Food!

I've been waiting this entire trip to save up enough pictures of food to have one big post. For those who might not know, I love food. Unfortunately, I would not describe Ugandan cuisine as the epitome of culinary experience... Here's some of what I gathered over the month. 

This is a "traditional" Ugandan meal: Here you'll find Beans (not bad, actually) and Matooke (kinda like mash potatoes but with no taste at all and a more chewy texture.. not my favorite).

Of course there's snacks such as Rolex: A Chiapatti (Fried dough) with Egg that is ubiquitous at small snack stands  and most importantly, the medical school canteen: 

Of course the Good Samaritan Canteen has been my lunch joint of choice this past month: 

My lunch of choice: a bowl of fresh fruit (which I have not gotten diarrhea from as I initially feared) and local Yogurt (which I'm pretty sure is made from whole milk which negates any healthy aspect of the fruit, oh well).

Staying at the Makerere Guest House has it's perks. I think our whole group agrees the best perk is the breakfast in the mornings: Fresh Fruit (Pineapple here is ridiculously juicy and sweet), Samosas, and some version of Egg is a part of my morning routine:

In Jinja I found Jack fruit growing in the wild:

 (Sorry for all the non-rotated pictures. It's one of my pet peeves but the internet is shotty today so I don't think I can rotate).

This fish sandwich near the Source of the Nile was one of the best I've ever had!

Traveling to Uganda has further proven that Coca-Cola is dominating the world. Some of their local beverages include Stoney Ginger Ale (super gingery and delicious!) 

... and Krest, a "bitter lemon" soda. The Bitter and Sweet contrast is really refreshing on a hot day... aka everyday.

When we met with Dr. Merry at the Serena Hotel we came upon a pastry and ice cream shop. This is not the typical food store you find in Uganda so I had to take a picture. In a way it represents the dichotomy of rich and poor you find in the city.

 Miscellaneous:

Passion fruit!

 Random Rooster walking around. This is not an unusual sight, even in a busy street in Kampala.

 One of the resident warthogs at our campsite. 

 As a final group dinner in Kampala we wanted to get authentic African food... so we went to a Ethiopian restaurant. Close enough? I'm not a fan of the bread (too sour) but the rest was delicious. Especially the cabbage and spinach.

This last picture is of a menu at Amagara, a cafe we ate at in Kampala our first weekend. It's not a particularly exciting picture but represents an important lesson that was brought to my attention. After we were done eating, the waiter gathered our empty dishes and thanked us for eating. He said he was happy we finished all our food because many people in the city do not have food. I was relieved that we had finished all the food we ordered. It occurred to me that maybe the waiter serving us had had many a hungry night or day. The translator who accompanied us to manyangwa explained that many of the children could not afford lunch during school. The whole story reminded me of a time in junior/high school when if you didn't finish your food, someone would say, "hey, don't you know there are starving kids in Africa?" To which you would reply, "Yeah but it's not like I can give this to them" or some variation on that theme. Well, being in Uganda and seeing the orphans on the street, the wasted patients on the wards, the malnutrition unit in pediatrics.. is a constant, blatant reminder of how some people lack the basic essentials in life... and this time if you don't finish your food there are so many people, all around you, who would gladly take it.

Manyangwa

Today our group went on a trip to Manyangwa, a village 20 minutes outside of Kampala. There we met with a herbal healer, a community clinic, a bone setter, and a local focus group. This post is long and rambling so I apologize in advance!

First, we visited a 67 year old community healer named Margaret. She explained to us in animated Luganda how she has used different plants she grows to treat certain diseases for the last 30+ years. I would say that she uses "traditional" Ugandan medicine but it's not quite like that... you think of traditional medicine as being passed down many generations and withstanding the test of time and experience. She explained that she didn't learn from anybody else-- that the remedies she uses come from dreams she has where an old woman tells her what plants cure what diseases. She is not actively teaching anyone else. The list of ailments she sees include colds, abdominal pain, vomiting, diarrhea, stomach worms, contraception, vaginal dryness, impotence, imperforate vagina, diabetes mellitus, demons/evil spirits. She brought out plant after plant and told us how she would boil, crush, and cook them for her remedies. She explained that everything in her house was given to her by patients who were healed. It was interesting how her philosophy of herbal remedies intersected with Western medicine. For example, she can treat diabetes mellitus but insists that her patients first go to the western medicine clinic in town to get a blood test. After feeling tingling in her toes, she herself went to the clinic to get tested. She explained that she treats many patients with HIV for their symptoms of vomiting, nausea, and diarrhea. Her own granddaughter is HIV+. Margaret takes her to Mulago for her anti-retrovirals which she continues to take. She has also bathed her in a herbal remedy and believes it has helped with the dermatitis resulting from HIV. She seems to understand that sexual activity is how HIV is transmitted and that chronic "wounds"/inflammation can lead to cancer... but she believes they are the same thing. She refuses to treat Tuberculosis patients because she knows the risks of close contacts causing infection and sends those patients to the local clinic. She herself was treated for breast cancer with what sounds like a lumpectomy at Mulago. She said she paid 450,000 shillings for a herbal drink and has not had any problems as a result. It seems that her own remedies range from 5,000-200,000 shillings. When asked, she states that she believes both herbal remedies and western medicine work. It's up to the patient to decide which they prefer. She explained that many people in the community cannot afford the expensive health care in the clinics. Because herbal remedies are so readily available and cheap, they often try those first. All of her patients are referred by previous patients who have been satisfied with her work. She pointed to a lack of compliance with western medication as a problem due to fears about side effects. There is also a fear of "cutting" and surgery leading many people to try herbal healing.

The community clinic we went to was quite the contrast. It was much more similar to a clinic in the States and included a pediatric unit, an adult medicine unit, HIV prevention, family planning, labor ward, and even an operating room for Cesarean sections. The clinic is run by nurses and general practitioners (doctors who have completed medical school and intern year but not a medical residency).

Like many of the clinics at Mulago, there was a long line of patients waiting to be seen at this clinic.

The LMP program helped build the operating room which opened in September 2012 and has hosted 8 C-sections thus far. 

The bone setter was our third stop. This clinic had been around for 3 generations and the bone healer's skills were passed down from generation to generation. He explained that many of the patients at his clinic had gone to Mulago first but did not want to stay there. They felt that at Mulago they would not get proper treatment. One man even stated that he feared if they operated on him he would become septic. (I can't say I disagree.) It was interesting to see the other side of the fence since many of the patient in the ER come after several months of unsuccessful treatment by a bone setter. The bone healer uses manipulation and splints made of wooden rods to "set" the bones. If patients have X-rays done then he can look at them but otherwise he does not require they get them. The clinic sees all types of fractures (open and closed), spinal cord injury (which they treat with exercise), and chronic problems such as joint pain. In addition to herbal rubs and creams, they use diclofenac and antibiotics. He explained that it costs between 200,000-400,000 to set a bone but he does not turn away patients if they cannot pay it all upfront. 

The room where the patients stay after being treated.

The outside of the clinic.

In the afternoon we met with a "focus group" consisting of healthy, local people ranging from young to old who had gathered to talk with us. It was really nice to be able to have a causal conversation with them and hear their point of view. Most of them seemed unhappy with the current health care in Uganda. They said that many years ago they could go to Mulago for a small fee but they would get the care they needed. Now that Mulago is "free", it actually costs more money. The doctors are overwhelmed with patients and some require "gifts" or extra payment to give you the attention you require. The imaging and medications often have to be purchased separately. Mulago seems to be a place that these people go when they have absolutely no other choice. Sometimes the local clinic will refer someone to Mulago and instead of going, they just go home. They called it a place of great pain. I can't say I disagree. Much of what they say is what I have seen as well. I thought I would hear more of a preference for herbal medicine over western medicine from this group. On the contrary, they seemed to prefer being seen at a western medicine clinic if not for the many barriers-- cost and lack of medical resources seemed to be the greatest. Each visit to the local clinic costs around 70,000 shillings, not including medications. The clinic in the community is understaffed and underfunded, definitely a contrast to the swarms of doctors in Mulago. A doctor at Mulago told me that >50% of the doctors in Uganda are at Mulago alone while >50% of the population lives outside of Kampala. 

Our group also talked about family planning and the cultural perspective on contraception. Many of the women agreed that contraception and family planning was a good thing. One man, however, said that a doctor put a hormone implant into his wife without telling him that she would never bear children again. When he found out he was very angry and divorced his wife. Because she is no longer producing, he says. Many women admitted to taking contraception in secret. If their husband found out it would be a big problem. In a country where the average woman has >6 children, it's no secret that women are expected to bear many children. At the same time, many of the people in the group recognized how the ever increasing population has placed great strain on their health care system. One of the women told a story of a foreign group who came and placed IUDs and birth control implants for many of the women in the village. When those women suffered side effects or wanted to stop the contraception, the local clinic wouldn't help them because they were not responsible for the initial implant. This seemed to be a prime example of when global health did more harm than good and a reminder to me of the need to comprehensively explore the ramifications of those efforts. 

  
Kids from a local school during recess/lunch. Apparently most of them had never seen a "muzungu" before. 

Four more days left in Kampala! I'm definitely getting excited to come back home.

Ward 4a

The internet has been broken at Makerere Guest House so it's been hard to post lately. Plus, this weekend our group went on a safari where we saw a ton of animals! Lions, Giraffes, Elephants (really close, too!), warthogs (two of which were semipermanent residents in our campsite), several variations of antelope, Baboons, Cape Buffalo, Hippos, Crocodiles... just to name a few. The Murchison National Park is the biggest national park in Uganda and home to a lot of different animals. The roads weren't paved which lead to quite the bumpy ride but I appreciated being able to see nature in it's untouched and preserved form. I left the experience with a new-found appreciation for nature-- the world is an amazing place.

Now we're all back to Mulago. I was able to spend the day on teaching rounds in Ward 4a. I haven't really been on a team with many Makerere medical students yet so this was my first day. It's interesting how similar yet completely different rounds work here. The students take charge of all the patients-- write notes, draw labs, deliver samples to the lab, pick up results. I really think nothing would happen on the wards without the students since there are essentially no nurses. The attending taught a lot which I always appreciate and focused on physical exam skills, something I am definitely lacking compared to these students. Due to the lack of resources and funding, the physicians here rely heavily on their physical exam skills. I feel like in the States even if we find something on physical exam, we still get imaging or labs to confirm it. Here their entire plan is sometimes based on just the physical exam. We saw quite a few meningitis patients today. Some physicians believe it's a requirement that every patient get a head CT to rule out mass lesions before getting a lumbar puncture. This is important because if you get an LP on a patient with a mass lesion, the pressure from mass effect can cause their brain to herniate through their skull. A head CT costs around 200,000 shillings-- about a month's pay for the average Ugandan and much more than that for may of the patients at Mulago. With a thorough neurological exam the attending concluded on many of the patients that there were no focal findings and we could do an LP. I can completely understand why they do this-- there simply aren't enough resources to have the type of protocols we have at NMH.

Somethings I have found on rounds that are similar:

• Medical students presenting patients are interrupted constantly by the attending
• Attendings like the Socratic method of teaching
• Patients will tell students one thing and the attending the opposite.
• There are still language barriers between patients and physicians (we had one patient who only spoke swahili, a dialect not many Kampalans speak.. except here there's no interpreter). 
• Attendings don't carry their own tools. 
• Everyone is advised to "read more".

That's all for now. Hopefully we'll get internet again at the guest house and I'll be able to post some pictures from the weekend!

Update:
Internet's fixed! Pictures as promised

Murchison Falls

In the Safari car where the roof lifted up :)

Hippos! The middle one has a huge gash from a recent fight... 

My favorite! We were so close to these elephants!

Superman

Today our group met with Dr. Merry, an infectious disease attending affiliated with Northwestern who has worked in Mulago for over 8 years (I think). It was really helpful to be able to talk to someone with an informed and enlightened perspective on global health. I thought I'd journal about some of the points I took away from the experience.

One thing Dr. Merry discussed with us was the reaction she thinks many students have when they arrive at Mulago and how similar it was to the Kubler-Ross stages of grief. I think I can identify with a few of those stages myself.

- denial: at first it was almost surreal to be here, in Africa, I almost didn't realize that I was here. After being at Mulago for a few days, thinking that perhaps the patients weren't getting as poor care as I thought.
- anger: being angry with the system we're thrown into here, where I feel so helpless to help patients even when I know what to do. Angry with the residents and attendings around me who seem so apathetic to the patients in front of them who lack care.
- bargaining: with healthcare workers around the area about speeding up care for patients.
- depression: seeing how many people lack the basic necessities for medical care was one of the most striking memories I had coming here. Realizing how wasteful our society is makes me feel guilty to waste the things I have when others have so little.
- acceptance: Perhaps something I'm finally getting to... using the experience to learn about medical care in a developing country and to figure out my role in global health in the future.

It was interesting to hear Dr. Merry's experience with other students who have come to Mulago. She told us a story about a few foreign medical students (not from NU) who came in the fall during the Ebola outbreak. The students had just arrived and became so paranoid about Ebola (which is transmitted through skin contact) that they were wearing TB masks and gloves even at Makerere Guest House. Their behavior was a reaction to panic and anxiety from escalated rumors and being in a foreign place. Ebola is a disease with great mortality and I can't necessarily say I would have acted too differently in a similar situation. Their behavior had started to spread paranoia throughout the guest house and community-- not only had their presence in Kampala not been at all constructive, it was actually destructive to the people around them. They all booked flights out of the country. Dr. Merry had a chat with them in which she described how her son at a young age aspired to be Superman and wanted to "save the world". Everybody at some point wanted to be Superman (or any other superhero of your choice). She explained that as we age, the dream to become Superman becomes replaced but it does not disappear. I remember being an idealistic teenager, ready to save the world. I think over the years, I've felt myself coming to the realization of how seemingly impossible most things have become. (Jaded, I believe, is the appropriate term). Anyways, she encouraged them to find that inner Superman, even if only for the 48 hours they had left in town, and use their efforts to improve the community in some way-- eat at a restaurant, explain to the guesthouse workers how to avoid contracting Ebola, put together a pamphlet for the surrounding community. Well I suppose those students all found their inner superhero because they all stayed. Her point was that it didn't take anything astronomical like stopping a speeding train to be Superman. Everyday, anywhere there are simple things you can do to find your inner Superman. This mantra was very poignant to me and something I hope to always remember.

I hope no one gets too nitpicky about the details in these stories. Remember they're an abridged version of our discussion with Dr. Merry and I only meant to capture the meaning (which I hope I have) and not the minutia.

It looks like there's going to be a huge monsoon today! Although I just got a winter advisory warning for Chicago so I should count my blessings.

Systems

I had a conversation with a Mulago resident today. He was telling me about how at a public hospital the physicians make around $600/month starting salary. In the private sector a physician can make that much from a single surgery but it's hard to find a job/patients that way. What many of them will do is start off a Mulago hospital and simultaneously work as much as they can in the private sector. This means that many physicians will just come for 2-3 hours a day and leave. It doesn't matter how many patients they see (or don't see) on the Mulago wards but in the private sector the more patients they see the more money they make. You can't blame the doctor.. $600 is not enough to cover the cost of living in one month.

Inefficiency and lack of organization has been a recurring theme over the last couple of weeks. The bureaucracy leading to unnecessary paper work, the lack of a reliable and efficient way to order tests and treatments, the lack of efficient triage. I was outside the Emergency Department today when I saw a police truck pull up. The policemen walked in and brought out a stretcher. The opened the back of the truck where there were rows of seats (empty seats). They pulled a woman from under those seats and put her on the stretcher. When they entered the Emergency room the brought her to the main patient area and put her on the floor. A discussion went on for 15 minutes about what had happened to her and what they should do. It looked like she had been hit (in most likely a boda boda accident). She had abrasions on her trunk, arm, head, and back and was not very responsive to questions. They finally get her onto a bed and a few nurses come to clean up the blood. No doctor had seen the patient yet. The nurse cleans around the wounds and then proceeds to suture the lacerations. It's interesting what is prioritized in this kind of situation. The lacerations are closed but no abdominal ultrasound, chest XR, or even neurologic exam is performed. I thought about NMH and the protocols we have for a situation such as this one. The protocols we have for most situations and the simulations we run for practice.

I think here it is not so much a lack of resources or a lack of knowledge-- as I had thought before I came. The doctors are competent, there are most necessary supplies. It seems to be a systems-based problem. There is no organization of resources whether it be doctors, nurses, or medical supplies. The doctors have no incentive to work particularly hard and are not regulated. Sometimes when there are resources they're not allocated to the right areas (for example, on OB if we need suture for an episiotomy repair, there is none available on the wards because it is all locked in the matrons office.. who is out for lunch). I'm not saying that they have all the resources or training they need... but I think what they do have is poorly and inefficiently managed. I never thought I'd think that managers/management was crucial-- after all, isn't that who companies cut first during a recession? I could see patients all day and bring as many supplies as I could carry.. but those things alone would not solve these systems issues. An overhaul in the management system would accomplish more for patients than I could ever do. Perhaps I'm finally understanding what my consultant friends do..?

Jinja

I can now officially say I've rafted grade 5 rapids on the Nile River! The weekend at Jinja was definitely an adventure and a great escape from the busy city of Kampala. I had always imagined the Uganda that I'd be going to as more of a rural setting than an urban one:

The banana trees and farming villages were exactly the refuge I needed from the smog and congestion of the city. 

We stayed at a camp on the Nile Saturday and went rafting Sunday.

I was at first afraid of getting injured/worse after hearing some stories through the grapevine. Thankfully I came out of the experience with little more than a thorough washing with Nile River water. I feel extremely lucky to have had the chance to go to Jinja and brave the Nile rapids-- it was definitely a once in a lifetime experience. Driving through the villages I definitely noticed the disparity in wealth between us "muzungus" driving through in our giant cargo truck and the local farmers we passed. The Nile River Explorers, one of the busies and most popular rafting companies, to my surprise, was owned by foreigners from Australia. The Nile River is a part of these people's homes yet the company that profits from it is run by foreigners. Our guide, Alex, had grown up in the neighborhood surrounding the rapids and could probably raft them with his eyes closed. I asked him about the company and he explained that they contribute funds to local charities and put money back into the community. That made me feel better about supporting their business but I wonder how the local people feel about the tourism in the area. I also wondered about the healthcare in the rural setting. If Mulago is the national referral center for Uganda.. what is it like in an even more resource-poor village? When we mentioned to the guides that we worked at Mulago hospital they had an obvious aversion to the idea of the place. One guide described walking into the hospital and feeling like you would get sick immediately. They seemed to view it more of a place that people went to die than to get help. "You're better off at a witch doctor", said one of the guides. Before rotating through the hospital I might have thought these guys were crazy. After seeing some of the things in the hospital I'm not sure I can blame them. Don't get me wrong, I don't think the hospital is quite what they describe... but there is no mistake that there is vast room for improvement. Perhaps the general perception of the hospital is why most patients don't present until their disease is in its late stages.

That's it for today but I'll leave you with this: Another animal sighting -- Monkey!

Alive Medical Services

Yesterday our group went to work at Alive Medical Services, a free clinic for all HIV patients.

The road there was probably the bumpiest we've ever had (and that's saying something):

The clinic itself, though, was impressive.

An example of how an NGO could work and work well. There are 6-7 physicians and 4 PAs that work on a 24 hour basis in the clinic and acute care center. They see mostly HIV patients and have free testing for anyone who shows up. All treatments and drugs (including anti-retroviral), laboratory testing, and clinic visits are all free and funded by external sponsors (one of which is apparently Alica Keys...?). The clinic has it's own lab, it's own acute care ward, family planning, counseling, food distribution, and even a labor ward. 

One of the things I thought they did really well was psychosocial support for patients getting tested for HIV. They meet with a counselor first, the counselor goes over goals and expectations, get tested, and meet with the counselor again for the results. Patients with poor medication compliance meet with a counselor to discuss barriers to medication use or just for counseling given a new diagnosis of HIV. I haven't really seen this kind of system in place in a lot of American hospitals so it was great to see how they ran things here. The physicians see up to 600 patients a day and their resources are stretched thin.. but from what I can tell everybody gets the care they need.

I'm off to Jinja for the weekend! We're going to raft Grade 5 rapids on the Nile... Wish me luck!

Pharma

Today I went to a Makerere Medical School "Grand Rounds". It was different from what I expected because it seemed that mostly residents presented topics that were directed at a medical student level of understanding. The topic was on Peptic Ulcer Disease, Osteoarthritis, and the use of NSAIDs. I thought the topics presented were thoroughly covered.. to the point of repetition. It was interesting that they mentioned things like blood transfusion with a hgb <7.0 and ICU admission for certain patients.. when on the wards our group routinely sees patients with hgb of 4-5 who aren't receiving transfusion and patients we feel who warrant ICU admission who are on a regular medicine floor. One of the presenters even admitted that they wouldn't have endoscopy machines available for a few years. It's nice to know that if there was a better infrastructure or more resources these things might get done in the same way that we manage them back home.

At the beginning of grand rounds the physician leading discussion introduced two pharmaceutical reps from AstraZeneca sitting in the back. He explained that they had provided cokes for all of us during the lecture and they passed around cards about Nexium in the use of PUD. At the end of grand rounds he even said "I hope you all feel confident in prescribing Nexium in the future". Thousands of miles away from the US, here it was, Pharma. Pharma advertising at a medical student lecture, none-the-less. I guess in a country with few resources there is still money to be made...? Furthermore it was odd that the professor was endorsing it so strongly.. it was quite the contrast to Dr. Neely's adamant disapproval of pharmaceutical involvement in medical care.

Week 2

Today I met physicians from abroad: one from the UK and one from Canada. They are surgeons, here for two weeks, assessing complicated patients, and scheduling the necessary ones for the operating room.

The issue of sustainability in global health is one that I became familiar with during medical school. NU-AID, a student group I worked with first and second year, sent one-week long mission trips to Jamaica and Nicaragua biannually. An enthusiastic but naive student I have to admit I had not thought much about the issue of sustainability when I first joined NU-AID. I realized that a one week clinic would not solve chronic conditions such as diabetes and hypertension... and cooperation with the local health-care workers is an absolute must. I wondered though, if not sustainable, were these trips at least doing some good? If there is nothing else offered to these communities, could it be doing harm? These are questions I do not have an answer for yet.

I think the doctors I met today represented a model of global health that I believe is sustainable and one I could potentially follow in my future career. They come for a short time, yes: two weeks. (Most physicians in the US do not have the time or resources to do an extended trip unless going abroad is a part of their job). The surgeries they do are finite-- they typically do not require repeat procedures and there are no complicated post-operative requirements. Most importantly, they work with the local residents and physicians while seeing the patients. Mulago residents worked with the physicians, examining the patients together and coming up with an operative plan together. A lot of teaching went on and I have no doubt the residents benefited from the presence of these foreign doctors. One of the physicians had been coming to Mulago for the last 13 years and they were even collecting records from previous surgeries to compile the data for outcomes analysis. This is probably the most "sustainable" model of global health I've seen to date and one in which I have the most confidence in its "good". After almost four years of medical school I'd like to believe I'm still enthusiastic and slightly less naive. I wonder if in 10 years I'll look back on this and agree.

Muzungu

This was my first full weekend in Kampala so we decided to explore more of the city center.

First we went to 1000 Cups Coffee, a really great coffee shop popular with the "muzungus" in the area. (Muzungu means "European person" and is used to refer to any person of lighter skin). I've yet to figure out if this is a derogatory term...

For my Uncle and Aunt back home. :) 

We also explored all the arts and crafts shops around the city center. There were too many things I wanted to buy and here it is common to bargain for everything. I was never very good at bargaining in Shanghai but I thought I'd try it out. Throughout the process of bargaining with a woman for a picture made of banana leaf I thought she reminded me a lot of a patient I had in the hospital. I realized that for me the few thousand shillings difference was a difference of a dollar but for her it might be a meal or an outfit for her daughter. It made the whole process seem silly to me. 

Today we went to the Gaddafi National Mosque in Kampala. Apparently only 10% of the country is Muslim. We were all required to wear skirts and head scarves to go into the mosque. 

This seemed really unfair to the feminist in me because all the guys got to wear whatever they wanted. 

Stairs we climbed to get a view of the city.

Kampala is a lot bigger than I thought it was... given that I've just been exploring on foot in a 3 mile radius from Makerere it's not surprising. Sorry for another post full of pictures! I'll try to write more about the experience next time. I miss you all back home!