text: Uganda Medical Mission Trip- March 2010: March 2010
  Today I was sitting in the park, watching my 5 year old play on the swings while listening to a smaller child complain about having to finish her lunch. Two weeks ago, I wouldn't have given this a second thought. Spending time in a region where the children eat the same staples every day- hoping they will get three meals a day, has certainly changed my perspective.
  Our first days in Uganda were full of excitement and curiosity, which quickly came to a halt when we arrived at Tekera and met the children at Bridgitt's school. It was quickly obvious that we were surrounded by a poverty that is unparalleled in the United States. As much as I'd read about the region and despite all of the pictures I've seen, nothing prepared me for what I saw. Small children wandering around without a grown up in sight, wearing clothes ripped beyond repair, covered in dirt, wandering amidst large animals and near passing cars was the norm. Still, the children had a happy twinkle in their eyes. Five year old Rachel gladly took my hand, my BlackBerry and my camera and showed me around her space. She made me laugh and as soon as she was out of site made me cry.
  I was initially more optimistic after arriving at Mbiriizi Advanced Primary School- the site of our clinical work for this trip. We were to examine and treat as many of the 1000 students as possible in four days. When we arrived at the school, I had a sense of hope that things were not "that bad". The kids were all wearing uniforms and from a distance, appeared well nourished, clean and vibrant.
  At 10 am Monday, we opened the doors to our clinic. Already, there were 30 of the "sickest" children waiting to see us. Within the first 2 hours, we had diagnosed and treated two cases of pneumonia, two with severe ear infections, gastrointestinal disorders likely from worms and parasites, severe bronchospasm, malaria, dental abscesses, bone infections and AIDS. These were all children who were not sick at home- they were brought from their classes, and returned to class when we finished our assessments and treatments.
  Next we called for all of the students, one class at a time. At first the kids were afraid but this seemed to subside as the week went on. We know that the kids talked all about us at recess because after a while, they would dutifully take a seat in the exam chair and open their mouths without coaching!
  We found most of the children complained of headaches. I was naïve enough to do a full neurological exam on the first few with this complaint, before realizing that it was a daily complaint for most- from hunger, dehydration and sun exposure.
  Most also had stomach complaints- belly pain, constipation, nausea and most of all hunger. As one little girl stated, "My stomach cries all of the time." We were told that most had recurrent worm and parasite infections from contaminated water, soil and food. A regular regimen of "de-worming" was recommended and the children were due and we did this on the last day, serving each child albendazole and mebendazole with their lunches.
  Mixed with our "routine" checks, many walked in with acute complaints- injuries, vomiting, fevers. Most were reassured and sent back to class after a Band-Aid , ibuprofen or a drink. One boy had a temperature of 104 and was vomiting. He rested on our cot for an hour and as soon as he was able to stand he was told to go back to class. At first I thought this was cruel but it was explained to me that he had no other options. He would walk home at the end of the day with a group of other students when the sun was not as hot. If I sent him home at that point, he would walk by himself in the heat of the day. Only in extreme cases is transportation arranged for a child and it can be costly to the family.
  HIV is another problem. We met seven year old Mary on the first day. She was one of the "sick" children designated to see us first. She had what looked like a fungal rash all over her body, a distended and tender abdomen and a productive cough. Despite this, she was happy and playful. We took her to the clinic in Masaka for HIV testing and a clinical examination. She was confirmed to be HIV positive. No therapy was discussed and no CD4 count was done. She was given topical cream for her rash and an antibiotic for her cough.
  In Uganda, treatment through various agencies is readily available- and free. Unfortunately many choose not to be tested as HIV is considered a "gay-disease" and an HIV infected individual must be gay and is often shunned by their community. There is proposed legislation that will make homosexuality punishable by death. A caveat to this is an HIV infected person, a doctor treating HIV and therefore aiding a homosexual are both subject to prosecution.
  We asked Mary's mother to meet with us. We learned that Mary had been sickly her whole life. Mary's father was dying of AIDS. Mary's mother and two siblings had never been tested for HIV, nor was her mother aware that there were free centers where she could have delivered her babies and received perinatal anti-retroviral therapy. We gave Mary's mother information about free HIV testing and medications and we gave her money for transportation to the facility. Immediately she had questions about what this would mean for her and her children- she felt nobody with HIV would be accepted in her community. I tried my best to reinforce that the medicine does control the virus and extend life but was not convinced she would follow through with my recommendations. There was too much at stake and her reality was not one that I could comprehend.
  Another boy, Derek, came to us with a painful arm. His arm had obviously been fractured- it was deformed, exquisitely tender and had several areas that had foul drainage. We took Derek for more tests and discovered that his fracture was not healed and that he had infection in his soft tissue and bone. We also learned that his fracture occurred one year prior- his bone was not set and surgery was not offered despite severe bony displacement and obvious open wounds. He was started on oral antibiotics and we arranged for him to have surgery thanks to a generous donation to Sylvia's Children. Derek was at risk of losing his arm but the surgery could have bankrupted his entire family.
  Medical care is largely fee for service- especially when procedures and tests are required. Many families make difficult choices regarding health expenses. Derek's father was trying to avoid surgery and his son was at risk of losing his life or limb. In the United States, Derek could have walked into most emergency rooms and he would be cared for.
  We saw unimaginable dental disease. There are no regular dental exams, no tooth brushing and no fluoride treatments. Every child had cavities. Most had broken teeth and mouth pain. Those with abscesses or severely necrotic teeth were taken to the dentist by our group. Dental exams with extractions were less than $15 and the children we brought were able to be free of mouth pain by the end of the day.
  I was monitored closely by the owner and staff at the school. One girl complained of vaginal discharge- from her symptoms, it sounded as though she might have an STD. I asked if she could come back at the end of the day for a vaginal exam when we could have more privacy. For two days I called for her. I was told by the head mistress of the school that the nurse examined her in the evening and that her discharge was normal. So what happened? Was she examined? Was she normal? Was there an STD and was it treated? It was obvious to me that I had crossed a line. This was a deeply religious community- largely Pentecostal Christian and Muslim- both communities would frown on a teen with an STD.
  One dilemma that we faced was the possibility of diagnosing diseases that we could not treat. I detected 10 heart murmurs on exam. Cardiac surgery is only now being trialed in Uganda- those who can pay for an operation are being flown to India at a cost of $10-15,000 US. What is the point of diagnosing valvular or congenital heart disease in these kids? The nurse from Tekera, Bridgitt, told me she doesn't even listen to heart sounds because she can't do anything about abnormal findings.
  Realizing this was probably an exercise in futility, I sent 8 of the kids for ECHOs. One eleven year old had severe mitral regurgitation and I was told would need surgery in the next few years. Two had mild valvular heart disease and should be monitored clinically. The others were "within normal limits" which I'm certain means something quite different in the US as I heard these murmurs myself.
  The school had a child pass away within the year of heart failure. I'm glad we did these ECHOs as we now have identified a child who may benefit from an intervention. We will meet with her family when Sylvia's Children sends another group to Mbiriizi school in June. She will need to have a clinical examination by the physician in Masaka and be HIV tested and started on medications if appropriate. We are now in the process of researching possibilities for this child to have surgery.
  We left feeling we still had so much more to do. We did examine all but 8 of the children. We have a sense of what needs to be done. De-worming has to be ongoing. The kids need to stay hydrated and nourished and avoid excessive heat exposure. We need to find a way to have all of the children HIV tested and treated without posing risk to their families. We need to educate the children and empower them to be their own advocates especially regarding HIV diagnosis and treatment. We need to educate the nurse that resides there so she can be better equipped to handle the medical needs of the community.
  We need to pray and be thankful for the opportunities we have here in the United States for our children.
  Posted by Tricia Todisco Gilbert, MD at 9:28 PM 1 comment:
  We have a few minor details to take car of this morning before we spend the day celebrating with the kids. I have so much to say, but too much to type into my BlackBerry- looking forward to putting my experience down on paper when I get back. I miss home and am looking forward to returning to the US.
  We did a lot of good work- didn't put a dent in what really needs to be done but for 1000 kids, we made a difference.
  Posted by Tricia Todisco Gilbert, MD at 8:14 PM No comments:
  Posted by Tricia Todisco Gilbert, MD at 2:17 PM 1 comment:
  I had the chance to visit with my friend Kaaya Dickson over the weekend. He is a second year medical student and we had some great discussions about the differences in medical education and the practice of medicine in Uganda vs USA.
  There were many similarities- similar courses, cased based approach to learning, and the consensus that there is so much reading to do and never enough time. One astounding difference is that students usually do not buy their own books- the cost is prohibitive. Tuition is currently $430/semester- they use the same texts as US medical schools which can range from $30-200 per text. Here in Uganda, all texts are kept in the library and the students must share. I brought Kaaya "Robbins- Pathology" and with this, he will have more flexibility with his study time.
  Regarding the practice of medicine- conventional insurance does not exist- there are private fee for service centers and government centers which are supposed to be free but one local nurse revealed that the treatment may be free but supplies and medicines must be purchased. As Kaaya said, those with serious illness and no means to pay often will just be left to die- even from a treatable ailment. Mercy killing is also an acceptable alternative.
  Physicians often work with inadequate resources. Kaaya said that even gloves sometimes are not availabe. The physician must make an ethical decision- do I take care of this bleeding wound with bare hands and risk exposure to HIV and heptitis or do I let this patient bleed.
  I am in the van heading over to our make-shift clinic. We are set up to see 250 today. Yesterday we made the decision to give worm tablets (albendazole and mebendazole) to all 1000 children this week. The task ahead seems daunting but we're going in with great energy and high hopes. The current nurse (self taught) Lydia will be working alongside me and the US nurses- we will be teaching one another. Lydia was thrilled with all of the supplies we brought. She has never seen a pulse oximeter or nebulizer. She is bright and eager to learn.
  I'm almost at the Mbiriizi school- will update later with our experiences from day 1.
  Posted by Tricia Todisco Gilbert, MD at 9:55 PM 2 comments:
  Today we made our way from Etebbe to Masaka and met up with an amazing woman (Bridgitt) and her husband (Bruce). Bridgitt is a nurse from Canada who fled Uganda under threat of execution from Idi Amin in the 1970's. She vowed then she would return and she kept her word. Six years ago, she started a school, clinic and women's co-op in Tekera.
  She is a true hero and has sacrificed many conveniences and luxuries to live a modest (understatement) life in Uganda. There are 240 kids in the school and about 100 women who use the co-op. The co-op is structured so that women can work on the farm or make crafts in exchange for health care or children's tuition.
  They use solar power and water is available (they use a foot pump that looks like a stair-master) to fill the water tower manually from the well- the water is in limited supply and used sparingly. The whole operation is actually losing money- not many people are able to pay for health care so they use points earned though working at the co-op. The co-op crafts are sold in Tekera which was at the end of a very long winding dirt road and doesn't fet any tourist traffic.
  One item that she sells for 5000 shillings ($2.50 US) is a "delivery bag" for expectant moms. It has all the necessary items to ensure a safe birth- a piece of plastic so the newborn isn't put down on a dirt floor, two pieces of wool to tie the umbilical cord, a clean razor to cut it, a pair of gloves a present for the new baby (a small hat or pair of socks).
  The babies are delivered by a labor assistant. This is an experienced lay person. She said that many of them cannot count so when they deliver a baby, they put a stone in a jar. The government official may visit the assistants to keep track of the census- the official will then count the stones in the jar. Less than 10 % of pregnant women in this region receive prenatal care.
  My special companion today was a beautiful little girl named Rachel. She was about 5, followed me around all afternoon- no adult was in sight- there were small kids wandering all around the co-op. She was wearing an old dress that was torn beyond repair and covered in dirt. She had no shoes. She held my hand and walked with me, sat on my lap- had a contagious laugh with such a twinkle in her eyes that made me cry. She was playing with my BlackBerry and loved taking pictures with it and looking at them. She quickly learned how go from one photo to the next and giggled as she looked at pictures of my kids doing silly things.