Today is the last day of our two-week rotation on the Pulmonology Ward, which marks our first glimpse as Yale-trained medical students into the world of health care provision in a tropical setting. The senior residents with whom we’ve worked – Charles and Michael – have been superb at making us feel a part of the team; several times our input (and that of our Oxford Handbook of Tropical Medicine) has influenced decision-making for a patient’s care. Yet, as part of the team, I’ve also empathized with the other side of care provision in Uganda: the stark limitations of poverty. The knowledge and skill of a physician trained at the best medical school in the world is rendered impotent in the face of a lack of medical resources and a patient’s inability to pay for treatment.
There are times when it doesn’t seem too bad. We take a comprehensive history, do a thorough physical exam listening carefully to their chest, and order the labs that are free for patients at Mulago: a sputum smear with Gram stain to check for tuberculosis or pneumonia, a complete blood count, and liver function tests. I eagerly scrutinize results when the patient can afford to pay for a chest x-ray, an ultrasound or a biopsy sent to an outside pathology laboratory to help us make our diagnosis. I let out an internal sigh of relief when there is money and an attendant available to buy the cheap generic drugs we prescribe. Or when all they need are the drugs Mulago can provide for free like ceftriaxone for a community-acquired pneumonia or the four-drug regimen for tuberculosis. We are able to do what we have been trained to do: diagnose and treat illness. The patients begin to feel better and we get to send them home.
Yet there are heart-wrenching days when those stark limitations rear their ugly head, leaving us - and the patients - powerless. This week was particularly tough. Physicians at Mulago have designation to crudely assess the financial means of a patient called ‘the blanket sign.’ Bedding is not provided for patients in the hospital, so if a patient has sheets and a blanket, they have a ‘positive blanket sign,’ meaning they had money to be able to buy the blanket and likely have money to be able to pay for tests and treatment.
Yesterday we rounded on a 25 year-old HIV-negative man who was lying on a bare mattress and had no attendant. He had been admitted to pulmonology because he had a cough, but we quickly found that his blood pressure was 250/140, which is a malignant level (normal is less than 130/80) and he was in acute renal failure. However, he could only afford a less-than-optimal medication for lowering his blood pressure and could not afford a much-needed ultrasound of his kidneys to investigate a cause. He took the medication, but his blood pressure was unchanged. We managed to check a set of electrolytes and found his potassium levels to be dangerously high, which can lead to cardiac arrest. This patient also needed to be placed on supplemental oxygen, but since there were only two oxygen tanks on the pulmonology floor, and there were already two patients on oxygen, we had to take the pulse oximeter and measure all three patients to determine who had the two lowest oxygen saturations - the one with the highest just had to cope without it. We gave the patient some medications to lower his blood pressure and his potassium, and stabilize his heart, but what this man really needed was urgent dialysis and admission to the intensive care unit (ICU). There is one dialysis unit in Mulago, but we were informed that it costs $250/session (and patients usually have three session per week). Our senior resident managed to track down a nephrology consultant, who detailed to us the things that needed to be done. He asked if the patient could pay for dialysis and the resident responded simply, '"Blanket sign is poor." There was little else we could do for the patient. This morning when we arrived the nurse informed us that he had passed away at 10pm last night.
Two days ago we moved to the bed of an HIV+ woman in her 20s who was completely buried under blankets, motionless. Her chart read that she had had negative blood cultures and had received various courses of antibiotics, evidently to no avail. Pulling back the covers, I could see she was emaciated and unresponsive. Her lungs sounded rhoncorous with infection as she labored to breathe, using accessory muscles to take rapid gulps of air. Just as concerning were her hands that were like blocks of ice in the humid tropical air. The resident asked me to take her blood pressure. Though her heart was beating very rapidly, I couldn’t find a peripheral pulse at all – her blood pressure didn’t register on the sphygmomanometer. This woman was in septic shock, her system crashing due to widespread infection. We gave her oxygen and the resident desperately tried to find a peripheral vein that wasn’t collapsed through which to insert an IV and given the fluids her system needed. After half a liter (and 10 precious minutes) it became obvious the fluid was actually infiltrating into the tissue of her arm, causing it to swell, and not into the vein. We found another vein in the opposite arm and put in another liter and a half, but there was little response. And that was it: watch and wait. According to the resident, that was all we could do, and that was how we left her. In the U.S. this woman would be intubated, have labs drawn, receive massive amounts of intravenous fluids, antibiotics, and maybe pressors and steriods to support her blood pressure, among other things. Then she would be admitted to the intensive care unit with one-on-one nursing care and a physician on-call.
In the morning, the patient and her bed were not on the floor when I arrived. She had died during the night.
It is one thing, as a physician, to watch a patient die, knowing you have done everything you can possibly do for them. It’s quite another to watch a young patient die knowing that in another part of the world there is much more you could do and with those resources you might save their life. I was prepared by many people before I came to Uganda that I would see patients die at Mulago: because they are in advanced stages of disease, because they waited too long to seek care, because they have HIV… And, while tragic, it is not so much the death itself that bothers me, but the fact that people die because they are poor and live in an impoverished country. How do we, as a global community, accept the injustice that the world’s wealthy get to live and the poor have to die?
Friday, January 30, 2009
Thursday, January 22, 2009
Mulago Hospital
Hard to believe it's almost the end of my first week here - everything is flying by so quickly. This week Esi, Sara and I are rotating on the pulmonology ward, which mostly consists of patients who have, or are being ruled out for tuberculosis (TB). But let me step back for a bit and describe some more about Mulago Hospital.
Mulago, as it stands now, has been open for 25-30 years, though there has been some sort of hospital or clinic here since colonial times. I was told that it has 2,500 beds, but on any given day there can be 5,000-10,000 patients. It is a government hospital that is the only 'tertiary care' center in the country, which means it technically receives referrals from other regional hospitals within the country for specialist care. However, many patients refer themselves, even from very long distances. There is very little primary or preventive care in the country - it's more crisis management and patients waiting until they are very ill in end-stages of disease before they come to a clinic or hospital. Consequently, the mortality rate at Mulago is very high (20-30%). The hospital itself is a large building and the grounds contain a host of other outpatient clinics, the nicest of which is the Infectious Disease Institute that has about 10,000 patients on highly-active antiretroviral therapy (HAART) for HIV. It was funded by Pfizer and hosts many doctors from all over the world who care for patients and conduct HIV-related research.
As a government hospital, Mulago is subject to receiving funding and resources from the government. Thus, there are almost constantly shortages in medical equipment and medications. Patients are expected to pay for most of the services, studies and medications themselves, as well as get themselves to the lab, radiology, etc. There is a phenomenal shortage of nurses and medical support staff here, so family members or friends - called 'attendants' by the medical staff - basically fulfill the roles of nurses, nurse's aides, and orderlies. If there is no attendant for a patient then often things the patient needs to have done (like a chest x-ray) will not be done, or it will be drastically delayed while the physicians attempt to find someone who can take the patient. Likewise, if the patient cannot afford to pay for a medication that needs to be prescribed, then it will not be taken unless there has been some sort of donation given by foreign aid or a private organization. However, one of the residents did say that there was a small fund to help patients who cannot pay (no idea where that money comes from). While donations from outside organizations are helpful, they can also be problematic. Recently the hospital received a large donation of the antibiotic ceftriaxone. Because there are shortages of many other antibiotics in the hospital pharmacy, they've basically been prescribing ceftriaxone for everything under the sun, whether or not it's what would be the optimal clinical management. Just to avoid confusion, you can buy almost any drug you want at any pharmacy in Uganda. There's no shortage - everything is available here, but you just have to be able to pay for it to do any good.
Medical equipment - even simple things like a blood pressure cuff or a pulse oximeter to measure the oxygen level in someone's blood - is often unavailable. There is one family physician here from Iowa who had donated some blood pressure cuffs and a few other things to the Casualty (Emergency) Department when he was here a year ago, but upon his return he found they'd all disappeared. There is little security at the hospital, so donated equipment is often stolen because it can make a lot of money. One resident told me that there is actually a good deal of medical equipment in the hospital, but it is locked up in storage and not used for fear that it will be stolen.
All of that said, let me clarify that just because there are lack of funds to buy medicines, a shortage of medical professionals and resources, and inappropriate use of some drugs, that does not mean that the clinical judgment of physicians here is poor. On the contrary, every doctor I've met is incredibly intelligent, well-trained and impeccably skilled at providing medical care in a less than optimal setting. They are much better at physical diagnosis skills than doctors in the U.S. (if I may make a gross overgeneralization) because they have to operate in an evironment in which they cannot rely on hundreds of laboratory and radiologic tests. Moreover, they are much more broadly trained and confident at doing many more procedures, surgeries, and deliveries (of babies) than U.S. doctors.
Brief overview of the medical training system in Uganda: After highschool students enter medical school which is 5 years long. For the first 3 years they study basic sciences, then the last two they have rotations in the hospital. After that, they do an internship, where they live in the hospital and are on-call 24 hours a day, 7 days a week, 365 days a year for an entire year. Internship in the U.S. pales in comparison. To go to residency in Uganda, you have to pay for each year of it (unlike in the U.S. where we are paid). Thus, after their intern year (for which they are paid a small stipend), many doctors work for several years to save money in order to be able to go to residency. One resident I spoke to today had worked in northern Uganda for four years, doing things like amputations, treating broken limbs and gunshot wounds in the region of civil conflict, before he was able to save enough money for residency. Even during residency many physicians work two months out of the year to be able to support themselves for the rest of their training. And once a physician finishes residency, if they work at Mulago hospital they only earn about $600/month.
I have little to whine about practicing medicine in the U.S.
I have to run to my first Luganda language lesson, but will write more soon about my experiences on the pulmonology ward.
Mulago, as it stands now, has been open for 25-30 years, though there has been some sort of hospital or clinic here since colonial times. I was told that it has 2,500 beds, but on any given day there can be 5,000-10,000 patients. It is a government hospital that is the only 'tertiary care' center in the country, which means it technically receives referrals from other regional hospitals within the country for specialist care. However, many patients refer themselves, even from very long distances. There is very little primary or preventive care in the country - it's more crisis management and patients waiting until they are very ill in end-stages of disease before they come to a clinic or hospital. Consequently, the mortality rate at Mulago is very high (20-30%). The hospital itself is a large building and the grounds contain a host of other outpatient clinics, the nicest of which is the Infectious Disease Institute that has about 10,000 patients on highly-active antiretroviral therapy (HAART) for HIV. It was funded by Pfizer and hosts many doctors from all over the world who care for patients and conduct HIV-related research.
As a government hospital, Mulago is subject to receiving funding and resources from the government. Thus, there are almost constantly shortages in medical equipment and medications. Patients are expected to pay for most of the services, studies and medications themselves, as well as get themselves to the lab, radiology, etc. There is a phenomenal shortage of nurses and medical support staff here, so family members or friends - called 'attendants' by the medical staff - basically fulfill the roles of nurses, nurse's aides, and orderlies. If there is no attendant for a patient then often things the patient needs to have done (like a chest x-ray) will not be done, or it will be drastically delayed while the physicians attempt to find someone who can take the patient. Likewise, if the patient cannot afford to pay for a medication that needs to be prescribed, then it will not be taken unless there has been some sort of donation given by foreign aid or a private organization. However, one of the residents did say that there was a small fund to help patients who cannot pay (no idea where that money comes from). While donations from outside organizations are helpful, they can also be problematic. Recently the hospital received a large donation of the antibiotic ceftriaxone. Because there are shortages of many other antibiotics in the hospital pharmacy, they've basically been prescribing ceftriaxone for everything under the sun, whether or not it's what would be the optimal clinical management. Just to avoid confusion, you can buy almost any drug you want at any pharmacy in Uganda. There's no shortage - everything is available here, but you just have to be able to pay for it to do any good.
Medical equipment - even simple things like a blood pressure cuff or a pulse oximeter to measure the oxygen level in someone's blood - is often unavailable. There is one family physician here from Iowa who had donated some blood pressure cuffs and a few other things to the Casualty (Emergency) Department when he was here a year ago, but upon his return he found they'd all disappeared. There is little security at the hospital, so donated equipment is often stolen because it can make a lot of money. One resident told me that there is actually a good deal of medical equipment in the hospital, but it is locked up in storage and not used for fear that it will be stolen.
All of that said, let me clarify that just because there are lack of funds to buy medicines, a shortage of medical professionals and resources, and inappropriate use of some drugs, that does not mean that the clinical judgment of physicians here is poor. On the contrary, every doctor I've met is incredibly intelligent, well-trained and impeccably skilled at providing medical care in a less than optimal setting. They are much better at physical diagnosis skills than doctors in the U.S. (if I may make a gross overgeneralization) because they have to operate in an evironment in which they cannot rely on hundreds of laboratory and radiologic tests. Moreover, they are much more broadly trained and confident at doing many more procedures, surgeries, and deliveries (of babies) than U.S. doctors.
Brief overview of the medical training system in Uganda: After highschool students enter medical school which is 5 years long. For the first 3 years they study basic sciences, then the last two they have rotations in the hospital. After that, they do an internship, where they live in the hospital and are on-call 24 hours a day, 7 days a week, 365 days a year for an entire year. Internship in the U.S. pales in comparison. To go to residency in Uganda, you have to pay for each year of it (unlike in the U.S. where we are paid). Thus, after their intern year (for which they are paid a small stipend), many doctors work for several years to save money in order to be able to go to residency. One resident I spoke to today had worked in northern Uganda for four years, doing things like amputations, treating broken limbs and gunshot wounds in the region of civil conflict, before he was able to save enough money for residency. Even during residency many physicians work two months out of the year to be able to support themselves for the rest of their training. And once a physician finishes residency, if they work at Mulago hospital they only earn about $600/month.
I have little to whine about practicing medicine in the U.S.
I have to run to my first Luganda language lesson, but will write more soon about my experiences on the pulmonology ward.
Wednesday, January 21, 2009
Arrival in Uganda
Arrival: Sara, my classmate, and I arrived in Kampala on Sunday night half an hour early. Everything about our trip shattered my preconceived notions (or maybe just my experience) with travel to Africa. Our flights were on time, our baggage wasn't lost or damaged, a driver was there to pick us up, and customs consisted of us smiling and waving at the customs officers as we cruised through the exit door. The weather is humid, but pleasant, in the 60s-70s - my heavy fleece was quickly stowed in my backpack. After meeting the driver it became clear that they were also taking another group from Canada to Makerere University, where we are staying, so Sara and I were crammed into the front of one van with the driver, with all the luggage piled floor to ceiling in the back. The drive from the airport was about 40 minutes, but there was zero traffic at 9:30pm on a Sunday night. From what I've been told, and observed, since then, traffic in Kampala is awful. Our other classmate, Esi, arrived on Monday from where she had been working in Ghana (where she's from). So the three of us are staying together until some other residents from Yale arrive in February.
The Flat: The flat we're staying in is luxurious by Ugandan standards. There's a fully equipped kitchen, a living room with a TV and couches, a big dining room table, 3 bedrooms that sleep five people, one half-bath, and a full bathroom with a hot water heater! Last night we actually were able to watch the Obama inauguration, along with the rest of the Ugandan populace. His face was all over Ugandan newspapers and it was literally on every television channel. Even the lady who cleans the flat, Agnes, who speaks very little English, is enamoured with him. I think many people in Africa thought that the US would never elect a black president, much less one with East African ancestry. So it gives them hope, too.
Despite the luxury, however, lest you think we're being totally spoiled, the signs we're living in Africa are still here. The first night while we were boiling water and putting up our mosquito nets, I was inspecting a large water jug with 3 inches of water in the bottom to see if it was drinkable. I decided to try it and see, noticing that there was a slight tear in the lid that created a crack. Through the opening I noticed something at the bottom...peering closer I realized the entire bottom of the the jug was covered with hundreds of little tiny white eggs. Needless to say, I didn't drink it. In addition, we have many many ants who co-habitate in our kitchen. Over the past two days the electricity has gone out three times - once during the middle of preparing dinner.
The Food: Thus far, the Ugandan fare I've tried includes bean stew, baked and fried fish from Lake Victoria, peas, and matooke, which is basically liked mashed potatoes, only made from plantains. It's all pretty bland, not spicy like West African food, but filling. A plate of the above costs about $1.50 for lunch at the hospital canteen. We found a great hidden market in our neighborhood on the way home that are like the real African markets I know, not poorly stocked supermarkets with the same 20 products, but crowded stalls where women sit peeling their wares next to heaping piles of plantains, pineapple, papaya, passion fruit, mangoes, avocadoes, onions, tomatoes, yams – I now know where we should be buying food. This is Africa’s bounty. Esi is wicked good at bargaining, tilting her head disapprovingly at the price stated by the vendor, clicking her tongue and saying, 'Come on, my brother! Are you serious?' We found out the day after we went that we, in fact, paid fair prices for our goods, not the mzungu (white person) prices.
The People: The administrators and physicians overseeing our rotation have been more organized and on top of things than the people at Yale are. We had our first day in the hospital today on the pulmonology ward, seeing mostly tuberculosis patients, but my internet cafe time is running out, so I'll write more tomorrow about it. Overall, the rotation is going to be great. I'm signed up to rotate in pulmonology, infectious disease, STD/dermatology outpatient clinic, pediatrics and hematology during my time at Mulago Hospital.
Esi, Sara and I set up schedule for studying tropical medicine, with different topics we want to learn about each week that we'll read about together – type A Yale medical students at their best (okay, fine, nerds). We'll be learning because we can, because we want to – because these diseases are not just words in a textbook, but they have faces now. We will see them every day when we enter the hospital.
More to come...
The Flat: The flat we're staying in is luxurious by Ugandan standards. There's a fully equipped kitchen, a living room with a TV and couches, a big dining room table, 3 bedrooms that sleep five people, one half-bath, and a full bathroom with a hot water heater! Last night we actually were able to watch the Obama inauguration, along with the rest of the Ugandan populace. His face was all over Ugandan newspapers and it was literally on every television channel. Even the lady who cleans the flat, Agnes, who speaks very little English, is enamoured with him. I think many people in Africa thought that the US would never elect a black president, much less one with East African ancestry. So it gives them hope, too.
Despite the luxury, however, lest you think we're being totally spoiled, the signs we're living in Africa are still here. The first night while we were boiling water and putting up our mosquito nets, I was inspecting a large water jug with 3 inches of water in the bottom to see if it was drinkable. I decided to try it and see, noticing that there was a slight tear in the lid that created a crack. Through the opening I noticed something at the bottom...peering closer I realized the entire bottom of the the jug was covered with hundreds of little tiny white eggs. Needless to say, I didn't drink it. In addition, we have many many ants who co-habitate in our kitchen. Over the past two days the electricity has gone out three times - once during the middle of preparing dinner.
The Food: Thus far, the Ugandan fare I've tried includes bean stew, baked and fried fish from Lake Victoria, peas, and matooke, which is basically liked mashed potatoes, only made from plantains. It's all pretty bland, not spicy like West African food, but filling. A plate of the above costs about $1.50 for lunch at the hospital canteen. We found a great hidden market in our neighborhood on the way home that are like the real African markets I know, not poorly stocked supermarkets with the same 20 products, but crowded stalls where women sit peeling their wares next to heaping piles of plantains, pineapple, papaya, passion fruit, mangoes, avocadoes, onions, tomatoes, yams – I now know where we should be buying food. This is Africa’s bounty. Esi is wicked good at bargaining, tilting her head disapprovingly at the price stated by the vendor, clicking her tongue and saying, 'Come on, my brother! Are you serious?' We found out the day after we went that we, in fact, paid fair prices for our goods, not the mzungu (white person) prices.
The People: The administrators and physicians overseeing our rotation have been more organized and on top of things than the people at Yale are. We had our first day in the hospital today on the pulmonology ward, seeing mostly tuberculosis patients, but my internet cafe time is running out, so I'll write more tomorrow about it. Overall, the rotation is going to be great. I'm signed up to rotate in pulmonology, infectious disease, STD/dermatology outpatient clinic, pediatrics and hematology during my time at Mulago Hospital.
Esi, Sara and I set up schedule for studying tropical medicine, with different topics we want to learn about each week that we'll read about together – type A Yale medical students at their best (okay, fine, nerds). We'll be learning because we can, because we want to – because these diseases are not just words in a textbook, but they have faces now. We will see them every day when we enter the hospital.
More to come...
Wednesday, January 14, 2009
Before I go...
Okay, trying my hand at my first real post before I depart this Saturday. For those of you following my blog I thought it might be nice to give you a little background on Uganda. (If you have not been introduced to it, the BBC news online has great Africa coverage and is one of my preferred international news sources). In 2008, Uganda had a population of 31.9 million. The capital is Kampala and the official languages are English and Swahili, though not many people actually speak Swahili. There are over 30 indigenous languages in Uganda and Luganda is a more widely spoken local dialect (one that I'm going to try to learn some of). The major religions are Christianity and Islam. Life expectancies, according to the UN, are 51 for men and 52 for women. Uganda has been hit really hard by the HIV/AIDS epidemic - more about that and the health care system later. The GNI per capita in 2007 was $340 - that's less than a dollar a day that most people live on. The current president is Yoweri Museveni, who took power militarily in 1986, but was democratically re-elected in the first multi-party democratic elections held in the country in 2006. Overall he's been somewhat of a benign 'dictator', bringing much-needed stability to a country post-colonially frought with military coups and violent dictatorships. He has also been praised for reacting relatively rapidly to the emerging HIV epidemic. Yet most people agree it's time for him to step down and allow a true democracy to flourish.
The civil conflict in northern Uganda between the Lord's Resistance Army, led by Joseph Kony, and the Ugandan government is one of the world's forgotten conflicts that has been going on for over 20 years, creating nearly 2 million internally-displaced people (IDP). The LRA's brutal tactics include killing, torture, sexual abuse, and forced abduction and conscription of children as soldiers; the government forces have perpetrated similarly heinous acts against civilians. Human Rights Watch has a great report entitled, 'Uprooted and Forgotten' for those who are interested in reading more about the plight of IDPs. On October 6, 2005, an arrest warrant was issued for Joseph Kony by the International Criminal Court, though he has not been caught. On Christmas Day in 2008, 400 people were massacred by the Ugandan rebels just over the border in the Democratic Republic of Congo. Don't worry, I'm not going there. I will, however, post a longer analysis of the history of the conflict sometime soon.
All of that said, every Ugandan I've met in preparation for this trip has been so warm, kind, friendly and generous. It is those interactions that make me confident I will have a wonderful time in the country.
All of that said, every Ugandan I've met in preparation for this trip has been so warm, kind, friendly and generous. It is those interactions that make me confident I will have a wonderful time in the country.
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