The boda boda crackdown (see previous post, plight of the bodas) has eased up. Unlicensed, unhelmeted bodas have returned as the majority. Still, even without the police harassment, the life of a boda driver, despite the cachet of riding a motorbike for a living, is a hard one. Fuel prices in Kampala have shot up six or seven hundred shillings a liter in the last few weeks, eating into narrow profit margins. (most of the drivers rent their Indian made Bajaj Boxer 5 bikes for about 40000 shillings a day, making it twenty 2000 shilling trips just to pay the owner of the bike) And one slight misjudgment at one of the many universally disregarded traffic lights can land them on one of the cushionless blood stained gurneys in Mulago’s casualty ward.
One of my fellow VSO volunteers has fallen for her boda driver. Michael is an affable young man with a tight leather jacket and a winning smile. It is good to see them together. I’m jealous, among other things, that, after only a few months, she’s conversant in Lugandan, while I’m still stuck in the basic phrases and counting to 9 that I sort of learned my first few days in Uganda.
Last Saturday night we had an eviction party. (Dorothy had told us we’d be kicked out last Friday, but, as of this writing, the sheriff has yet to come beating on the door, and alternative housing has yet to fully materialize, so I guess, at the moment, we are squatting) A good number of my fellow volunteers got stranded by a rainstorm at the Wine Garage on their way to the party (fortunately, they did not suffer overly much), but a small and enthusiastic crowd made it and kept the loud music going for the neighbors until the wee hours.
And shortly after getting to bed, my phone rang. Michael had been found in a ditch by one of his fellow boda drivers, unconscious and bleeding from facial wounds. His friend Issac was called and took him to Mulago where they were unable to locate a doctor or a nurse. From Mulago they traveled to a clinic on the other end of town in Kireka where some unusually crude suturing (even by Ugandan standards) was perpetrated on his face.
I had to apologize that my alcohol level was probably not within a level you’d want your doctor’s to be. But I put her in contact with the IHK ambulance driver and, a bit later, caught a boda over to meet them at the hospital just as the sun was peeking up over the Kampala hills. Michael reclined on one of the gurneys. His head enlarged to half again its usual size. His left eye was swollen shut. Moses, our night doctor had already seen him and ordered a CT scan and neck x-rays as well as requesting consultations from a plastic surgeon and a neurosurgeon. Fearing the worst, I leaned in and called Michael’s name.
Slowly his good eye opened and focused with a hint of recognition.
He was going to be okay. But given that I wasn’t his doctor, and I was operating on a sliver of sleep and an incipient hangover, I figured it best that he go through with the CT scan. Which, not surprisingly, meant that he had to get back into the ambulance and go to a hospital with a functional CT scanner. The radiologist’s report from Kampala Hospital pointed out the obvious extracranial soft tissue swelling and some ‘mild cerebral edema,’ a finding that might be concerning in a setting other than Kampala where nearly every CT comes back with a reading of cerebral edema. To my eyes, the brain looked normal, but I have to admit that I’m out of practice reading the CT scan in multiple little 3 inch squares of film, since CT scans on film (now we read them on a monitor) disappeared from my practice 15 years ago…
So, given that Michael’s injuries were proving mostly cosmetic, the plastic surgeon swooped in for the kill. He wanted to take Michael to the operating theatre to reopen his facial wound and close it nicely. Estimated cost: another million shillings ($500, on top of the million and a half for the hospitalization and ambulance and CT). A bargain by American standards, but when you consider that VSO only gives us 500,000 shillings a month as a living allowance (and some volunteers aren’t fortunate enough to have a loving wife back home to support them in their folly, and so actually have to live within their allowance), it seems a daunting amount. And, of course, completely and utterly out of the question for a boda driver or your average Ugandan.
So stop and think about it for a couple of minutes. What would you do? Your loved one has a facial wound. There’s going to be a scar. The plastic surgeon seems very concerned (concerned enough to charge for 3, count’em 3, consultations for a 1 inch wound) and wants to make the wound look better. But it’s going to cost you another 2 months salary, on top of the 3 months you already owe. Think about it. Then pray that you never ever have to make this call.
We tried to get Michael onto the Hope Ward (IHK’s charity ward), but it was getting late in the day and Jemimah, the ward’s gatekeeper doesn’t like to work with this particular plastic surgeon due to his excessive billing issues.
At the end of the day, she took him home with the Frankensteinian sutures still in place.
I saw them on Wednesday. Michael was on his feet and looked one hundred percent better. His left eye was open and his smile was back. I wish I knew exactly how the scar is going to look a year from now. I can only hope it won’t be too bad.
Tuesday, April 6, 2010
Sunday, April 4, 2010
Further Impressions of Mulago, Part 1
A small boy walks tentatively into Casualty. In his left hand he clutches a fiber-plastic sack of clothes, in his right, a sheaf of rain and mud speckled papers. It’s about 5pm and all four stretchers are occupied by young men either coming to grips with their newly crippled status or completely oblivious of the fact due to the severity of their head injuries. Since you seem to be only one in the crowded room who will meet the occasional upward flicker of his sunken eyes, the boy shuffles over within reach. His scalp is a flaking field of scabs. He is dirty, dehydrated, and underfed. When he raises his right hand to offer you his paperwork, the minimal weight of his hand and its contents causes his forearm to droop like Harry Potter’s after Gilderoy Lockhart accidentally removed the bones.
The papers suggest that he is twelve years old, but to your eyes he’s an eight year old boy with eighty year old eyes. He has been abused by his father and step-mother. The police intervened and he was removed from the home and placed with, well, placed in the care of the state. In a country where the state has a lot more to worry about than the well-being and whereabouts of a lone 12 year old boy.
You examine his injured right arm. Both of the bones—the radius and the ulna—have been snapped in half. Then you notice that the arm holding the bag sways unnaturally as well. Both of his arms have been broken and untreated, from the dates on the papers, for at least 10 days.
You walk the boy over to the cast room and introduce him to the orthopedic house officer. Best as you can tell from the conversation, the house officer bawls the boy out for not coming sooner—now he’ll need surgery to fix the arms.
Later you find the boy on the crowded surgical holding ward. The boy now has plaster casts on both arms to above his elbows. His look of desperation grabs you by the trachea. You go to the canteen and buy a Fanta orange and a plate of chicken and chips and bring it back to the ward, feeling guilty as you walk by nine or ten other equally hungry patients. The boy looks at the food, and then to his hands—neither of which can now even begin to approach his mouth.
To the best of your ability, you feed the boy the greasy chicken and fries. You wipe the chicken fat and dirt from the boy’s mouth with a waxy napkin. You’ve heard, but never witnessed, that you can offer the nurses a little something to get them to actually pay attention to a patient, so, even though you have sworn to yourself that you would never do this, you go looking for a nurse. But 8pm is rapidly approaching and the nurses are making an exodus. At 8pm the ward will be down to night staffing: one nurse, one intern, 30 or 40 patients.
The night nurse and intern are nowhere to be found. You understand that the intern is probably in the process of barricading himself inside his call room. Much as you wish to help the boy, you have experienced what it is like to be the lone person in a white coat on a ward full of injured and dying patients (and their families) where you don’t speak the languages and you have nothing to offer more than another bottle of normal saline (if the IV fluids have been restocked today) and a helpless facial expression. You slink out the door behind the nurses.
The next afternoon you try to track the boy to the orthopedic ward and can find no evidence that he was ever in the hospital.
The papers suggest that he is twelve years old, but to your eyes he’s an eight year old boy with eighty year old eyes. He has been abused by his father and step-mother. The police intervened and he was removed from the home and placed with, well, placed in the care of the state. In a country where the state has a lot more to worry about than the well-being and whereabouts of a lone 12 year old boy.
You examine his injured right arm. Both of the bones—the radius and the ulna—have been snapped in half. Then you notice that the arm holding the bag sways unnaturally as well. Both of his arms have been broken and untreated, from the dates on the papers, for at least 10 days.
You walk the boy over to the cast room and introduce him to the orthopedic house officer. Best as you can tell from the conversation, the house officer bawls the boy out for not coming sooner—now he’ll need surgery to fix the arms.
Later you find the boy on the crowded surgical holding ward. The boy now has plaster casts on both arms to above his elbows. His look of desperation grabs you by the trachea. You go to the canteen and buy a Fanta orange and a plate of chicken and chips and bring it back to the ward, feeling guilty as you walk by nine or ten other equally hungry patients. The boy looks at the food, and then to his hands—neither of which can now even begin to approach his mouth.
To the best of your ability, you feed the boy the greasy chicken and fries. You wipe the chicken fat and dirt from the boy’s mouth with a waxy napkin. You’ve heard, but never witnessed, that you can offer the nurses a little something to get them to actually pay attention to a patient, so, even though you have sworn to yourself that you would never do this, you go looking for a nurse. But 8pm is rapidly approaching and the nurses are making an exodus. At 8pm the ward will be down to night staffing: one nurse, one intern, 30 or 40 patients.
The night nurse and intern are nowhere to be found. You understand that the intern is probably in the process of barricading himself inside his call room. Much as you wish to help the boy, you have experienced what it is like to be the lone person in a white coat on a ward full of injured and dying patients (and their families) where you don’t speak the languages and you have nothing to offer more than another bottle of normal saline (if the IV fluids have been restocked today) and a helpless facial expression. You slink out the door behind the nurses.
The next afternoon you try to track the boy to the orthopedic ward and can find no evidence that he was ever in the hospital.
Monday, March 29, 2010
A relatively calm week in Kampala
Last week was a week of mourning for the Baganda (people of the kingdom of Buganda). Many of them wore a strip of bark cloth or olubugo tied around their waist or pinned to their clothing. The inner bark of the Mutuba tree (ficus natalensis) is harvested after the rainy season and then beaten with wooden mallets to make a suede-like, terra-cotta colored cloth that swaddled and draped the Buganda royalty. The bark cloth reportedly dates back some 600 years to the second Kabaka. In more ancient times, the cloth was used as a shroud for the dead. As such the cloth is a potent symbol of Buganda culture and a sign of mourning.
The mourning Baganda also mounted photos of the Kabaka (Ronald Mutebi, king of Buganda) on their bicycles and motorcycles and matatus. The loss of the Kasubi tombs (see last week’s post) has hit the people hard. It is difficult for us to understand how people can mourn the loss of a tomb (the bodies of the four previous Kabakas, interred in the tombs, were undisturbed by the fire). In a way it seems odd to mourn for what has already been mourned for, but for the Baganda, fighting to maintain their culture in a rapidly changing world, it seems like the tombs were their link to the past glories of their kingdom. The tombs will be rebuilt. Maybe this time with better security, or wiring, but will they be the same?
On my side of town, Prasandan and I taught an ACLS-type course to the medical staff at IHK. Prasandan is the cardiac anesthetist from Kerala who has landed the unenviable task of starting the new IHK Heart Centre (this morning I asked a medical officer what the EKG showed for a patient that had gone into shock—and was told that the hospital’s lone functioning EKG machine was broken). ACLS is Advanced Cardiac Life Support and is a copyright of the American Heart Association, and, as such, if we were to teach an ACLS course here we would have to have the blessings and sanctions of the AHA, which we did not, hence ‘ACLS-type.’
ACLS mostly focuses on the skills and knowledge needed for resuscitation of people in cardiac arrest, although lately it gives some emphasis to the early treatment of heart attack and stroke as well. In a US hospital, the paramedics, most of the ER and critical care nurses, and many of the doctors would be certified in ACLS. Here in Uganda, where resuscitation is a new thing, the only people certified in ACLS are ex-pats or medical personnel that trained abroad. Given that IHK is about to become a ‘Heart Centre,’ I thought it a good idea that we begin teaching our medical staff the basics of cardiac life support. Prasandan agreed.
I will, up front, confess that my ACLS instructor certification expired during the Clinton administration. But I did manage to research the current ACLS curriculum and guidelines and put together an impressive array of shamelessly copied powerpoint slides. And our doctors stayed awake, for the most part, even after the traditional 1300hr bolus of matoke and gravy. Although they did seem amused by a few of the ACLS recommendations. For instance, the thought that you could get an EKG within five minutes of coming to the ER (at IHK, the EKG machine, when it works, is in cardiology, and you send the patient, without a monitor, to cardiology to get the EKG. The walk to cardiology alone would take up your 5 minutes). Or a head CT within 45 minutes (even if it worked, it would take that much time just to locate the key to the room). Too dang funny. What kind of stuff is the AHA smoking anyway?
My evenings in the Casualty ward at Mulago were a little less didactic. At least this week no one was shot (or, if they were, they weren’t brought to Mulago while I was in attendance). But, at one point I was taking care of 3 patients with Glasgow Coma Scales of less than 8. (the Glasgow Coma Scale or GCS was, not surprisingly developed in Scotland as a prognosticator of head injuries, anything below 9 is considered a major head injury) As is typical of my unflagging optimism, I tried to get some CT scans of my patients damaged brains. Unfortunately, the tech that runs the scanner had gone home and ‘couldn’t be called back in unless it was a true emergency…’
I have decided that I really do not wish to be around Mulago when the ‘true emergency’ comes through the doors.
Fortunately I was not at Mulago on Friday when the Baganda mourning was brought to a close and the bark cloth was unknotted and the tears were dried. The Kabaka and the Nnabagereka (his queen) came to Kasubi to officially bring an end to the mourning period. The tens of thousands of people at the site pushed forward to see the Kabaka and between 150 and 250 people were injured and 2 people trampled to death.
The mourning Baganda also mounted photos of the Kabaka (Ronald Mutebi, king of Buganda) on their bicycles and motorcycles and matatus. The loss of the Kasubi tombs (see last week’s post) has hit the people hard. It is difficult for us to understand how people can mourn the loss of a tomb (the bodies of the four previous Kabakas, interred in the tombs, were undisturbed by the fire). In a way it seems odd to mourn for what has already been mourned for, but for the Baganda, fighting to maintain their culture in a rapidly changing world, it seems like the tombs were their link to the past glories of their kingdom. The tombs will be rebuilt. Maybe this time with better security, or wiring, but will they be the same?
On my side of town, Prasandan and I taught an ACLS-type course to the medical staff at IHK. Prasandan is the cardiac anesthetist from Kerala who has landed the unenviable task of starting the new IHK Heart Centre (this morning I asked a medical officer what the EKG showed for a patient that had gone into shock—and was told that the hospital’s lone functioning EKG machine was broken). ACLS is Advanced Cardiac Life Support and is a copyright of the American Heart Association, and, as such, if we were to teach an ACLS course here we would have to have the blessings and sanctions of the AHA, which we did not, hence ‘ACLS-type.’
ACLS mostly focuses on the skills and knowledge needed for resuscitation of people in cardiac arrest, although lately it gives some emphasis to the early treatment of heart attack and stroke as well. In a US hospital, the paramedics, most of the ER and critical care nurses, and many of the doctors would be certified in ACLS. Here in Uganda, where resuscitation is a new thing, the only people certified in ACLS are ex-pats or medical personnel that trained abroad. Given that IHK is about to become a ‘Heart Centre,’ I thought it a good idea that we begin teaching our medical staff the basics of cardiac life support. Prasandan agreed.
I will, up front, confess that my ACLS instructor certification expired during the Clinton administration. But I did manage to research the current ACLS curriculum and guidelines and put together an impressive array of shamelessly copied powerpoint slides. And our doctors stayed awake, for the most part, even after the traditional 1300hr bolus of matoke and gravy. Although they did seem amused by a few of the ACLS recommendations. For instance, the thought that you could get an EKG within five minutes of coming to the ER (at IHK, the EKG machine, when it works, is in cardiology, and you send the patient, without a monitor, to cardiology to get the EKG. The walk to cardiology alone would take up your 5 minutes). Or a head CT within 45 minutes (even if it worked, it would take that much time just to locate the key to the room). Too dang funny. What kind of stuff is the AHA smoking anyway?
My evenings in the Casualty ward at Mulago were a little less didactic. At least this week no one was shot (or, if they were, they weren’t brought to Mulago while I was in attendance). But, at one point I was taking care of 3 patients with Glasgow Coma Scales of less than 8. (the Glasgow Coma Scale or GCS was, not surprisingly developed in Scotland as a prognosticator of head injuries, anything below 9 is considered a major head injury) As is typical of my unflagging optimism, I tried to get some CT scans of my patients damaged brains. Unfortunately, the tech that runs the scanner had gone home and ‘couldn’t be called back in unless it was a true emergency…’
I have decided that I really do not wish to be around Mulago when the ‘true emergency’ comes through the doors.
Fortunately I was not at Mulago on Friday when the Baganda mourning was brought to a close and the bark cloth was unknotted and the tears were dried. The Kabaka and the Nnabagereka (his queen) came to Kasubi to officially bring an end to the mourning period. The tens of thousands of people at the site pushed forward to see the Kabaka and between 150 and 250 people were injured and 2 people trampled to death.
Sunday, March 21, 2010
another trauma update
Last Friday we had a case conference to discuss a trauma patient who sat around at IHK for over two weeks with an undiagnosed, unstable neck fracture. The conference, in itself is progress—actually getting doctors together to talk about a bad outcome and make plans for prevention of future occurrences is a huge step forward here. (I’ve been trying to get IHK to start having a monthly morbidity and mortality conference since I got here, but, as it turns out, nobody really wants to talk about minor details like how many patients died last month) Granted, if we had been having this particular case conference back home, we would have been sitting down with our insurance company to decide just how much money we should give the patient and the patient’s lawyer to keep them from suing the bejesus out of us.
But, as it were, we sat down with the director of nursing, the director of OPD, the orthopaedist, the radiologist, the ward doctor, the head of physio, and the medical director (one of 3) for the hospital and talked about what went wrong. Well, okay, actually the discussion seemed to focus on what went right. We didn’t kill the patient (or worse, make the patient a ventilator dependent quadriplegic) despite having multiple opportunities and trying really hard several times. And the physiotherapist didn’t choke the living shit out of the ‘spine specialist’ even though she had every reason.
It turns out, according to the orthopaedist who removed the patients stiff collar based on his ‘clinical judgment’ (despite looking at an x-ray, which, albeit a pretty crappy excuse for a film, showed the fracture on the patient’s first night in the hospital), that missing neck fractures is an everyday occurrence and we shouldn’t make a big deal of it. He suggested that we ‘Google missed cervical fractures’ and we would find loads of them. I was going to do this, but the internet is down today.
I tried to suggest how following certain protocols for patients with multiple trauma—such as the one where patients with head injuries or distracting injuries (another painful injury that might take the patient’s mind off their neck) similar to this patient had to have a complete series of neck x-rays (not done) and maybe a CT (not done) and have those films reviewed by someone who actually knows how to read x-rays (not done) prior to the collar being removed—might keep this from happening again. But I was shouted down by the orthopaedist and the radiologist. They weren’t going to start ordering a bunch of extra films or CTs on patients just because we missed one little neck fracture.
The general consensus among the doctors present seemed to be that the care was ‘good enough for Uganda,’ and that my ideas for a trauma team, and protocols, and forcing the radiologist to actually look at all x-rays taken in the ICU, well, they were all well and nice for ‘over there,’ but they just weren’t practical for IHK.
So my question of the other day has been answered. (see one of the updates posts where I mentioned that IHK/IMG has a new vision statement—to deliver medical care to ‘international standards’) To which international standards are we striving?
Here’s to the international standard of being good enough for Uganda.
But, as it were, we sat down with the director of nursing, the director of OPD, the orthopaedist, the radiologist, the ward doctor, the head of physio, and the medical director (one of 3) for the hospital and talked about what went wrong. Well, okay, actually the discussion seemed to focus on what went right. We didn’t kill the patient (or worse, make the patient a ventilator dependent quadriplegic) despite having multiple opportunities and trying really hard several times. And the physiotherapist didn’t choke the living shit out of the ‘spine specialist’ even though she had every reason.
It turns out, according to the orthopaedist who removed the patients stiff collar based on his ‘clinical judgment’ (despite looking at an x-ray, which, albeit a pretty crappy excuse for a film, showed the fracture on the patient’s first night in the hospital), that missing neck fractures is an everyday occurrence and we shouldn’t make a big deal of it. He suggested that we ‘Google missed cervical fractures’ and we would find loads of them. I was going to do this, but the internet is down today.
I tried to suggest how following certain protocols for patients with multiple trauma—such as the one where patients with head injuries or distracting injuries (another painful injury that might take the patient’s mind off their neck) similar to this patient had to have a complete series of neck x-rays (not done) and maybe a CT (not done) and have those films reviewed by someone who actually knows how to read x-rays (not done) prior to the collar being removed—might keep this from happening again. But I was shouted down by the orthopaedist and the radiologist. They weren’t going to start ordering a bunch of extra films or CTs on patients just because we missed one little neck fracture.
The general consensus among the doctors present seemed to be that the care was ‘good enough for Uganda,’ and that my ideas for a trauma team, and protocols, and forcing the radiologist to actually look at all x-rays taken in the ICU, well, they were all well and nice for ‘over there,’ but they just weren’t practical for IHK.
So my question of the other day has been answered. (see one of the updates posts where I mentioned that IHK/IMG has a new vision statement—to deliver medical care to ‘international standards’) To which international standards are we striving?
Here’s to the international standard of being good enough for Uganda.
Crazy week in Kampala
The Kasubi Tombs go up in flames (photo credit: Fans of Kampala FB page)
President Musaveni's security detail clear the way for the presidential visit by 'shooting into the air' (photo credit: Fans of Kampala FB page)It has been a crazy week in Kampala
Kampala made the New York Times last week. That doesn’t happen very often.
Monday afternoon I was giving my emergency preparedness and basic first aid lecture to a large but near-comatose group of employees at Total (the Ugandan affiliate of the French mega-oil corporation). The employees at Total Uganda have their health coverage from IAA (International Air Ambulance--the health insurance arm of IMG which, ironically enough, doesn’t cover air evacuation or, for that matter, even have an air ambulance), and as part of this coverage they get to have little health promotion talks from people like me who haven't figured out how to say no loudly or quickly enough. David, from IAA sales, and Lorna, from customer care, had arranged my visit. Despite doing everything but smack myself in the face with a two by four, I couldn’t get an iota of audience participation to save my life. Until I put up the slide with ‘Questions?’ Suddenly hands all over the room flew up.
Wow, I thought, they really were paying attention and actually have an interest in the subject. I called on one eager looking man at the back of the room who, strangely, was holding a file full of x-rays.
And the man launched into a lengthy diatribe about a knee injury several years before when he worked for another employer, seen my multiple doctors in Uganda, surgically repaired in India, now causing him pain, referred to an orthopaedist at IHK who doesn’t accept IAA and only takes cash. The man with the sore knee finished off his tirade by pointing his rolled up x-ray folder at me and asking, ‘So I just want to know if you doctors are interested in helping people or are just in it to make money?’ Not exactly the question I was expecting to come to Uganda as a volunteer to hear, I will have to admit.
David and Lorna, as you may have guessed, had set me up. My lecture hadn’t been well attended out of an interest in first aid. Instead, almost every man and woman in the room had a beef or a horror story to share about their health insurance.
Monday night, the final rowdy campaigning for the student guild president of Makerere University (Uganda and perhaps East Africa’s most prestigious higher education institution) got a little out of hand at the God Is Able Guest House. The supporters of the Kenyan candidate tried to shut out the supporters of the Ugandan NRM (national resistance movement—Musaveni’s party) and things got a little nasty and the private security guard for the guest house thought that some of the car’s parked at the guest house might be damaged. The guard, who was described in the Monitor as ‘not a regular drunkard’ but ‘harsh and violent toward the students,’ discharged his rifle ‘into the air as a warning.’ Thus answering the question in all of our minds about whether or not those elephant guns left over from Ernest Hemingway’s last safari that the private guards carry are actually loaded.
Yes, they are. Or at least this one was. The bullet passed through one boy’s chest, through another’s and finally penetrated a third boy’s neck. The boys lay ‘in a pool of blood for about an hour’ until their fellow students got enough money together for a ‘special hire’ taxi to take them to Mulago where the two boys with chest wounds were pronounced dead.
Tuesday the students rioted. They broke into a carpenter’s shop to steal a coffin with which to parade around Makerere and into several confrontations with the riot police. At one point the word was passed that they were marching to Mulago (where I was helping take care of the students with baton injuries) to get the bodies out of the morgue so that they could be buried in the central square of Makerere. Apparently, riot police cut the march short with batons and tear gas. Students these days. No follow through.
Tuesday night, as I left Mulago, I noticed a glow in the western sky that I couldn’t quite place.
The Kasubi Tombs, final resting place of the last four Kabakas (Kings of the Buganda kingdom), were burning. As the ‘world’s largest grass thatched roof structure,’ you can imagine it went up like, well, like a (grass) house on fire.
The Baganda (the people of Buganda) gathered to express their grief at the loss of this monument to their culture, and, in doing so, reportedly blocked the Kampala fire brigade’s only two fire engines (one of them, reportedly, a tanker truck that no longer holds water) from responding to the fire. Both trucks were damaged and six firefighters assaulted.
The Tombs on Kasubi Hill occupy the site of the palace of Kabaka Mutesa I—the Muziba Azala Mpanga, built in 1882—the 30th Kabaka of Buganda, who was later buried there. Mutesa was the first Kabaka buried with his facial bones intact. The Baganda believed that a man’s soul resided in his jawbone, so it was removed prior to burial and a special shrine was made to the disarticulated mandible. You can imagine what the missionaries had to say about that.
The Tombs have been listed as a UNESCO World Heritage Site and they are Kampala’s biggest (only, if the truth be known, unless you consider kabalagala at 4am) tourist attraction. I am sad to say, lameass tourist that I am, I had not been to the tombs yet. (my excuse being that I thought it would be something that Nancy and I could do during her upcoming [!!]5 week visit to Uganda)
On Wednesday, President Museveni came to the Tombs to inspect the damage and offer his condolences to the Baganda. As you may remember, the riots that occurred last September involved a presidential edict limiting the travel of the Kabaka, so there is no love lost between the two leaders. A large crowd of angry people tried to block Museveni’s convoy from entering. To gain control of the situation, the presidential guard fired their weapons ‘into the air, as a warning.’ Again, defying most Newtonian Laws of Physics, six men were injured by these warning shots—the two that were later pronounced dead in the resuscitation room at Mulago had gunshot wounds to their chests.
Things have been relatively quiet since Wednesday. But there is much speculation about the possibility of arson. Some suggest that the fire was set by the opposition in order to further the rift between the Baganda and the NRM in advance of the 2011 presidential elections, whereas the Baganda seem to be accusing the NRM of setting the fire to deprive them of tourist income and out of general nastiness.
A UNESCO report from a year or so ago has surfaced suggesting that the wiring for the structure was unsafe. Additionally, part of the shrine was a fire kept continuously burning to symbolize the living Kabaka as part of the unbroken lineage dating back to the 13th or 14th century. So arson and political sabotage may not be the only explanation to what amounts to a huge loss for the Baganda and the people of Uganda as a whole.
Later in the week an announcement was made by the Assistant Chief Inspector of Police that private security guards at student hostels in Makerere will not longer be allowed to carry lethal weapons. We can only hope that maybe they'll expand this to all of Kampala. Although I wouldn't want to be the guy who comes to take away Wilbuforce's (who guards our gate) bow and arrows...
Tuesday, March 16, 2010
Some Lessons American Health Policymakers could learn from the Healthcare System in Uganda.
Last night was the Uganda Irish Society’s St. Patrick’s Day Ball. Guinness was flown in all the way from Dublin. As was the band. There may have been irish whiskey as well… and dancing on tables… who knows… I’m pretty much denying any firsthand knowledge of anything that happened after midnight. Any videos circulating on Youtube have obviously been doctored. All this to say that I’m writing with a wee bit of a headache and a queasy stomach. And this may make me just a bit of a contrarian.
So, yes, I do understand that really I’m supposed to be here teaching the Ugandan doctors what they can learn from American medicine, but, unfortunately, there is no way in hell that Uganda will ever be able to afford American-style medicine (neither, if truth be told, can the United States). It would take a hundred-fold increase in healthcare spending to bring medicine in Uganda within sight of medicine in the developed world. And, given that over ninety percent of the public healthcare budget in Uganda is provided by foreign aid, it is unlikely that the aid-giving countries would go along with such a ramping up of the budget. (Maybe this is the first lesson we could learn. Maybe we need to get our healthcare system is such disarray that the EU will take pity on us and we can get their taxpayers to pay for our healthcare. Don’t laugh, many of our healthcare statistics are drifting down to third world levels.)
Lesson 1: Free basic healthcare for everybody.
Okay, so nothing is free, let’s say taxpayer-funded access to basic healthcare for everybody. As a Ugandan citizen you can walk into a Ministry of Health (MOH) hospital anywhere in the country and be seen by a doctor or a nurse and, if you need to be admitted to the hospital, you will be assigned a bed, or a mattress, or a little piece of floor space. All for free. I can hear you saying that in America you can walk into any ER and get treated without paying a cent, and this may be the case, but always a bill is generated that most people can’t begin to pay. If you are truly destitute, sure, it’s free for you (wasn’t there a Janis Joplin song about that?), but for the rest of us, struggling to keep our hamster-wheels spinning, if you don’t have insurance (and sometimes even if you do), that bill will screw up your life.
Sure. In Uganda, basic healthcare is very basic. Very very basic. Appallingly, horrifyingly basic. But if congress can put together a trillion dollar healthcare bill, certainly we can decide upon an acceptable level of basic healthcare and find a way to pay for it. We have decided, for example, as a country of taxpayers, that we will pay to educate our children K-12. Basic education. Additionally we have decided to subsidize higher education. Surely we could determine what constitutes basic healthcare—annual health visits, childhood vaccinations, prenatal and postnatal care, emergency care, hospitalization, etc—and what would be covered entirely, and what would be subsidized.
Lesson 2: Price tags.
At Mulago, basic care is provided to all, without charge. Depending on what is in stock, this may include IV fluids, some medications, or a CBC (complete blood count). If you need a CT scan, however, it will cost you 150,000 shillings (about $75). A night in the ICU—300,000 shillings. A month of dialysis—3M shillings.
In most cases, the extra fees are demanded upfront. In cash.
In America, in contrast, nobody really knows what things cost. A CT scan might be $1200, but this price isn’t out in the open, it’s buried in a computer program somewhere—and Blue Cross might pay $605 for it while Aetna pays $660 and Medicaid pays $300. The true cost of the CT scan, however, would be a few cents for electricity and digital storage, a few dollars of time for the technician running the machine, fifty dollars or so to the bank that financed the purchase of the multi-million dollar scanner, and maybe throw in a few extra dollars of profit for the hospital—or, about $75.
In American healthcare, neither the provider nor the consumer has a complete grasp on the cost of the service. We all want the best possible healthcare, we want it immediately, and we want someone else to pick up the bill. And, oh yeah, while your at it, don’t even think about raising our taxes. You don’t have to be a Greenspan or a Keynes to figure out that this is not a sustainable economic system.
Only by putting price tags that actually reflect what things cost and making those price tags readily available, can we, as a country and as individual consumers, make educated choices as to how our healthcare dollars are going to be spent.
Lesson 3: Re-involve the family.
In Uganda, a patient comes to the hospital with one or many family members. While the patient is in the hospital, among other things, the family will keep the patient clean, feed the patient, and help the patient move to the toilet. If, for instance, the patient is suffering from some sort of meningo-encephalitis related to his advanced HIV and is delirious and thrashing about in bed, the family will calm the patient, keep the patient from harming himself, and clean up the urine and fecal matter afterward. In the US, the restraining of an agitated patient would divert most of the staff from a ward or unit, it would significantly disrupt care for all of the other patients on the ward, and the fact that strangers were involved would exacerbate rather than sooth the patient’s delirium.
Granted, a patient that comes to a MOH hospital in Uganda without family can actually starve to death on the ward. But there are ways around this. Family members for hire, for instance.
Having family present on the ward leads to a better transfer of information about the patient’s condition and better ongoing care when the patient is discharged. And the family that better understands the medical conditions is better educated to make the financial decisions involved (see Lesson 2). Will the family choose to continue grandma’s dialysis, or will they choose to spend the money on the grandchildrens University? I can hear the gasps of shock and indignation already. But isn’t it more honest to make these decisions at a family level than to defer the decision to Congresses’ budgetary obfuscation? (What? You don’t believe that there is a relationship between the cuts in funding for higher education and the tremendous costs of healthcare in the last year of life? And just exactly how does the easter bunny get all those eggs painted?)
Lesson 4: Let hospitals be hospitals.
Nowadays, hospitals in the US are judged more on the quality of the double latte at the espresso stand in the grand atrium with the dynamic sculpture garden and water feature, and less on the bacterial resistance of the bugs in the ICU. Hospitals in Uganda don’t serve lattes. They don’t have customer service representatives. But, with the exception of a few that, due to plumbing issues, don’t have running water, most hospitals have the basics that a hospital needs: beds, nurses, doctors.
Let’s go back to building hospitals (yes, as a matter of fact, I am advocating the building of new or the reopening of old public hospitals) designed for the practice of medicine and stop with the idea that a hospital should look like a Grand Hyatt and have a five-star restaurant to match. A hospital should not be a place that you look forward to visiting.
Let the families (see Lesson 2) take care of the patient’s food and bedding. If the family wants to bring poached salmon and 1400 thread count linens, so be it. Let the hospital worry about the competency of their medical staff, not the quality of their catering.
Lesson 5: The ER is for emergencies.
The American ER has morphed from a single room into one of the most efficient (and expensive) places for accessing healthcare. And success is burying it. The American people like waiting for their CT scan just about as much as they like waiting for their Double Cheeseburger. The definition of what constitutes an emergency has been diluted to the point of absurdity. Additionally, the unfunded mandate that is EMTALA (emergency medical treatment and active labor amendment) makes the ER the only place that many uninsured and underinsured patients can get healthcare.
The entrance to the casualty ward at Mulago has a sign in English and Lugandan. It says that if you don’t have a life or limb threatening problem you should go away. When you enter the lobby area, the eyes of dozens of sick or injured patients scan you for outward signs of illness or injury—a mental triage to decide if you are going to bump them further down the waiting line. You are ushered behind the triage curtain and the nurse takes your complaint and vital signs. The nurse’s assessment may take a few minutes. If the nurse thinks you have an emergency she makes a color-coded dot on your chit, signifying your priority in the queue. If she doesn’t think you have an emergency, she may refer you to one of the outpatient clinics. She may just tell you to leave.
Lesson 6: More creative use of floor space.
Most of America’s hospitals are operating near or over capacity—either they actually have all the beds full, or they don’t have the nurses to staff the ones they choose to leave empty. What this means to you is that if you are sick and in the ER and need to be admitted to the hospital, you may lie for hours or even days in a corridor of the ER until a bed comes ready in the hospital. And it may mean that the ambulance that you think is taking you to the hospital where your doctor works may get ‘diverted’ to another hospital miles away because your hospital is closed. It also means that hospitals in the US have no ‘surge capacity’ as seen this past flu season when many US hospitals were overwhelmed by the relatively mild H1N1 pandemic.
Mulago doesn’t close. There’s always room for another patient.
Ward 3BEM is the holding ward for medicine admissions. Anybody that is admitted to the hospital from the casualty ward after 4pm has to spend the night in 3BEM before going to the wards. The ward was designed for 18 patients. Currently there are beds for nearly 40 patients and, in the far corner, a tall stack of foam rubber mattresses. When the beds run out, the patients’ families come in and pull a mattress over find a piece of floor space. When the floor space runs out, the patients spill out through the door into the hallway.
Lesson 7: More clinical involvement of the medical students and residents.
Back when I was a medical student (and it wasn’t that long ago, okay, so maybe it was along time ago, more than two decades) an intern was left to supervise us on the medical or surgical wards, while the residents and the attendings were off doing important stuff like heart surgeries or colonoscopies or lunch or something. Nowadays, things like that don’t happen. Medical students are barely allowed to touch patients, let alone make decisions about their care. Interns and residents are no longer allowed to act independently as physicians—every patient interaction needs to be overseen and countersigned by an attending (a board-certified, residency trained doctor).
This is the result of several things: fear of malpractice suits, legislation limiting the work-week of a physician in training, and convoluted Medicare billing regulations. The result is that medical students and residents get less hands on clinical teaching and practice now then they did twenty years ago. It means that they’ve been educated in a system of fear and paranoia that hasn’t taught them basic clinical skills (such as the physical exam) and has taught them to mistrust the clinical skills they do have and to only feel comfortable when they’ve ordered several thousand dollars worth of imaging studies and lab tests to back up even the most insignificant decision.
At Mulago, if you see anyone with a white coat, that person is likely to be a medical student or an intern. Most of the care is provided by the interns (the interns actually show up to work, as the internship is a requirement for registration in medicine in Uganda) under the intermittent supervision of the residents. It is a rare thing when a consultant walks the public wards. I’m not saying that the interns always make the right choices. Far from it. But at least they are out there day after day, meeting the patients, examining the patients, learning how to make medical decisions based on a very small amount of information—not just reading about it, or practicing on a computer simulator.
So, yes, I do understand that really I’m supposed to be here teaching the Ugandan doctors what they can learn from American medicine, but, unfortunately, there is no way in hell that Uganda will ever be able to afford American-style medicine (neither, if truth be told, can the United States). It would take a hundred-fold increase in healthcare spending to bring medicine in Uganda within sight of medicine in the developed world. And, given that over ninety percent of the public healthcare budget in Uganda is provided by foreign aid, it is unlikely that the aid-giving countries would go along with such a ramping up of the budget. (Maybe this is the first lesson we could learn. Maybe we need to get our healthcare system is such disarray that the EU will take pity on us and we can get their taxpayers to pay for our healthcare. Don’t laugh, many of our healthcare statistics are drifting down to third world levels.)
Lesson 1: Free basic healthcare for everybody.
Okay, so nothing is free, let’s say taxpayer-funded access to basic healthcare for everybody. As a Ugandan citizen you can walk into a Ministry of Health (MOH) hospital anywhere in the country and be seen by a doctor or a nurse and, if you need to be admitted to the hospital, you will be assigned a bed, or a mattress, or a little piece of floor space. All for free. I can hear you saying that in America you can walk into any ER and get treated without paying a cent, and this may be the case, but always a bill is generated that most people can’t begin to pay. If you are truly destitute, sure, it’s free for you (wasn’t there a Janis Joplin song about that?), but for the rest of us, struggling to keep our hamster-wheels spinning, if you don’t have insurance (and sometimes even if you do), that bill will screw up your life.
Sure. In Uganda, basic healthcare is very basic. Very very basic. Appallingly, horrifyingly basic. But if congress can put together a trillion dollar healthcare bill, certainly we can decide upon an acceptable level of basic healthcare and find a way to pay for it. We have decided, for example, as a country of taxpayers, that we will pay to educate our children K-12. Basic education. Additionally we have decided to subsidize higher education. Surely we could determine what constitutes basic healthcare—annual health visits, childhood vaccinations, prenatal and postnatal care, emergency care, hospitalization, etc—and what would be covered entirely, and what would be subsidized.
Lesson 2: Price tags.
At Mulago, basic care is provided to all, without charge. Depending on what is in stock, this may include IV fluids, some medications, or a CBC (complete blood count). If you need a CT scan, however, it will cost you 150,000 shillings (about $75). A night in the ICU—300,000 shillings. A month of dialysis—3M shillings.
In most cases, the extra fees are demanded upfront. In cash.
In America, in contrast, nobody really knows what things cost. A CT scan might be $1200, but this price isn’t out in the open, it’s buried in a computer program somewhere—and Blue Cross might pay $605 for it while Aetna pays $660 and Medicaid pays $300. The true cost of the CT scan, however, would be a few cents for electricity and digital storage, a few dollars of time for the technician running the machine, fifty dollars or so to the bank that financed the purchase of the multi-million dollar scanner, and maybe throw in a few extra dollars of profit for the hospital—or, about $75.
In American healthcare, neither the provider nor the consumer has a complete grasp on the cost of the service. We all want the best possible healthcare, we want it immediately, and we want someone else to pick up the bill. And, oh yeah, while your at it, don’t even think about raising our taxes. You don’t have to be a Greenspan or a Keynes to figure out that this is not a sustainable economic system.
Only by putting price tags that actually reflect what things cost and making those price tags readily available, can we, as a country and as individual consumers, make educated choices as to how our healthcare dollars are going to be spent.
Lesson 3: Re-involve the family.
In Uganda, a patient comes to the hospital with one or many family members. While the patient is in the hospital, among other things, the family will keep the patient clean, feed the patient, and help the patient move to the toilet. If, for instance, the patient is suffering from some sort of meningo-encephalitis related to his advanced HIV and is delirious and thrashing about in bed, the family will calm the patient, keep the patient from harming himself, and clean up the urine and fecal matter afterward. In the US, the restraining of an agitated patient would divert most of the staff from a ward or unit, it would significantly disrupt care for all of the other patients on the ward, and the fact that strangers were involved would exacerbate rather than sooth the patient’s delirium.
Granted, a patient that comes to a MOH hospital in Uganda without family can actually starve to death on the ward. But there are ways around this. Family members for hire, for instance.
Having family present on the ward leads to a better transfer of information about the patient’s condition and better ongoing care when the patient is discharged. And the family that better understands the medical conditions is better educated to make the financial decisions involved (see Lesson 2). Will the family choose to continue grandma’s dialysis, or will they choose to spend the money on the grandchildrens University? I can hear the gasps of shock and indignation already. But isn’t it more honest to make these decisions at a family level than to defer the decision to Congresses’ budgetary obfuscation? (What? You don’t believe that there is a relationship between the cuts in funding for higher education and the tremendous costs of healthcare in the last year of life? And just exactly how does the easter bunny get all those eggs painted?)
Lesson 4: Let hospitals be hospitals.
Nowadays, hospitals in the US are judged more on the quality of the double latte at the espresso stand in the grand atrium with the dynamic sculpture garden and water feature, and less on the bacterial resistance of the bugs in the ICU. Hospitals in Uganda don’t serve lattes. They don’t have customer service representatives. But, with the exception of a few that, due to plumbing issues, don’t have running water, most hospitals have the basics that a hospital needs: beds, nurses, doctors.
Let’s go back to building hospitals (yes, as a matter of fact, I am advocating the building of new or the reopening of old public hospitals) designed for the practice of medicine and stop with the idea that a hospital should look like a Grand Hyatt and have a five-star restaurant to match. A hospital should not be a place that you look forward to visiting.
Let the families (see Lesson 2) take care of the patient’s food and bedding. If the family wants to bring poached salmon and 1400 thread count linens, so be it. Let the hospital worry about the competency of their medical staff, not the quality of their catering.
Lesson 5: The ER is for emergencies.
The American ER has morphed from a single room into one of the most efficient (and expensive) places for accessing healthcare. And success is burying it. The American people like waiting for their CT scan just about as much as they like waiting for their Double Cheeseburger. The definition of what constitutes an emergency has been diluted to the point of absurdity. Additionally, the unfunded mandate that is EMTALA (emergency medical treatment and active labor amendment) makes the ER the only place that many uninsured and underinsured patients can get healthcare.
The entrance to the casualty ward at Mulago has a sign in English and Lugandan. It says that if you don’t have a life or limb threatening problem you should go away. When you enter the lobby area, the eyes of dozens of sick or injured patients scan you for outward signs of illness or injury—a mental triage to decide if you are going to bump them further down the waiting line. You are ushered behind the triage curtain and the nurse takes your complaint and vital signs. The nurse’s assessment may take a few minutes. If the nurse thinks you have an emergency she makes a color-coded dot on your chit, signifying your priority in the queue. If she doesn’t think you have an emergency, she may refer you to one of the outpatient clinics. She may just tell you to leave.
Lesson 6: More creative use of floor space.
Most of America’s hospitals are operating near or over capacity—either they actually have all the beds full, or they don’t have the nurses to staff the ones they choose to leave empty. What this means to you is that if you are sick and in the ER and need to be admitted to the hospital, you may lie for hours or even days in a corridor of the ER until a bed comes ready in the hospital. And it may mean that the ambulance that you think is taking you to the hospital where your doctor works may get ‘diverted’ to another hospital miles away because your hospital is closed. It also means that hospitals in the US have no ‘surge capacity’ as seen this past flu season when many US hospitals were overwhelmed by the relatively mild H1N1 pandemic.
Mulago doesn’t close. There’s always room for another patient.
Ward 3BEM is the holding ward for medicine admissions. Anybody that is admitted to the hospital from the casualty ward after 4pm has to spend the night in 3BEM before going to the wards. The ward was designed for 18 patients. Currently there are beds for nearly 40 patients and, in the far corner, a tall stack of foam rubber mattresses. When the beds run out, the patients’ families come in and pull a mattress over find a piece of floor space. When the floor space runs out, the patients spill out through the door into the hallway.
Lesson 7: More clinical involvement of the medical students and residents.
Back when I was a medical student (and it wasn’t that long ago, okay, so maybe it was along time ago, more than two decades) an intern was left to supervise us on the medical or surgical wards, while the residents and the attendings were off doing important stuff like heart surgeries or colonoscopies or lunch or something. Nowadays, things like that don’t happen. Medical students are barely allowed to touch patients, let alone make decisions about their care. Interns and residents are no longer allowed to act independently as physicians—every patient interaction needs to be overseen and countersigned by an attending (a board-certified, residency trained doctor).
This is the result of several things: fear of malpractice suits, legislation limiting the work-week of a physician in training, and convoluted Medicare billing regulations. The result is that medical students and residents get less hands on clinical teaching and practice now then they did twenty years ago. It means that they’ve been educated in a system of fear and paranoia that hasn’t taught them basic clinical skills (such as the physical exam) and has taught them to mistrust the clinical skills they do have and to only feel comfortable when they’ve ordered several thousand dollars worth of imaging studies and lab tests to back up even the most insignificant decision.
At Mulago, if you see anyone with a white coat, that person is likely to be a medical student or an intern. Most of the care is provided by the interns (the interns actually show up to work, as the internship is a requirement for registration in medicine in Uganda) under the intermittent supervision of the residents. It is a rare thing when a consultant walks the public wards. I’m not saying that the interns always make the right choices. Far from it. But at least they are out there day after day, meeting the patients, examining the patients, learning how to make medical decisions based on a very small amount of information—not just reading about it, or practicing on a computer simulator.
more updates
More Updates on Updates:
The week I was walking in the Rwenzoris (‘the place from which the rains come’) was a rainy week for much of Uganda. Mudslides on the slopes of Mount Elgon (to the east of Kampala) loosed some massive boulders and wiped out the village of Bududa, killing and injuring an estimated 500 people and displacing hundreds of thousands more. Mudslides on the western side of the country near Kabale closed the road to Rwanda and brought the number of homeless people to nearly a third of a million. Stacey, a nurse manager and fellow volunteer, contacted the VSO office to see if VSO was planning any actions in relief of the mudslide victims. She was curtly rebuffed and informed that such actions were not considered part of ‘VSO’s mandate.’ (this is the first time I’ve heard that VSO even has a mandate) Sarah, who loves her memoranda of understandings, did mention that maybe VSO should have a MOU with the Uganda Red Cross in the case of natural disasters.
We contacted the Uganda Red Cross directly to offer our respective professional services and were told that the best thing we could do is donate old clothes.
Cholera has struck the UDPF camp of soldiers cleaning up the mudslide.
The rains have been hard on Kampala as well, flooding the slums and washing away the already tenuous road surfaces. Cholera is back in Namuwongo. Two patients from Namuwongo and a patient from neighboring Kibuli were admitted to Mulago in the emergency medicine holding ward with profound diarrhea last week. They were transferred to the ‘cholera camp’ (a series of tents out behind the hospital—see previous post about the cholera camp) the next day, but not until after sharing a toilet with 50-60 other patients and caregivers on an open ward…
My walk to work has been seriously eroded as well. Which is actually a good thing as MSF has diverted the flow of SUVs in and out of their compound, slightly decreasing my likelihood of being struck dead by a Toyota Landcruiser speeding through a residential neighborhood, late for yet another meeting at the ministry (with the trendy no weapons bumper-sticker--as if that was the big threat). One of the roads that slopes down past the La Foret to the hospital had been shored up with white fiber bags that I had mistaken for sandbags at first glance. But the other day, one of the bags had been struck by a car and torn open to reveal its contents—it was stuffed with used disposable diapers… I don’t know, maybe they have something here. Maybe they’ve found the perfect, environmentally sound use for this otherwise impervious substance.
The week I was walking in the Rwenzoris (‘the place from which the rains come’) was a rainy week for much of Uganda. Mudslides on the slopes of Mount Elgon (to the east of Kampala) loosed some massive boulders and wiped out the village of Bududa, killing and injuring an estimated 500 people and displacing hundreds of thousands more. Mudslides on the western side of the country near Kabale closed the road to Rwanda and brought the number of homeless people to nearly a third of a million. Stacey, a nurse manager and fellow volunteer, contacted the VSO office to see if VSO was planning any actions in relief of the mudslide victims. She was curtly rebuffed and informed that such actions were not considered part of ‘VSO’s mandate.’ (this is the first time I’ve heard that VSO even has a mandate) Sarah, who loves her memoranda of understandings, did mention that maybe VSO should have a MOU with the Uganda Red Cross in the case of natural disasters.
We contacted the Uganda Red Cross directly to offer our respective professional services and were told that the best thing we could do is donate old clothes.
Cholera has struck the UDPF camp of soldiers cleaning up the mudslide.
The rains have been hard on Kampala as well, flooding the slums and washing away the already tenuous road surfaces. Cholera is back in Namuwongo. Two patients from Namuwongo and a patient from neighboring Kibuli were admitted to Mulago in the emergency medicine holding ward with profound diarrhea last week. They were transferred to the ‘cholera camp’ (a series of tents out behind the hospital—see previous post about the cholera camp) the next day, but not until after sharing a toilet with 50-60 other patients and caregivers on an open ward…
My walk to work has been seriously eroded as well. Which is actually a good thing as MSF has diverted the flow of SUVs in and out of their compound, slightly decreasing my likelihood of being struck dead by a Toyota Landcruiser speeding through a residential neighborhood, late for yet another meeting at the ministry (with the trendy no weapons bumper-sticker--as if that was the big threat). One of the roads that slopes down past the La Foret to the hospital had been shored up with white fiber bags that I had mistaken for sandbags at first glance. But the other day, one of the bags had been struck by a car and torn open to reveal its contents—it was stuffed with used disposable diapers… I don’t know, maybe they have something here. Maybe they’ve found the perfect, environmentally sound use for this otherwise impervious substance.
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