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.