Malnutrition

One of the saddest conditions we see here is malnutrition and this year has apparently been unusually bad. There are two types of malnutrition, oedematous and non-oedematous (also known as Kwashiorkor and Marasmus). Nobody really knows why some children develop one and some the other, but the oedema seems to be due to protein-deficiency. It causes the children's feet, abdomens and sometimes faces to swell and they also develop skin changes, curly, light hair and they become sullen and apathetic. The other type is due to lack of calories full-stop, and they are usually lighter (less than 60% of the expected weight for their height). Both groups of children are at risk of serious infections and because of the malnutrition they don't always have fevers, raised white cell counts or positive malaria tests, so we treat them empirically with the strongest antibiotics and with antimalarials. Then are started on milk called F-75 which is then changed to F-100 when the swelling is gone and they are more lively and seem hungry. Sometimes they respond really fast, one day they'll be lying still looking miserable, the next day you might get a smile and the next day they're playing! The tiny babies seem to take longer to respond. Once they've put on weight and are doing well they are started on a peanut-based food called RUTF which they go home on. This and the F-75 and F-100 are free. The F-75 and F-100 are made from milk from the hospital's farm (which I didn't know existed until two Brits came over to work on it a couple of weeks ago). The remaining milk is used to make tea for the staff! Water, oil and sugar are added to the milk using a recipe from the WHO. The hospital are trying to get ready-made sachets of the milks though because these contain other things like vitamins and minerals which they can't get separately. If anyone knows how they can get the ready-made milk please let me know!

Malnutrition affects many of the children we see to some extent, and malaria and other serious illnesses can trigger it, so it becomes a vicious cycle. The other children who are at high risk are those with HIV. On the last ja-ja day I was talking to the nurse who organises it, Laheri. She was getting worried about a couple of the children because they were looking sad and not playing. This withdrawal is often a sign of malnutrition and she says that's how they often lose the children. Many of them are looked after by grandparents who struggle to find food for all their grandchildren. During each ja-ja day they have 2 meals- firstly porridge and then a lunch which they call 'balanced-diet food' as it contains matoke (a type of green banana, mashed), rice, beans, meat and cabbage. I've never seen plates piled so high and even the smallest children ate about 3 times as much as I could and took the left-overs home for later. For most of them it's a once a month treat as they can't afford to eat that well normally. Ja-ja day ran out of money last year and they had to stop for 6 months and apparently quite a few children died of malnutrition during that time. It's tragic that children with HIV are on free treatment and so don't die of AIDS but instead of hunger.

The crazy thing is that Uganda is really lush, green and fertile. It rains a lot and they can grow so many crops. The farmers I mentioned above have said that the farming here could easily be productive enough to feed the population and stop malnutrition but so far it's hasn't worked. I don't know enough about farming or economics to comment but there definitely seems to be lots of food around, it just doesn't get to the people who need it.

Neonates

I promised ages ago to write about the neonatal ward and never did, so here goes. The ward is next to the main paeds ward and has two sections- the main room with cots, a resuscitaire (used in the UK to resuscitate babies but here as another incubator) and a few incubators, of which only one works. There's also a bed so one Mum can be there with her baby. The other room has 7 beds and is used for the stable babies on antibiotics to be with their Mums and also the preterm babies receiving Kangaroo care. The number of babies varies from about 3 to about 25, but there are usually 10-15. The unit looks after babies from birth to 1 month of age. Most come in straight from maternity or from the community on day 1 or 2 of life. Some have fevers or other signs of sepsis and are treated on a cocktail of antibiotics for 5-10 days. These babies usually do well. Another set of babies are suffering from birth asphyxia (basically lack of oxygen either because of a problem during the pregnancy, during labour or straight after labour). This is a lot more common here than back home, mostly I think because most births are in the community and problems aren't recognised until very late. Giving birth in hospital is expensive. The caesarian rate here is really high because only the most complicated cases come. These babies are often quite unwell and can have lots of seizures. Sometimes they respond well and recover quickly but others don't and you can tell from quite early on that they are likely to develop cerebral palsy or other long-term problems. It's really sad because if they survive they are much more likely to end up malnourished when they are older and are less likely to survive to adulthood.

There are also lots of premature babies. We don't usually know exactly how premature they are because most women aren't sure when they are due but some are very small. When they are first born they are put in the incubators if available and given oxygen and intravenous fluids. We use aminophylline to help prevent apnoeas (stopping breathing suddenly due to the immaturity of the brain). In the UK we use caffeine which is apparently a metabolite of aminophylline. They also all have antibiotics. Once their breathing settles they are started on feeds of expressed breast milk given via a naso-gastric tube. At this point they can usually start Kangaroo care. This is a great system that was started in Colombia and involves postioning the naked baby next to its Mum's bare chest and then wrapping them both in lots of layers. It's basically using the Mum as an incubator and is used a lot now in low-resource settings. The babies are discharged home once they have reached 1.5kg and continue Kangaroo at home. At this stage they are still too small and immature to breast-feed so the Mums continue nasogastric feeding or give them expressed milk using a spoon.

There are also a few babies with other problems, such as congenital problems or babies who came in from the community. One baby I saw had been burnt really badly because her older siblings had been playing with a candle near her. In the UK, a story like that would trigger at least a discussion with social services but here there's no child protection set-up. Another baby that stands out was a tiny little thing who was brought in at 2 weeks because she hadn't been feeding or crying. It was immediately obvious that she was very premature which was probably why she couldn't feed. She'd been born in a rural village and been taken to a traditional healer. She was extremely malnourished and really unwell. It broke my heart because she'd probably have done ok if she'd been brought in a birth but as it was we never managed to get her any stronger and she died after a couple of weeks. There are so many factors involved and it's stories like that that make you realised the importance of education, community health programmes and working with traditional healers to teach them how to recognise their limitations and when to refer to a hospital.

In my second week here I was by myself (except for a very helpful and very good medical student) and I was petrified at the idea of having to do the neonatal ward round. The ward was really busy and lots of the babies were very sick. I was right to be worried, and I almost left at the end of the week! There was a pair of twins, one of whom was very poorly but there was nothing else to do for her. She was on antibiotics and fluids and although she was jaundiced the only treatment for that here is sunbathing (!) and she wasn't stable enough for that. I worried about her all night and the next day saw her first on the ward round. I was just about to examine her when I realised she wasn't breathing. Luckily Emma was there and Jess, the student and together we started to resuscitate her. I'd never been at a full-blown neonatal resuscitation before and was very grateful I'd done the course as otherwise I'd have been totally overwhelmed. Even then though it was pretty stressful. We tried everything but never got a heart rate so after 25 minutes I decided we should stop. I spoke to the Dad (one of very few people in Kagando who spoke good English) and explained what had happened. It was awful, but it got worse because I suddenly realised the nurse had restarted resuscitating her, saying she thought she had a heartbeat. The Dad looked hopeful for a bit but we went over and listened and there wasn't one so I put my foot down and said we had to stop. I think the nurse was quite inexperienced but so am I and the whole situation was so awful. Thankfully the other twin did really well and the parents were so sweet and so in love with her! I really didn't want to go back the next day but I had to, because there was nobody else. A couple of days later we had another resuscitation of a very premature baby who'd come in after being born at home. Her twin had already died. Unfortunately the outcome was the same, but the nurses were much more helpful and supportive and it helped so much. I don't really feel ready to be making decisions about stopping resuscitation but here even the nurses sometimes have to, as there are so few doctors. Luckily it will be years before I'm in a similar position at home.

There are lots of neonatal deaths here, and I imagine we are only seeing the tip of the iceberg as many probably don't make it to hospital. It's really sad but it's also sad to see the ones who survive but you know will have developmental and health problems long term. On the other hand most get better and it's lovely when you see the premature babies coming back for review and they've put on loads of weight and are doing well. The 'kangaroo' room is also always really sociable and happy as all the women chat and help each other. If a mother's too ill to care for her baby or if she dies in labour everyone else works together to help and the babies are usually looked after by relatives or neighbours. Ugandans are such warm friendly people, almost always smiling!

Soon I'll be working in a big tertiary Neonatal Intensive Care Unit in the UK. It will be interesting to compare it to Kagando's NICU!

The last week

I wanted to write a bit about my last week in Kagando as I think it sums up a lot of aspects of hospital life. They've employed a new medical officer on paeds and it was his first week. A medical officer is similar to an SHO in the UK. When Ugandan doctors leave medical school they become an intern for one year, during which they rotate around medicine, surgery, paeds and obs and gynae. They then work as a medical officer for a few years after which they can do a masters to become a specialist. It's crazy though because they're not paid during their masters so they have to study fulltime and work in the evenings to earn money. Unless they are very well-off they also need to find a sponsor to pay their tuition fees. The masters take about 3 years and then they can work as a specialist. The new medical officer has just finised his intern year so is quite inexperienced. However he's expected to do ward-rounds by himself and learn on the job. I tried to teach him as much as I could before I left and I think he'll do well but it's definitely a lot of responsibility. I can't wait to be back in a team of doctors and have lots of people with more experience to ask for help!

It was a frustrating week as the machine to do CBCs (full blood counts, including a haemoglobin, white cell count and platelet count) was broken and, for 2 days, so was the other machine that only does haemoglobins. As so many of our patients are anaemic this meant we couldn't quantify the degree of anaemia so we had to just decide clinically whether to give them blood transfusions and how many. Some of the sickest children need lots of transfusions as the malaria breaks down their red blood cells. Luckily the blood here is all screened for diseases like HIV and hepatitis so it's relatively safe but we quite often ran out of some blood groups. We also couldn't test blood glucose as they'd run out of the test strips. This was difficult because we had 3 unconcious children who were having seizures. Low blood sugar levels can be the cause of seizures and they can also be the result of being very unwell and not having any nutrition other than intravenous fluids. I therefore decided to give a couple of the children intravenous glucose empirically just to be safe.

Two children died one night and both had been in for a couple of days on treatment so it was really upsetting and frustrating that we hadn't managed to save them. We don't even know what was wrong with them because we couldn't do many tests, but neither had clear-cut malaria. They both deteriorated during the night and the nurses resuscitated them without any doctors there so we couldn't even get a clear picture of what happened. Normally the children who die do so in the first few hours in hospital before the treatment's had time to work. It still seems crazy to me that a child can die without a doctor being called and without knowing what the cause was. In the UK it's such a rare event now that there's an investigation into every child death and it's just so sad to think that here and in so many places it happens so often. 

One of the biggest challenges here has been working with the staff and trying to get the right balance between being assertive but also not feeling like the Western doctor coming in and telling them what to do. I have met some amazing and very dedicated nurses who have taught me so much and made my job so much easier and more fun. Unfortunately there were also some who were less good and I can't remember how many times I stamped my foot because none of the children had had any observations done! In the UK every patient has a heart rate, respiratory rate, oxygen saturations and temperature at least twice a day and sometimes up to every 30 minutes or hour if they need it. If anything changes they call the doctor on-call. We'd be lucky to get one temperature measured a day, even on the children in high-care. I tried everything I could think of to persuade them to do more observations but it never seemed to make any difference. There was a particular low point when I'd been away for a weekend and on the ward round on Monday noticed that hardly any children had had their medications over the weekend. Often this means the parents had taken their children outside so weren't there during the drug rounds but this time it included some of the really ill children who couldn't have gone outside. You realise how well the drugs work when you see how ill the children are without them! Luckily none had died but it meant lots of children had to stay in longer which increased the cost for their parents. I've never been so cross at work but the senior nurses (who don't work weekends) were great and got really cross too. The next day things weren't much better but the following day they'd really improved and they never got so bad again. I think the senior nurses threatened to take the money it would cost the patients to stay longer out of the pay of the nurses who'd been at work!

It feels strange to have left Kagando. By the end I was starting to feel quite confident with most things I was doing, although I still much preferred the days when my consultant was there than when I was alone and had nobody to ask for advice. I've looked after lots of very sick children and almost all of them have got better which is great. I've done ward rounds of sometimes 60-70 children and neonates and had to decide what treatment they need and way up the benefits of investigations and treatments against the cost to the families. It's hard not knowing what you are treating always or if you are doing the right thing but I think my clinical skills and decision making have improved massively. I do feel that I've helped and made some difference but with that comes a feeling of guilt for having left, especially as we're now having a holiday before we go back. However it's been hard work and emotionally draining and we both feel we need a break. I'm really excited about working in a lovely NHS hospital again with lots of nurses and doctors and never needing to worry about running out of drugs or not being able to do the investigations the patient needs. I hope to come back though, with a bit more experience under my belt!

Our little house

I wrote this blog about 2 weeks ago but my (usually very good and user-friendly) blogger app had a bit of a strop and it’s stuck in the process of publishing it, so I’ve had to re-write it. Now I back everything up before I press ‘publish’!

I feel it’s about time I described where we live a bit better. We are staying in a big compound across the road from the hospital. The compound is massive and we’ve only seen a tiny bit of it. It houses the nursing school and their accommodation and also most of the staff of the hospital and their families. It’s on a hill so the walk to work is downhill all the way but it’s a very steep trudge back home! The compound has locked gates with a security guard. Apparently there’s a curfew in this part of the country of 10 o’clock and I met a student who’d got back from playing badminton too late and spent the night in a police cell! It’s strange because we’re basically in the middle of nowhere apart from one village so it doesn’t feel very dangerous but I guess it’s nice to know we’re safe.

They gave us a choice of living in the doctor’s guesthouse or a house. It’s so nice to have a house. It’s basically a bungalow in a little garden just off the main path through the compound. Rita’s house is next door. There’s a concrete area between the 2 houses and the side doors come off this so there’s about 2 metres between our door and Rita’s. The main door is round the front with a covered porch. The garden has a few plants, a hedge, a lawn and a big coconut tree, as well as a washing line. We used to have 2 but random people have been chopping down one of our trees for wood and they broke one. We don’t really sit outside much because the lawn is on a steep slope and there are lots of things that bite in the grass!

The main room at the front has a sofa, 2 armchairs and a rocking chair and some pretty hangings on the walls. We spend almost all our time in here, reading books, sewing, writing blogs etc. I don’t think either of us have read so many books in such a short time before, I must be on over 30! Off the sitting room is a dining area and then off this to the right is the kitchen. We have a fridge-freezer, 2 hobs, a sink and a big dresser. The kitchen’s very well-equipped thanks to the many people who have lived here over the years. The bathroom’s small. We’re meant to have hot water but it’s broken and it’s hard enough to get the engineers to sort out the big problems so we’ve decided it’s not a battle worth fighting! In a country where lots of people walk for miles to collect water, our running water is enough of a luxury. After a big rainstorm the water sometimes turns a nasty brown colour because it picks up mud. It’s ok to shower in but slightly disconcerting for washing clothes or when we boil it for drinking water! Emma’s bedroom is off the same corridor and mine is off the sitting room. I have a queen-size bed which is nice but the mattress is broken down the middle so I have to sleep diagonally. My room has a washing line too so we can dry our clothes there when it rains. I often have puddles on the concrete floor afterwards and you can see which way it slopes!

The ‘rubbish bin’ is a hole in the ground just up the path from our garden. Apparently they burn the rubbish when it gets full but it never seems to get any fuller because the birds and animals get in and spread the rubbish around. It definitely doesn’t feel like the tidiest or most hygienic solution but I guess it’s hard without rubbish collectors. People burn stuff a lot here on bonfires. They always smell awful and we can’t close our windows so the smoke sometimes gets in  the house.

Our electricity comes from a company in Kasese and we have a card which we have to top up in town and then we put into a little box outside our house to get more power. It’s usually pretty cheap but we’ve had a problem with ours and it uses way more than normal (like 5 times more). We think it’s either the fridge or a loose connection but the electricians came and didn’t get anywhere. It’s still only about £5 a week but it does mean we have to plan ahead so we don’t run out! We have a lot of power-cuts here, at the moment there seems to be about one a day. There’s a generator we can use when the power goes off. We turn a handle in our house and then wait until the generator has been started. It runs on oil and apparently once during an operation there was a power-cut and they were out of oil so they had to send someone to buy some whilst keeping the patient breathing manually without the usual machines! Sometimes it takes a while for the generator to be turned on so candles and head-torches come in useful. Because of our electricity problems though we quite like being on the generator because it’s free. We also have a special box which we use to charge tablets and laptops so they don’t get fried by the power surge when the electricity comes back on!

As I mentioned before, most of our cooking is done on gas and a few weeks ago we ran out and had a tough couple of days before we got more. All these things make you realise how easy life is back home, although we’re very aware that our lives here are much easier than most people’s in Africa. Our house definitely has its quirks though. The other day after a power-cut, the power came on but not enough for any of the lights except the bathroom light. Now they’re all working again but the bathroom light has stopped working, so we have to shower by the light of a head-torch!

We’ve had various house-guests/pets whilst we’ve been here. We always have a few geckoes, 3 of whom we named Tom, Dick and Harry but we’ve forgotten which ones they were! For a while we had a praying mantus who lived on our door called Rupert but he’s long gone. One night when I was ill Emma woke me up asking for help because she’d seen the biggest spider. It was literally the size of our fists and was very hairy. We’d heard strange noises earlier in the evening and I’d searched my room before I went to bed thinking it was coming from there. I definitely think an added bonus of a mosquito net is to keep out other bigger wildlife too! Emma tried to pick the spider up using a cup but it reared up at her so she swept it out with the broom. We’ve also had to sweep out frogs, cockroaches, loads of beetles and worms and other creepy-crawlies we can’t identify! The most dangerous animal in Africa is definitely the mosquito and all our windows are covered in netting so most of the time they don’t get into the house. Lots of people keep chickens and goats in the compound and there are quite a few cats that wander around and fight at night. In the evening the crickets all come out and make a racket so all in all it can get quite noisy! The other day there was a swarm of grasshoppers that arrived in a rather biblical fashion overnight and the next day all the Ugandans were frying and eating them. Apparently they’re a delicacy and normally quite expensive but I chickened out of trying one.

We’ve been very lucky to have had such a nice place to live and I’ll definitely miss it. However I don’t think I could live in a compound like this for a long time and daily life is definitely easier (and quieter) in the UK.

How to save a life

The hospital here is a missionary hospital and money is in short supply. When we arrived they said they were so grateful to have us because they'd run out of money and they couldn't afford to pay a new doctor until the new financial year, which starts at the beginning of July. The hospital doesn't have a lot of the basic equipment that we take for granted in the UK. For example, we only have 2 oxygen machine on the paeds ward, whilst neonates has 3. I'm very excited because at my Mum's work they have been raising money for the hospital whilst I've been here, and that plus the money I have saved should be enough for a new oxygen machine. It's so nice to be able to tell the doctors and nurses that we'll be able to buy them something so essential and I wanted to write a bit to explain what benefit it will have.

Anyone who has done basic first aid will remember the acronym ABC for how to care for a patient in an emergency. The same applies in hospital. A stands for airway and you decide whether the patient can maintain their own airway or needs help. In the UK, this means an anaesthetist gets called and any patient who cannot keep their airway open is sedated and a tube is placed into their windpipe so that their breathing can be controlled by a machine in the Intensive Care Unit (called being intubated and ventilated). All patients who are unconscious or semi-conscious come into this category. Here, we regularly have children who this applies to, but there are no intensive care facilities and only one patient in the whole hospital can be intubated at a time, as there is only one ventilator, so it is usually reserved for the operating theatre. This means that we basically skip A and move onto B, which stands for breathing.

To assess breathing you need to count the respiratory rate, look at, feel and listen to the chest and measure the oxygen saturations. This is done by using a pulse oximeter, a hand-held machine that clips onto a finger or toe and tells you the saturation of oxygen in the patient's blood and their heartrate. It's actually amazing technology but it's also something we take for granted in the UK. Here, they have a monitor in neonates but not on the paeds ward, and it's almost unheard of for a child to have their saturations checked unless we explicitly ask a nurse to go to the neonatal ward and get the machine and check the sats whilst we are with the patient.

The main treatment for breathing problems is, of course, oxygen. As I have said, we have 2 oxygen machines on the main paeds ward. Ideally, any child with low saturations should be on oxygen, as should any child who is unconscious or very unwell. Unfortunately there are often way too many children who need oxygen and if the neonatal machines are all being used only 2 children can have it (they have them on the adult wards but there are never enough there for all their patients either). I've had to decide which of two unconscious children with severe malaria to leave without oxygen when another needs it more. Since I've been here we've had about 10 children die (excluding neonates). I'm not sure if any would have survived with oxygen but it's not inconceivable. Furthermore, the children take longer to recover without oxygen and we have had a number of older children become very confused and agitated for a long while after recovering from a severe illness, be it cerebral malaria, meningitis or encephalitis, and I imagine that these children might have done better with oxygen therapy. It's frustrating and upsetting as in the Uk we  have oxygen supplies by almost every bedspace and all patients have their saturation levels recorded regularly so they can be started on oxygen as soon as it's needed.

The machines they use here are concentrators, so are able to create air with added oxygen. This is really useful as it means they can be used time after time and not have to be re-filled like the canisters back home do. Therefore, one oxygen machine can be used for a long time. My aim is to collect enough money to buy an oxygen machine, one or two sats machines and some resuscitation bags and masks. These are used for patient's who aren't breathing and basically involve a mask that goes over the nose and mouth and a bag that attaches to the mask which you squeeze to force air into the lungs. There's an attachment for oxygen. As I mentioned in a previous blog, we had a horrible resuscitation attempt when nobody could find a mask that fitted and so I had to start giving mouth to mouth before we got one. Even then it barely fitted and 2 of us had to hold it still onto his face. Resuscitating a child is  awful enough without these problems. I tried to order some here but it's proved very complicated so I'm going to buy some and send them over.

I'm sorry this hasn't been the cheeriest blog but I wanted to write it to says thanks and explain where the money's going and I guess  to say to anyone else that if you have any spare money you want to give I'd be very grateful. I'm going to collect it and donate it to the UK charity Friends of Kagando because that way we can get gift aid. I'm liasing with the staff here to make sure the money goes to the right place. I promise it will help enormously, and I hope it might save some children's lives.

Rain, rain go away.

As they say, you can take the girl out of Britain, but you can't take Britain out of the girl, so I'm going to write about the weather! Most of the tropical countries I've been to have had similar weather most days but here it's almost as unpredictable as back home.

Traditionally, there are two wet seasons a year and 2 dry seasons. One wet season is from March until the end of May. True to form, it's rained a lot since we've been here and everything is pretty lush and green. Apparently though in recent years the seasons have been less clear-cut and this year has been particularly strange. December is always dry and sunny but this year it rained quite a lot we've been told. Meanwhile, during the last few weeks everyone was warning us that come June it would be sweltering and very dry. The first week of June it was hot but since then we've barely seen the sun. It's slightly worrying and you can't help wondering if global warming is to blame. I guess we'll see...

When it rains here you know about it! We also get loads of storms. They can be really impressive, with massive sheet-lightening over the mountains. The weather changes quickly too. Often we'll be sitting in our house and it will be sunny outside and then suddenly the wind picks up and within a few minutes the sky's dark and there's a tropical storm. I think the weather here is particularly dramatic because we're so near the Rwenzori mountains, which are very high and on the other side of them, in the DRC, is a massive rainforest. To be honest though, whilst we're working it's nice to have cool weather as it gets ridiculously hot down in the hospital when it's sunny. Fingers crossed for sun when we're on the beach though!

Food, glorious food

Having just finished the best meal we've had yet in Kagando, I figured it was about time I wrote about our food here. We had the option of eating in the guesthouse or having a cook but we decided not to, not least because the 2 main vegetarian meals they cook are beans and rice (and Emma hates beans) and omelette (and I hate omelette!). Most of our shopping is done in the local village which is about a 5 minute walk away. In the village there are loads of stalls, almost all selling the same things. We still have no idea how it works when 10 people in a row are all selling tomatoes but they seem happy enough and they man each others stalls when needed and give each other change. The main vegetables are tomatoes, avocadoes, aubergines and potatoes and often green peppers and cabbages. One day there were carrots which was very exciting but they haven't reappeared! At first, the only fruit available were pineapples, passionfruit, lemons and bananas of varying sizes but since we've been here the mango season has started to our great delight (although the first ones were tiny and were almost all stone!). Oh and watermelons are appearing too. The food is very cheap- about 5p for an avacado twice the size of one at home. I think the people in the village know us now but they still seem to find us hilarious! There's also an `African and English supermarket' or as we call in the `muzungo shop' as we are the only people who seems to use it! It's much more expensive and sells store cupboard ingredients like tomato puree, jam, pasta, rice and milk, juice and eggs. They used to have porridge oats (all out of date) but we bought them all and I don't think things get replaced very often...

We have now been to Kasese, the big town 45 minutes away, 3 times to do a big shop in the supermarket there (actually the size of a corner-shop). They sell the most exciting thing of all- cheese! It's a big round gouda cheese that costs about 6 pounds and would taste pretty bland in the UK but here is's made so much difference to our meals! They also have heinz ketchup and kidney beans, low-fat milk and other delights.

For breakfast we either have toast or porridge, depending on when we wake up and whether we can find oats. The bread here is white and very sweet. It's really not very nice! They produce lots of honey here so that's easy to get and we've found jam and peanut butter. Toast has got much better though since my lovely Mum sent us a parcel containing mini, hotel style, sachets of marmite, nutella, jam and honey. Equally excitingly, we also managed to buy some 'salty' (i.e. normal, not sweet) brown bread on the way home from Rwanda. We're having to ration our second loaf though! At weekends when we're here we sometimes cook pancakes. Lunch is usually bread-related and has got much better since we bought cheese. Our ktichen is amazingly well-equipped and even has a toastie-maker!

We're quite proud of our reportoire of evening meals using the basic ingredients. We started with pasta with tomato and aubergine sauce. Everything takes a long time to prepare as we peel all the vegetables, including the tomatoes before we cook. It is fun thought to know that every meal is made from scratch and the ingredients are definitely local and in season! Once we found curry powder we started making the same sauce but with rice and calling it curry. The cabbage inspired bubble and squeak which we usualy have with guacamole and fried eggs. We've also mastered chips and have eggs, chips and guacamole or, most excitingly of all, bean burgers and chips. We cook on 2 gas hobs. They are adjustable but only really from hot to very hot so when we cook rice we have to keep turning the gas on and off to keep it at a simmer! Just before we went away for a week our gas ran out. Luckily we'd just finished cooking but we had to wait a couple of days until someone was going to Kasese and was able to take our gas canister and fill it up at the petrol station. We managed to cook pasta salad by soaking the pasta in boiled water for a while and then adding cold vegetables, but we left it rather too long so it was a bit of a soppy mess, not our best meal!

About halfway through our time here we found an oven which is basically a small glass bowel with a lid that has a fan in it, so it becomes a fan oven. We've now made 3 cakes, pizzas, oven-chips and today we made bread rolls. We started making the dough using some brown bread flour but I realised that the wholegrain seeds I'd seen were moving and were actually weevils! So we tried again using normal white flour and they worked perfectly. We've just eaten an amazing meal of kidney bean burgers in rolls, oven-cooked chips, guacamole and left-over curry as a relish. Only the tomato ketchup wasn't homemade.

We're feeling pretty spoilt now thanks to the parcels from mum as we have a house full of real English chocolate, tea-bags, sweet, cereal bars etc. African chocolate is made to not melt in the hot weather, but it therefore doesn't melt in your mouth either!

For drinking we mostly boil water and then filter it through my scarf! We sometimes have passionfruit squash and for a treat we buy sodas from the hospital squash. They have coke, fanta, bitter lemon or stoneys (ginger beer). They come in glass bottles and you are exepcted to take the bottles back as the shops have to give them back or they get fined. They are the re-used which seems like a much more sensible idea that recycling the glass. Alcohol is banned at the compound, but we really haven't missed it and it makes being away more of a treat if we can have a cocktail or glass of wine. Another one of our luxury buys (at about 3 pounds for a big jar) is Cadbury's hot chocolate powder, simple pleasures!

I think our time here has made us both better cooks and it's been fun but I think we are both still dreaming of supermarkets full or every food you can imagine, and bakeries full of salty bread!