white people are less often seen; if we pass a school or group of children in a vehicle they will come running out to call Mzungo, Mzungo.  This is not meant to be offensive it is just the name for any white person who is around who is not known by their name.

I also spent half a day in the path lab. This is a wooden structure that happens to be on top of a very large termite nest. The termites seem to have had a feast on several parts of the structure especially the partitions and the roof. A new path lab is under construction alongside the hospital building, but it can’t be ready soon enough for the staff who work there on a daily basis, but it is a concrete shell at the moment.  I have agreed with Denis the Coordinator this week that one of my objectives will be to try to get the lab as operational as possible by the time the German Ambassador to Uganda visits on 16 November, so that we can have an offical opening (no pressure!!). 

I was lucky to be shown how the tests for HIV, TB, malaria and blood cross matching. I have looked at the stained slides and seen a malaria infection when it is just starting and a malaria infection when it is well established in the blood – fascinating.  I was surprised that an HIV test takes a matter of minutes; I always thought it was complicated but it’s not. Essentially there are 3 types of indicator sticks that are very similar to pregnancy testing kits that can be bought from the chemist at home.  A drop of blood is placed on the bottom of the indictor stick together with a drop of buffer solution. If it is positive then a line comes up across a particular part of the stick. There is also a ‘control ‘ line that shows up. If this is clearly positive then that is it. If the result does not appear to be clear then a second test is done on a different type of strip. If this agrees with the first test then no further action is taken however if there is a difference in the first two results there is a third test that is done. This gives the concluding result. It was explained to me that where there are confusing results but the conclusion is that the HIV test is negative, it is usually because there is also another infection such as TB present. All the different test sticks have names which are too complicated to remember, I was just fascinated how straightforward it is to test for HIV.

 

More tomorrow (internet permitting).

Arrival at Salem

 Salem (Mbale) is a 10 acre compound which provides a hospital, nurse training school, outreach healthcare, a children’s home and a tree planting project. There also seem to be other things going on. It was raining when I arrived and very muddy so my suitcase was covered in the red sticky mud by the time we had walked to the volunteer accommodation. The volunteer accommodation is not the same as the guest house - which is for the fee paying guests, and is much more in line with what my first impression was when I imagined coming out here – a bit psychic maybe??

I met up with my 2 housemates from Germany who have been here for a while. Having unpacked I thought I would try out the shower as apparently it’s a bit warmer in the afternoon then the morning or late evening. As there is no hot water except what is heated up on the burner. It was refreshing to say the least, but I suppose you can get used to it (maybe).

One positive thing that surprised was that Vanessa assured me that the water is safe to drink at Salem, so no need to be buying limitless bottles of water. Not at all what I expected to hear.

I think today has been the biggest culture shock for me, especially when was unpacking in my room and realised this is it for the next 8 weeks – what have I done??

This is our kitchen.

This is what my room looked like when  I first arrived.

This is me upacked and settled in ... and my creaky bed.

Still I have yet to meet all the rest of the people here.........

First impressions of Uganda

The journey from the airport to the hotel gave me an opportunity to see a snapshot of everyday life in Uganda. My very first impression was the smell of dust which is very much like the smell when you open a bag of unwashed potatoes. Now that I have been here 2 days I don’t notice it anymore.

As we passed along the roads there were people everywhere, the children were walking to schools, adults were waiting for the Matatu. The matatu is a minibus that appears to be one of the main forms of transport for the general population.

The other main transport is the boda which is a scooter/motorbike used to take passengers. Some boda had up to 3 passengers on them. This is possible if everyone sits astride the vehicle but females using the boda usually sit side saddle. A variation on this is the bike boda which had the rear wheel cover strengthened so that a cushion fits onto it. The bike boda also seems to be used to transport anything heavy; I’ve seen sacks of rice, huge bundles of bananas, strips of wood or metal sometimes 10ft long, and water canisters several at a time.

Recycling is apparent in a big way although I suspect this is largely through need that choice. I’ve seen workshops where they strip down cars and lorries to sell on the parts, in one place you seemed to be able to purchase the whole front of a car. Probable quite good after a head on bump.

 After few hours sleep to recover from the flight I decided to venture out into Kampala. The streets are very busy and the traffic is gridlocked coming into and going out from the city at the beginning and end of the day. The traffic moves quite slowly as there is so much of it – the matatu, boda, bike boda and pedestrians all jostling for a space on the road.

I’m surprised that I did not see any bumps as it was often centimetres between vehicles and pedestrians, but everyone seems to be very aware of other road users and actually it all moves very slowly which probably helps.

Street children were evident in some areas..

...when I spoke to some of the local people they said that the children were often brought into Kampala from outlying regions to beg. Because of this they felt that giving is probably best discouraged but it is very sad to see some youngsters about 6 years old sitting begging on the street or coming up and asking for money.

I was a bit stressed for a while when I tried to get some money from the bank. Our briefing pack said that ATMs are generally available, but not that the only card they take is VISA – and guess who had a MasterCard & Maestro card????  After visiting several banks and talking to their customer service departments I was advised that Barclays might take it which they did – but not through an ATM I had to pay for an international transaction or something along those lines. This had never been a problem before when travelling in Europe thee are widely accepted – but not further afield it seems. 

Back at the hotel http://www.hoteltriangle.co.ug/  I had an in country briefing with Edward, who took me through all the main pints about the placement and the arrangements for the next day. He very helpfully took me through putting money on my phone which was a great help.

In the evening I tried to log on at the hotel. I thought I had problems with my laptop as I kept getting a message to say I was connected but obviously wasn’t. It seemed then that the internet was down for a couple of hours. The staff in reception were really helpful and phoned me to say that it was back on line.

My journey to Salem started at 9am on Tuesday. I was collected by a driver and we headed off toward Mbale. The road out of the city was very heavy with traffic again; some of the potholes were amazing. I’m sure I could have stood in them up to my knees, and one was right across the width of the road. I was impressed at how all the drivers skilfully navigated their way around them especially those with passengers precariously perched on the back. Soon we were on fairly clear and even road out towards Jinja. Jinja is known as the source of the Nile as this is where the water flows from Lake Victoria into the Victoria Nile. It is known for its white-water rafting by those seeking adventure. As we crossed the bridge the driver pointed out the hydro electric plant which is situated on the dam and which provides all the electricity for Uganda and also to some for neighbouring countries as well.

As we travelled along I also saw the sugar plantations, tea plantations, rice fields, and banana trees. Many of the new buildings that I saw were new schools provided by either religious groups or other charitable organisations. Some were very grand indeed which was not really the same as the other local schools.

When I got to Mbale at 1pm I was given a warm welcome by Vanessa the long term volunteer at Salem. We had some lunch and then got a private taxi to Salem which is just off the main road at Nakaloke. As I wwas dragging my suitacase along the bust street I’m sure a felt by bag being undone, but when I looked it was only the side pocket so I tucked it very tightly under my arm and prayed they hadn’t got anything else (which they hadn’t).