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Human Ecosystem

Living in a city like Kampala has changed the way I view people.  A staggering amount of life fits into a small area here, a vast web of interconnected lives hustling through challenges together.  It is much easier to see all the different ways in which people interact, because life here is fast, visceral, and emotional.  Markets, vendors, and taxi stands fill every available inch of space. People crowd the streets, laughing, sitting, cooking, sleeping.  While there is no formal organization, vendors and boda drivers find their preferred areas of business, like university students with preferred seats in a lecture hall. It is charming and flattering that every time I leave the hospital, the same three drivers leap for an opportunity to drive me home; a chance to hear unusual stories about my time in the ER while making a few dollars.  Every small transaction, from buying food, minutes on your phone, even TV channels, occurs via an interaction with another human.  Taking time to learn and understand the lives of these people is one of the most important things I have learned to do, as I have come to understand that this is the true meaning of global perspective.  In doing so, I can begin to taste the true complexity of human interconnectedness, and how it is an aspect of human life we should never take for granted.  The routine, back-and-forth between home and work lifestyle seen in the West is not present here, mostly because of the difficulty present in finding a home, finding work, and finding a way to commute between them.  However, the resulting lifestyle is so colorful and rich it is hard to feel sorry for too long; quickly you realize that in exchange for poorer services and infrastructure, you gain a completely different style of living, where people are the mediating agents of every experience, instead of technology.  I am grateful for this opportunity to view the world and its people in a new light, and to remember to appreciate the aspects of living that make it truly worth living.

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Rural Medicine

The HELP foundation is committed to conducting large scale medical camps in rural underserved areas, in the hopes of providing much needed care and consultation to a large population in a short amount of time.  The setup and execution of these camps is a testament to the power of collaboration, determination, and hard work.  While the quality of treatment in these camps is far from ideal, the alternative is thousands of conditions going untreated for decades, resulting in broken families and communities.  HELP foundation’s medical camp in Mukono resulted in around 981 treated patients on days 1 and 2, plus 48 successful surgeries on days 3 and 4.  What follows is a not so brief account of this experience.

Day 0: Hotel Alvers

Our journey begins on Saturday, as we prepare for a week of grueling work.  Our team: Dr. Ali Arsiwala, head of HELP foundation; Ismail, a second-year medical student; Jamil, our trusted driver; and myself.  Our task; stockpile enough medicine, surgical supplies, and medical staff to treat as many people as possible in four days.  Jamil drives us early morning to our temporary home in Mukono. The gate guard opens the fence, and we are treated to a small complex with two floors of rooms, an office, and a large dining hall all separated by a courtyard and garden. The quaint compound is quiet and empty as we enter, a light breeze shifting the palm trees above our heads.  We walk up the uneven stone stairs into the office.

“Can we have 11 rooms for tonight and tomorrow please?”

“Absolutely.”

Hotel Alvers is happy to have us.  With a stray cat and the occasional bat to keep us company, we begin planning the next phase of our journey.  We sit in the garden and compile a list of medicines already present in storage, along with the ones we plan to buy.   The medicines are categorized by related disease, and each is paired with a short protocol designed to expedite writing a prescription.  Two hours and four beers later, our list is complete.  We head to the pharmacy.

The proprietor of Abacus pharmacy, known as “Mehul the Gujarati”, is also happy to see us.  A long-time friend of the foundation, he helps us sort and compile our stock of medicine.  It is not simple; some medicines are unavailable, other have expired. We compromise where we can; no adult Lumarten (for malaria) is available, so adults will have to receive a doubled child’s dose. There is no Gabapentin, used here to treat a variety of conditions, so we substitute Amitriptyline.  Once we have our stock, it is loaded into the truck.  

Our next stop is the grocery store, where we make a quick purchase of 500 packs of biscuits, 480 boxes of strawberry milk, 4 crates of water, and 1 Cadbury fruit and nut. A small crowd watches as we load the truck and head to our final stop.

We arrive at our destination: the village next to the clinic where our camp will take place.  We are joined by Dr. Garvin Henry, the owner of Herona Hospital, where we will be conducting our camp. He acts as our guide; he was born and raised in this village.  Dirt paths and thatched roof houses surround us as we venture onwards by foot.  Dr. Ali wants to find a child with glaucoma who was present at the previous camp, and never showed up to his follow-ups.   Our motley crew conducts a brief search, and eventually we see him; sitting on a bench, quiet, and fully blind.  An unproductive conversation with his mother reveals she never bothered to bring her child in for checkups.  Eventually she promises to bring him to the clinic tomorrow; it’s the best we can do. The sun has set now, so after briefly stopping to help two kids fix their bicycle, we head to Alvers.

Back at the hotel, the rest of our team begins to trickle in.  Medical students, pharmacists, doctors, dentists, and one physical therapist will be our family for the next few days.  Together we eat a dinner of motoke (mashed plantain), biryani, paneer, and goat, and head to bed.

A sewing shop in the village where HIV patients are given work; Two children and their bicycle, which has since been repaired; A beautiful Range Rover at hotel Alvers.

Days 1 and 2:  Herona Hospital

Our camp begins early morning on Sunday.  The truck navigates through the thick morning fog, not yet dissipated by the rising sun. At Herona hospital, a line of patients already extends across the compound.  We disembark, unpack our supplies, and get to work.  My role begins with patient registration; each newcomer receives a number and a patient chart.  The number will allow the camp to proceed in an orderly fashion; the patient chart serves as their medical record for the duration of their care.  I begin by recording the patient’s name, age, and hometown.  Many bring their children, friends, and children of friends.  After receiving their paperwork, they take a seat under one of many tents set up in the parking lot.  Some patients require assistance, as they are too old to move on their own. Others are hindered by large masses on their arms, legs, and faces.  A loudspeaker drones in the background as a nurse barks instructions in a rotating set of languages.  

Each patient begins in triage, where a team of nurses conduct an initial assessment.  Once their vitals are taken and urgency is determined, they are sent to one of six doctors who will attempt to determine a diagnosis and administer immediate treatment if needed.  Any tests, if available, will also be done at this point, and the prescription is written on the patient’s paperwork.  The process takes around 6 minutes on average.  If the patient requires surgery, they are also told to return in the next two days for the surgical camp.  Once the patient has their prescription, they bring it to our makeshift “pharmacy”; a large closet filled to the brim with drugs, supplies, and sweating pharmacists.  This is where I find myself each afternoon; passing out drugs and copying prescriptions into the log book.  At the end of each day, the book is the only record that remains of these patients; their names, condition, and treatment provided.  

During the day, I bounce between the pharmacy and clinic assisting with simple cases that need an extra pair of hands.  Surprisingly, apart from bacterial and fungal infections, the most common problem we see is peptic ulcer disease, though its etiology here is different from the West. In the elderly, we commonly see back pain, degenerative joint disease, and neuropathy.  These patients mainly receive a cocktail of drugs and some counseling.  Other patients present with a variety of strange complaints, which must be treated with some creativity.  One man comes in with hearing loss, due to dense accumulation of ear wax in both ears. After a brief and unpleasant smelling water extraction using a cut butterfly syringe attached to a syringe, the man jumps with joy as dark clumps of wax wash out of his ears.  He grins ear to ear as we ask him questions; it is the first time he has clearly heard someone speak in years.

Another patient comes in with massive swelling in her cheek.  It is an abscess, a growing collection of pus.  Though a permanent fix will require proper surgery, we can help her by draining it and providing painkillers.  50 milliliters of pus later, this 16-year-old girl doesn’t feel very helped.  The lidocaine provides some comfort, but the pain will not stop until after surgery. The mother is given cash and referred to a dental surgeon.

Many patients come in with dental problems, such as dental caries or gingivitis.  They are referred to the dental clinic where they are placed in a reclining lawn chair and receive treatment from our dental team.  It is not unusual for these patients to receive 4 or 5 extensive fillings in one sitting; for most, it is the only time they will ever see a dentist.  All are given antibiotics and sent on their way with upgraded smiles.

Another common problem is sickle cell anemia, particularly in children.  In the USA, the new treatment for sickle cell is a spoonful of l-glutamine mixed into water, once a day, for the rest of their lives.  It is supposed to help prevent sickling crises, though is usually used in conjunction with other treatment.  Unfortunately, our stock of l-glutamine here is limited, and we are only able to give patients one month’s supply. We ask them to return to the pharmacy to resupply each month, but most will not, because they cannot afford to.

As the sky darkens at the end of each day, the torrent of patients slows, and the team can begin to relax.  The work is never finished, however. Two trauma patients are rushed in on the second day, just as we are preparing to leave.  As the medicine is packed into boxes outside, these two victims of a boda-boda accident are patched up in the clinic.  One is given simple wound dressing on his face and leg and sent away. The other is missing a chunk of his eyelid and lip and will need proper stitching.  The light in the clinic is poor, so an iPhone flashlight is held over the operation.  I try not to slip on the blood as I hand over sutures and gauze to Dr. Ali as he reconstructs the victims face as best he can.  This man will stay overnight as the medicine wears off and go home in the morning. By the time we are loading the patient into the ward, night has come.

As we head back to Alvers on the night of the second day, despite aching feet and tired minds, we can be satisfied with two days of successful work. However, our job here is not done; the next two days brings nearly 50 patients requiring advanced surgery. The team congratulates each other on a job well done; most will leave here and head back to their respective jobs. Only a few of us, the original four, will remain for the surgical camp. We eat fried chicken and fish, and sleep.

Jamil helps me translate as I record patient information; Ismail and I pack up medical supplies; Dr. Ali operates on a trauma victim.

Days 3 and 4: Church of Uganda Surgical Theater

It’s noon on a sunny day. Through the glassless window behind me, some women are hanging flowing dresses on a clothesline.  A few geese and chickens wander about, and a man is changing into a dirty suit behind an outhouse.  I refocus and turn back to the surgical operation happening in front of me. I am holding a phone flashlight above it, because there is no power.  “Bleeding in Love” by Leona Lewis plays quietly from it, while below, Dr. Ali yanks a lipoma out of an elderly man’s forehead, sending a gout of blood upwards.  

“Are you ok, muzei?” he asks, as he begins to stitch closed the blood vessel he just opened.

The man grunts in ambiguous response.  No general anesthesia is available, so he is conscious while his head is being operated on.  With the lipoma now removed, his injury can be stitched and dressed.  He will go home today, with just a scar in place of the bulbous mass on his face.  His case is relatively simple, just one of over twenty operated on today, all receiving only lidocaine despite varying degrees of invasiveness.  The most common problem we see are hernias, either inguinal, or in the case of children, umbilical.  Many go untreated for years, reaching the size of footballs before they are corrected.  We are further challenged by a lack of supplies, as it is difficult to sterilize and reuse enough equipment to complete 50 surgeries in two days.  Fortunately, almost all of these surgeries are completed successfully; 30 hernias corrected and 10 cysts removed without incident over two days.  It is the other cases we see that provide more challenge.

One man comes in with what appears to be a double hernia.  However, a quick ultrasound reveals a large testicular mass on one side, and a massive hernia on the other.  Not knowing if it is cancerous, it is simply removed.  He will still be able to have children, though with 2 wives and 9 kids at age 27, this man doesn’t really need to worry.  He talks about them during the procedure, proudly describing each of their achievements in sports and progress in school.

After each surgery, we take a quick break in the office, drinking tea and eating bananas and boiled eggs. Some children sleep in the corner on a pile of scrubs; one is recovering from surgery, the other is a bored child of one of the nurses.  Each day, we examine each of our patients to determine exactly what their condition is; though they were seen once at the medical camp, it pays to be more thorough before surgery.  Then, they wait in line outside the theatre (operating room) while we complete the surgeries.  With four surgeons and two operating rooms, one large and one small, we can complete three surgeries at a time.  Still, with this many patients, we work each day until the sun sets.  And even then, the work is never complete; one of the nurses, “Uncle” Sam, is rushing a child into the theatre at the end of the first day.

“What’s wrong with him?” My heart sinks, as operations on children are never simple.

“He’s got a rubber stuck in his ear.”

“A condom!?”

“No, a rubber eraser, like from a pencil.”

Oh.

This simple problem is much more complicated than it seems, with our limited equipment.  Though a suctions machine is present, we don’t have the proper attachment.  We first try washing it out with water, but its slick rubber and is stuck fast.  The kid is extremely stubborn as well, and I must hold him in my lap as we spend 40 minutes running water through his ear, periodically checking our nonexistent progress with an otoscope.  Trying to hook the rubber with a tool is out of the question, as the kid squirms and fights each time we try. One of the nurses, “Aunty” Maureen, suggests sedation.  We administer the ketamine, and the five-year-old enters a trance.  Still, despite his stillness, hooking the eraser is impossible, and after 20 minutes the child begins to wake up.  Another dose of ketamine is given, but this time, his lungs refuse and his breathing stops.  I feel a knot in my stomach as the pulse oximeter beeps in protest, O2 saturation rapidly decreasing. Fortunately, Dr. Ali gives the boy a quick sternal rub; the stimulation is enough to bring the child’s breathing back.  We give up there; this child will require treatment at a better equipped facility. The child is carried back to his mother, who is given some cash and referred to an ENT.  Despite the scare, it is our only failed procedure over the course of two days.  

Though our work at the surgery camp is done, there are always more patients to treat here.  The surgical staff at Church of Uganda hospital work almost 10 hours a day, seven days a week. We help where we can and leave most of our extra supplies for them to use.  The rest we pack up, to put in storage for the next medical camp. Though the work can seem endless, there is progress being made.  

This is the third and final medical camp conducted by HELP foundation in this location, and each time runs smoother than the last.  In addition, there were less patients each time, coming from further away; hopefully a sign that the community is being slowly healed, one camp at a time.  For now, we will continue to follow up with patients who need continued care, a make sure they receive treatment over the next few months.  Ismail already has 84 patients on his list, all of which will receive some sort of follow up.  The next camp location will begin the cycle again, in a new community desperate for help. And although the work is never finished, we will never stop working.

The wonderful HELP foundation team.

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Welcome to Mulago

Kampala is a city of rolling hills and sprawling architecture.  One of its largest hills is summited by Mulago National Referral Hospital, the largest of its kind in East Africa.  The massive complex spans an area of several square miles and contains both the hybrid hospital/town of Old Mulago and the New Mulago hospital complex, which is experiencing a state of interminable reconstruction.  It is easy to get lost in the jumbled walkways, crumbling streets, and vibrant sounds of Mulago, saturated with a colorful selection of patients, medical students, doctors, and animals.  Each day, the ebb and flow of Mulago’s various occupants breathes life into its crooked skeleton of open buildings and meandering streets.  An institution plagued by many problems, Mulago itself is a remarkable analogue to its vast network of suffering patients.

My time at Mulago hospital has been spent rotating with a group of 5th year medical students: attending lectures, going on rounds, and clerking their patients.  Learning here is truly old school; sparse technology means most lectures happen as an informal conversation, often in front a patient whose condition is being discussed.  A huge emphasis is placed on history taking and physical examination because diagnostic scans and tests are expensive and rarely available to assist in a diagnosis.  Despite being a public hospital, much of the necessary funding for equipment, staff, and medicine mysteriously disappears on the way from the government to the patients. As such, a CT scan will often cost a patient around $95 USD. (The GDP per capita in Uganda is $604 USD). This means the students and doctors must often rely solely on their own ability to build rapport with their patient and elicit the correct information quickly.  With widespread tuberculosis, along with an nosocomial infection rate of around 35%, many patients can end up with two or even three infections; time is always a factor.  A disorganized team with insufficient history taking or examination skills will not be able to settle on a diagnosis, often resulting in a patient’s death.

The lack of organization also means patient care is entirely up to the doctors’ discretion, with little recourse for patients who feel they are receiving inadequate care.  As pediatrician Dr. Michael explains:

��People don’t really pursue litigation in Uganda.  Although, if they feel cheated, they will find means of alternate justice.”

He continues on to tell me the story about the time he was almost murdered as an intern (resident) at Mulago hospital in Kampala.  While delivering a child in the Obstetrics unit, the mother experienced an unpredictable stroke during labor, forcing an emergency C-section.  The child survived, but the mother did not, due to inadequate life support technology.  Furious at the hospital’s apparent incompetence, the father gathered a lynch mob and stormed the obstetrics department, out for blood.  For several hours, Dr. Michael and his team hid in a locked supply closet while the police sorted the situation.  

Life isn’t easy for doctors at Mulago.  The result of these problems, however, is a generation of doctors and students with an astounding capacity for interpersonal connection, appraising symptoms, and critical thinking.  It is not suprising; these traits are simply necessary to navigate the disorganized and financially crippled hospital complex.  The highly social culture of Uganda breeds a unique relationship between doctor and patient that is indicative of much stronger human connection and trust when compared to Western Medicine. And yet, regardless of how competent the staff is, the shortcomings of medical technology in Uganda will always affect the potential success of its patients.  In this sense, Mulago is a reminder that technlogy can provide us with an immense advantage, but perhaps at the cost of our humanity.

Mulago: A university, village, and hospital folded together into one self contained complex.

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Ordinary Death

Warning: Graphic

“We do the best we can do.  The rest is in God’s hands”.

The door opens, and the cart rolls slowly into the room.  Fluid slowly drips down the cloth, joining a growing pool on the floor.  The color is a sickening, impossibly bright red, almost like candy paint.  The wound gapes just above the left eye, opened now further by the surgeon as he assesses the damage.  The brain is visible just below the torn meninges, pulsing in synchrony with the EKG monitor and dripping blood; together a gruesome symphony.

“That’s a bad injury.”  Nobody else speaks.

The patient has suffered an impact fracture of the skull, tearing through the protective layer underneath and exposing the brain.  He is brought to CURE neurosurgery hospital to receive emergency treatment.  The best the surgeon can do is repair the opening, and hope the brain damage does not cause significant impairment.  In an ideal setting, the fracture skull fragment would be removed and kept in sterile storage while the brain heals safely over the course of some months.  Instead, the damage will be repaired immediately, despite swelling risks, and the patient sent on their way in a few weeks.  

The dura is torn in three parallel lines, which the surgeon stitches together neatly.  The skull fragment is removed, hammered and stitched back into a reasonable shape, and returned over the wound.  Absorbable gauze is placed between each layer, and the skin sutured to finish the job.  The power goes out five or six times during the operation.  The generator keeps the operation running, but several machines need to be reset each time.  The staff has no option but to continue on tirelessly, and be grateful for what they have.  Here at CURE hospital, they are better equipped than most.  

This patient is just one of thousands who suffer near identical injuries each year in Uganda, due to wild traffic and unenforced helmet laws.  CURE, despite being one the best equipped hospitals in the nation, can only help so many.  Generally, patients like these can’t afford private treatment, and many will go untreated when the public hospitals are full. At Mulago hospital in Kampala, where I will be spending the rest of my internship, patients like this may not even receive treatment fast enough to survive.  At least at CURE, this patient may live to see his 6th birthday.

Residents of a village that overlooks Mbale, the city where CURE hospital is located.

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Kampala

“A personal relationship is more valuable than being a hero to the world.” 

It’s another cool evening in Kampala, and I am sitting in my apartment watching the sun set over the neighboring slum.  Fires slowly burn in the distance, their source unknown.  “Have you ever been in love?” asks Hassan, drawing me back into the conversation.  The question startles me, as its something I would never expect to hear from a young adult who I met just days prior.  I can’t be suprised for long, as I have come to appreciate the immense sociability and personality of Ugandans such as Hassan. Social connections are very valuable to him, and he is eager to learn all there is about everyone he meets. Hassan is a great example of youth in Uganda; bold and proud, the 25 year old engineer is upset with the corruption of the various institutions he has been a part of, namely the medical and governmental systems.  Across Kampala, the young educated population like Hassan are experiencing a revolution, pushing back at the current administration.  Slated to rule until 2031, President Museveni’s already 32 year long reign has grown stale. Just the previous week, I joined nearby residents on our balconies as we listened to gunshots ring out across the city; a former chief of police gunned down in his car.  This shooting followed weeks of clashes between police and peaceful protestors on the streets of Kampala, as the youth rally behind an opposition politician, Bobi Wine, who was kidnapped and beaten in an attempt to silence his inspirational “People Power” movement.  Though Hassan hopes to leave Uganda and reach the United States, many young Ugandans are committed to staying and providing a new framework for Uganda through political action, and strengthening the medical, educational, and governmental systems.  There is a remarkable energy throughout the city, growing each day as the population explores an unplumbed dimension of empowerment never before available to them.  Ismail, a medical student, informs me that the fires I am seeing are not just trash fires, but in fact built by the poor in protest to their treatment by the city.  Hassan elaborates that the current political movement is not isolated just to Kampala, or educated youth; all across Uganda, the people are uniting to make a change.  As I gaze out my window with my two new friends, the fires in Kampala tonight feel particularly bright.

Ismail and Hassan pose just after they help me sign my lease.