It takes about 45 minutes to drive the short distance from the airstrip at Arua city in the northwest of Uganda to the compound of the Anglican Diocese in Aru town in the northeast of DRC. Before colonisers saw fit to draw a straight line on a map and create two new nation states, both places belonged to people from the same tribe, which explains why the names are so similar. Ugandans and Congolese on either side of the border still speak the same tribal language but they live in different worlds. The frontier may only be marked by queues of petrol lorries, a piece of string, a large tree and immigration office buildings (locals are allowed to bypass the heavy bureaucracy that is applied rigorously to foreign visitors and can move from one country to the other quite freely) but Ugandan infrastructure does not extend across it: the tarmac ends abruptly, along with Arua’s electricity and water services, its streets of shops, artisans, offices and solid houses, it’s busy markets and it’s large, reasonably well-equipped hospital.
Meanwhile Aru, a few miles away, feels more like a sprawling village. It still has one or two old colonial bungalows from the time when it enjoyed the status accorded to an important border town. They still have splendid verandahs, but their pillars are crumbling and their low-pitched tine roofs are rusty. A few fancy modern villas have sprung up on the town’s outskirts, but many residents live in traditional mud and thatch dwellings. A straggle of kiosks and shops line the main street; the tiny wooden kiosks have wonderful names like ‘Dieu mon Sauveur SIM’, ‘Merci a Jesu Snacks’. In the town centre there is almost nothing to buy beyond a few clothes, beer, fizzy drinks and some basic groceries. Nothing much seems to being made either, although I did spot quite a large carpentry business churning out purple coffins (which I hoped wouldn’t come in handy during our stay). Amongst the little kiosks are several that buy and sell tiny quantities of gold. To the north of Aru is a gold mine that is exploited by both artisanal and large-scale, international mining operations. Sadly, apart from one well-graded dirt road, a telephone mast and one or two modern hotels (we stayed in one of these, along with a number of Chinese men) the mine does not appear to have brought much benefit to the local community. Having said that, it did fund Aru Centre Hopitalier’s new mortuary building, which may not sound like much but is actually a very important facility in a warm climate for a population that has a high birth rate and short life expectancy.
Soon after 8.00am every morning Dr David, the Medical Director of the small hospital in Aru, picked us up from our hotel to take us to the training venue, which was in the compound of the Anglican Cathedral. Our task here was to help to improve the capacity of local doctors and nurses to prevent, diagnose and treat non-communicable diseases (NCDs) like diabetes, hypertension and cardiovascular disease. For many years, international funds have been available to low-income countries to pay for mother and child health and the tests and medicines needed to diagnose and treat HIV, TB and malaria. While these all remain very important health problems, more people are now surviving for longer and are suffering from the morbidity and premature death caused by complications arising from NCDs. Right across DRC, NCDs are being diagnosed much too late, often not until patients arrive needing an amputation or having suffered a stroke or heart attack or in renal failure. The World Health Organisation estimates that NCDs are responsible for 27% of deaths in DRC, yet these conditions receive little attention, no international funding and are often badly managed. None of the 25 health professionals we training had had any teaching on NCDs since they were at medical school or nursing college; so it’s not surprising that their knowledge and skills are much lower when it comes to managing patients with these problems than it is for infectious diseases, childhood illnesses and maternity care.
There could be no better illustration of why we have been invited here than Dr David’s daily experience as a hospital physician. By the time he collected us, he had already been to the hospital to review some patients on the ward and see a few outpatients, so on the short journey we would chat through some of his clinical conundrums. Throughout the week his great preoccupation was a man in his early 40s who arrived at the hospital with severe, untreated hypertension and anaemia. The hospital laboratory has the necessary equipment to assess renal function by measuring serum creatinine and detecting proteinuria, so he was able to confirm that the patient was in end-stage renal failure. He managed to lower the man’s blood pressure a bit, and to arrange a blood transfusion, but beyond that there was nothing he could do. This patient happened to be a wealthy local politician, so on Friday his family moved him to Kampala for dialysis, after which they intended to see If they could transfer him to Nairobi. Dr David was only too aware that such access to health care would be way beyond the wildest dreams of almost every other family in this part of DRC. But a diagnosis of renal failure secondary to undiagnosed, untreated hypertension or diabetes was all too common. He sees patients like this every week – it’s one of the commonest reasons for an urgent admission to Aru hospital – and without access to dialysis, it’s a death sentence. Early diagnosis (before symptoms appear) and good control of blood pressure and blood glucose, along with simple, systematic checks for signs of damage to kidneys and feet, could prevent much of the suffering Dr David has to deal with.
Dr David and his colleagues could do worse than to start by screening the staff, students and congregation of the Anglican Diocese in Aru. Unlike in the UK, where obesity is strongly linked to poverty and deprivation, in DRC it is more often a sign of wealth and prosperity – and there is very little awareness or understanding of the health problems it can pose. On the Saturday after our training finished, we were invited to attend the joint Graduation ceremonies for the students of both the state University and the Diocese’s Technical Institute that trains nurses, midwives and a range of paramedical personnel. This was a very formal occasion of hats and gowns, long speeches, certificates and processions, intermittently derailed by episodes of thunder, lightning and heavy rain, that frequently risked descending into anarchy through the unrestrained joy of the successful students’ proud families. It was also very long. To divert myself, I spent much of the time counting risk factors for cardiovascular disease amongst the assembled dignitaries and audience and was shocked to see how many people present had all the features characteristic of walking time bombs for heart attacks and strokes. There were even a number of obese children present, which was not something I had seen before in this population where nearly half the people are aged under eighteen.
But it’s not just in urban areas that risk factors lurk undetected. On the day after our arrival, we visited a village health centre about 30km away from Aru, a journey that took nearly two hours. This was neither one of the most remote nor poorest communities served by the medical services run by the Anglican Diocese, but it still served to give us an essential insight into some of the challenges faced by health workers in rural settings. We left Aru on the broad, well-graded dirt road that leads to the gold mine. After a few miles we turned off this onto a road in a much worse state of repair, lurching and bouncing over ruts and holes until we reached another turn, this time onto a track that was almost hidden by overgrown bushes and was no wider than a hiking trail. It’s the start of the rainy season, when the landscape is lush and green, the time for planting: rice, cassava, ground nuts, plantains, sweet potatoes, avocados, bananas. The rains are abundant and the soil rich, so the country is unbelievably fertile – you could put a stick in the ground and it would sprout – but agriculture remains at subsistence level for lack of storage and processing facilities and an organised system for exports. From time to time, we would pass
sacks left by the side of the road, bulging with avocados and other produce, waiting to be collected and taken to market by trucks that may never come – much is simply left to rot for lack of transportation. Moving around is not easy. Inevitably, at the foot of an incline just beyond a stream, our vehicle became stuck and had to be pushed out, wheels spinning in liquid orange mud, exhaust belching black, sooty fumes. Sitting in the middle of the back seat, clinging to the seats in front of me to stay more or less upright, I tried to imagine what it must be like for a woman in labour, or a man with an acute abdomen, to make this journey in order to reach the expertise and equipment available in Aru. I also tried to imagine what it would feel like to be the nurse at the health centre (for there are no resident doctors) to have to make the decision to transfer a sick person to the town, knowing how long it might take and how uncomfortable the journey would be.
The Eastern part of DRC rarely features in our news and only when conflict or war erupt, atrocities are perpetrated or armies or militias threaten major cities like Goma and Bukavu and the safety of aid agencies and interests of mining companies, there to exploit the region’s rich mineral deposits. At present, a militia known as the M23, supported by Rwanda, is still occupying strategic cities and areas of the country south of Aru, near places where many of the doctors and nurses who came to our training live and work. It was too dangerous for them to travel by road because of the multiple check points en route, manned by trigger-happy militia soldiers. Some were able to take an internal flight, whereas others had to travel by bus into south Uganda, and take another ten-hour bus ride north to Arua, where they could cross the border safely back into DRC. No one pretends it is an easy place in which to live, but everyone was at pains to stress that for the majority of the population, most of the time life goes on from day to day as normal – and, aware of their country’s dark reputation, they insisted that we must communicate this normality and stability to the outside world on our return. In Aru, petty crime is a risk, as it is anywhere in which life for most people is hand to mouth, but there is no sense of a deeper threat; on the contrary, it is a place of ambition and energy, where people expect life to improve steadily for the next generation.
For us, it is also a place of unrivalled welcome and warmth, where we were embraced into community and cared for in every possible way (not least through the daily provision of the most magnificent avocados you could possibly imagine); where music and dance are as natural as breathing; where people bear witness to how God has sustained them through life’s greatest challenges; where He is worshipped and served not just through song and harmony, but through the wisdom and courage of people whose faith has been tested and has held firm.