The Patient. Olive Kobusingye

was on the plane to the US to work with Belcher on a proposal that would hopefully get funded through his Senate connections. Their hard work paid off. A War Victims Fund had just been established, and the Belcher-Mutyaba proposal talked of helping to treat the huge backlog of both veterans and civilians that had been injured during the five-year civil war in Uganda. With time, the money came, and the Department of Orthopedics was born.

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      Kweete had been on the antenatal ward for a week already. She had been admitted for observation, and to ensure that she would get specialist attention when she went into labour. So far, her pregnancy had not worsened her heart condition as had been feared. She did not know what to expect, this being her first pregnancy.

      By 1986 Flavia Katende had been a tutor and midwife in Mulago for more than a decade. In that time, she had taught several generations of nurses and medical students to deliver babies safely. Yet every year there was some additional form of improvisation. She remembered that during her own training it would have been unacceptable for there to be only one health worker at a delivery. The doctor or midwife usually had a receiving nurse, so that once the baby was out, the receiving nurse took care of the baby while the midwife ensured that the placenta, or afterbirth, was delivered safely. They gave the mother ergometrine injection to reduce the bleeding, and gently rubbed the abdomen to encourage the uterus to contract, further reducing the bleeding from the placenta bed. The midwife or attending doctor did not leave the mother’s side until the bleeding had stopped, and the mother was clean and comfortable. Katende was aware that on some nights only one midwife was on duty in the maternity unit, assisted by inexperienced student nurses that were still terrified of the thought of cutting through skin and flesh. Delivery sets, the collection of instruments and supplies that one had to have in order to perform a safe delivery, had dwindled to a pair of rewashed gloves, old needle forceps, a blunt reusable needle, and loose cotton swabs. She had finally stopped giving her teaching on how to prepare for a normal delivery, because she could not bring herself to go through what were clearly fictitious lists. Students would never have seen the entire set anyway.

      The evening of 25 January 1986 the maternity unit was unusually quiet. Lately the insecurity around Mulago had reached such levels that patients who did not come in before dark could not come in until the following morning. For some that would be too late. Katende would have gone home already but she was concerned about the teenager on the corner bed who was unlikely to have a normal delivery. She was the textbook high risk prime gravida, or first time pregnant: short frame, narrow pelvis, and baby’s head high above the pelvis despite the increasing contractions. Katende usually told young doctors to be aware of this ‘failure to progress’ in labor, and to plan intervention sooner rather than later, as a normal delivery was unlikely and unsafe. The doctors always took the decisions, but the more experienced midwives could tell which patients were not going to make it on their own. Katende knew the teenager was headed for a C-section, but there was no anesthetist in the theatre. There were no doctors either.

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      The war had been advancing from Luweero towards Kampala for a long time, and in many people’s minds this was how things were always going to be, but the last one month had been different. It was becoming clear that the guerrillas – ‘abayeekera’ – were going to enter the city, and that the government forces were not able to stop them. The day before the gunfire had been so close that the midwives joked that they did not need to deliver the babies – they were popping out at the sound of the shootings. But today was strangely quiet. The Senior House Officer and the interns should have been here. If they were not in the hospital by now, they were not coming. What was she to do with the young mother? Then there was the patient with heart disease as well. These two were going to need doctors.

      ***

      Kweete went into labour in the night. The labour progressed without incident and at dawn she gave birth to a baby boy, assisted by two student midwives. Shortly after birth the baby started turning blue, a sign that he was not getting enough oxygen into his blood. The nurses took the baby to the nursery where newborn babies received more intensive care. A few hours later the tragic news came – despite the doctors’ best efforts, the baby had died. The doctors said there were serious defects in his heart and major blood vessels which were incompatible with life. Kweete was plunged into the depths of grief. She declined to have a post mortem done, and chose to bury her baby ‘without him being turned into a specimen’. As the country started to cautiously celebrate the victory of the NRA and the end of the bush war, Kweete mourned the death of the baby that had barely lived.

      ***

      Professor Francis Omaswa was coming back to Mulago after a hiatus of more than 10 years. For three years, he had headed the Cardiothoracic Department at Kenyatta Hospital in Nairobi. He had just spent five years at Ngora Hospital in eastern Uganda, and he could hardly wait to get back into heart surgery at a big hospital. But Mulago had scars and wounds from years of abuse and neglect, and he was about to find out the hard way that fixing a hospital could be harder than fixing hearts. It felt great walking along familiar corridors, running specialist clinics, and deciding what patients to schedule for surgery. His first heart operation was a straight forward one, the surgery went well, and the patient was taken to the Intensive Care Unit on 3D as planned. At the end of the day, Omaswa went by to see how he was doing, and was pleased to find him stable. The hospital was quickly emptying out, and the evening shift was giving way to the night staff. The big hospital routines were all very familiar.

      The following morning Omaswa went to the ICU to check on the patient before heading to the ward for a teaching round. An unpleasant surprise awaited him. His stable patient of the previous evening had passed away in the night. The night team was gone, and there were scanty notes to explain how a patient that had done well at table and for the following several hours suddenly made a turn for the worst. That was not a good start, but Omaswa was not so easily discouraged. A week later he had another patient scheduled, and it was another fairly routine heart procedure. This time he gave more elaborate instructions, and went over them with the nurses in ICU to be sure that nothing would be missed. Before he left the hospital in the evening he want by the ICU, and was happy with the patient’s condition. He lived just above Galloway House within Mulago, and he told the nurses to call him if there were any serious concerns. Decades later, Omaswa still recalled how things evolved.

      “I was relieved that there were no calls in the night, as that meant that the patient had had a comfortable night. In the morning, I walked to 3D ICU to see the patient. As soon as I walked into the ward, I sensed that there was a problem. The procedure room was open and I could see there was a body behind a screen. As I turned to head towards the room where I had left the patient, the matron came out of the office. She did not waste any time. ‘Professor, I am sorry but your patient died.’ I stood still and felt a tightening in my chest. ‘How? When?’ I asked the questions, but somehow did not hear the answers. I knew it had to be the nursing care. There was nothing worrisome or highly complex about the procedures, I had done these same operations countless times before, and never had deaths. I turned and walked out of ICU without looking at the file. I walked down to the second floor, out into the parking, and I got into the car. A plan was quickly forming in my head, and the painful lumps in my chest and throat were not shifting. I knew I had to find a solution. A short while later I drove out of Mulago and headed straight to Nsambya Hospital. I walked into Dr. Duggan’s office and told her secretary that I had to talk to her, and that it was urgent. I got straight to the point. ‘I am looking for a hospital where to do heart surgery. I would do a weekly list.’ She must have heard the pain in my voice. Or maybe there were tears in my eyes. She was quiet for a while, then she simply said yes. I thanked her, and said I would be back to work out the details.

      From Nsambya I drove to Nakasero, to Dr. Ruhakana Rugunda’s office. He was Minister of Health at the time. I still had the sense of urgency, and I told him I needed premises for a unit where we could treat patients with heart problems. I had walked around Mulago looking for space before, but that day I had an urgency like fire under my feet. I had to find a way to treat patients safely. That second death had rattled me pretty badly. I was angry and depressed all at once. Rugunda listened to me, and asked if I had suggestions. ‘Yes. There are some old buildings in Old Mulago that accommodated internally displaced people from Luwero during