Uganda Summer 2012

In the few weeks I've been at the Rugazi Health Centre IV I seen some appalling conditions. A HCIV is supposed to be a step below a hospital but the facilities and equipment are sorely lacking. The site is short on basic medical supplies like gauze, sutures, and even medical tape for bandages. Drugs are on short supply so patients are often required to purchase their medical supplies and medication out of pocket outside the centre. I have not been in the IV storage room where the NS (normal saline) and blood are kept.

Once a patient is admitted, they are placed in one of the three wards; paediatric, male, or female (or the fourth, maternity). In all but the paediatric ward, people are supposed to bring their own beds, all are required to bring their own bedding. Food is not supplied and as mentioned earlier, they often have to pay for their own supplies and medication.

There is no full time physician at the centre; we do have a clinical physician (some diploma program that reflects a LPN in Canada) but no physician. The senior medical students conduct ward rounds; we have three. I'm told that the visiting physicians or students conduct rounds, not nurses meaning that if we were not here the patients would not be seen. Nurses give our medication on ward and dispense for out patients.

I would not say that the IV usage is safe. The staff is reluctant to use disinfectants because of the short supply and there is no sterile compounding area whatsoever. Sterile prep amounts to opening ampules, withdrawing without a filter needle, and injecting into the hard plastic IV bag (no injection site... just directly into the bag) or direct bolus dose without the use of a filter needle when withdrawing a preparation. No Y-site injection. No laminar air hood. No disinfecting. At least the needles are sterile in package. It is very unnerving to see the IV bag with an uncovered needle sticking out.

There is not enough blood for transfusion. One night last week there were four patients that came in with severe anemia in dire need of transfusion. There was only one bag of B+ blood in storage and none of the patients could receive it. One child died while the other three were rushed Ishaka (the nearest hospital). The person in charge of stocking the blood did not do his job; he claimed that the distance to get the blood was too far and that we should like the patients die.

In truth, some of the patients would not have benefited from a transfusion; their levels were so low that they would have died anyway. Still, it is very depressing that one could get to a state like that in the first place. Some patients come in like skeletons from malnutrition (the patient I have in mind was also HIV positive) and resemble some of the people I've seen in history textbooks about severe famine during wartime.

My experiences haven't been all bad. There are many times when I think I've learned a great deal about tropical medicine. I am just merely unloading some of my shock and experience from the past 3 weeks. I've seen some more grotesque problems but they are best left for another day (preferably in-person).

Posted by stt100 at 07:24 AM | Permalink

"Muzungu" is something I've been called since landing here back in June. I had assumed it meant foreigner for a period of time but have been informed that it translates literally as "white person". Can't say I've ever been called that before; it is eerie. The four of us are so incredibly visible, especially in the health centre (located in the Rubirizi sub-county). In truth I've been at this location for two weeks and recorded notes which I am using to write this post. I was informed of the meaning of "muzungu" before leaving Mbarara but have noticed it being used far more in the rural community. Even the nurses at the health centre call us "muzungu" and I've been mistaken for a doctor by some patients when I walk by on ward. In the market and once in the community I've been called 'china-man' but mostly it is "muzungu". Children are more apt to yell it at me whenever they see me, usually accompanied by "How are you?". On four seperate occasions, a young child has run up to me and grabed my hand/hugged my leg (the latest being just today). Occasionally they are scared and hide (this has happened twice).

After arriving in the community we were required to do a 'transect' walk to help identify the major challenges facing the local rural community. I wish we took a video of what happened but I'll do my best to describe it. At the first school in Kyakabunda (pronouced "Chya-ka-boon-da") village, children yelled and cheered as we passed. There were two mud brick and mortar buildings on either side of the dirt road, each with two classrooms. The children were in our equivalent of primary school and I do believe they've never seen a foreigner before. When one of my fellow Canadians moved to take a picture they rushed to the window trying to become featured. This proceeded to happen twice more at other schools.

The transect walk took a great deal of time; we passed through several villages and saw a pair of the numerous crater lakes in the area. Rugazi HCIV is right next to Queen Elizabeth National Park (one of the destinations of our safari). Over the past two weeks we have visited the rural communities 5 or 6 times, each of them an exhausting experience. The most tiring aspect of the walking is not the distance but the terrain. There are hills everywhere. We reach them by foot for a couple reasons, there are 14 of us which makes hiring "bota-bota" (motorcycle taxi) unreasonable and if we were to approach the community with vehicles we carry a superior air of wealth which makes the villagers believe that we come with a lot of money. This is a problem because we are supposed to help the community solve it's own problem; something we cannot do by injecting money into the system as this is neither sustainable nor effective.

Posted by stt100 at 07:33 AM | Permalink

The Ugandan education system is rather different than ours. It follows the UK system more closely and has O-levels and A-levels. They have primary school (7 years) and secondary school which runs for either 4 (for O-levels) or 6 years (for A-levels). One needs only complete O-levels for a high school diploma but A-levels are required for university. I’m told that A-levels are similar to first year university in terms of course material and workload; similar to CEGEP in Québec.

As a result, professional health programs like Medicine and Pharmacy are direct entry. The many differences may be due to differing focuses of our health systems. The challenges in Uganda are very different from Canada. For one, there is less emphasis on cardiovascular diseases which are traditionally regarded as developed world problems. Uganda focuses more on malnutrition, tropical diseases (most notable Malaria), and HIV. Why worry about CV diseases if the population doesn’t live long enough to even suffer from their effects. On a side note, one of the presentations during the program’s in-class week was about CV diseases in Uganda. They presenter was a physician who showed that the prevalence of CV diseases is on the rise in Uganda and many other places in the developing world. Major problems here in Uganda include poor sanitation, HIV/AIDS, high infant and maternal mortality rates, Malaria, and many, many more. There was some mention of mental illness which is pleasantly surprising. Not that I take joy that there are mental illnesses but I think it great that it is even on the health system’s radar. Even in Canada we handle the situation poorly and too often shun those suffering mental illness due to stigma despite the high prevalence.

Medicine is actually a 5 year program in Uganda. Students are in class throughout and have clinical experience starting early in the academic program. According to the Med student in my group, facilities at MUST leave much desired; their cadavers are not kept in cold temperature and are preserved with chemicals. Uganda lacks a rigid residency program which we in North America are so accustomed.
MLS is a 5 year program but I cannot think of an analogue in Canada. The closest I come is a diploma or certificate from technical institutes but not a university degree. I have yet to talk to nursing students about their program here in Uganda so I cannot really compare the programs. It is a university degree and takes 4 years, this is all I know of Ugandan nursing education.

Pharmacy is rather different, it is still four years but the topics covered are slightly different. In the summer after the second and third year, pharmacy student participate in community (community health, not community/retail pharmacy) and industry practical experience respectively. After the fourth year students must register as interns and work in a dispensary before they can take the national licencing exam. This is very different from our program in Canada. At the University of Saskatchewan a student will have all the practical hours needed at graduation to take the national licencing exams but in other provinces and programs (such as in Ontario) students must work under a provisional licence but are still considered pharmacists. Students in Uganda do not learn about laws and regulation in school but pick them up in practice.

I remain confused on how community (retail) pharmacy works in Uganda. I don`t think they use prescription pads in the majority of cases due to a lack of resources (especially in rural areas). I`ve also been told that if you are a foreigner and ask the pharmacy for something, they will give it to you provided you have the money which could be because they mistake you for a physician or maybe due to corruption; it`s illegal.

Posted by stt100 at 03:10 AM | Permalink

Our in-class week at MUST has started yet I remain a little uncertain as to exactly what we are doing in the community. The Canadian students are divided into two groups which must address different health challenges in the community however we are all going to the same health centre (Rugazi Health Centre IV). Our two groups are in different rooms for the purposes of the in class workshops that run from 8h30 to 16h00 every day. It comes as a surprise but we are the only international students participating in the Leadership in Community Placement class; the Ugandan student who presented the program with Dr. Nazarali mentioned that there were other health professional student from various countries whom participated in the past but this is not the case this year. Apparently the program is recently revamped. Again, I am not surprised seeing as they informed us of the shortened community portion from 5 to 4 week just the night before.

Rather than post an entry for every day of the in class work, I'm separating entries based on topic. Here I'll talk about the course material. The LCP program is very similar to my Pharmacy 417 class (Management in Pharmacy); a core class in Pharm 3 rated for 4 CU that covers over the Fall and Winter semesters. Topics of note include differentiating between management and leadership, teamwork and group work, and how to focus and identify challenges (not problems) in a given situation. The major difference is that it forces us to put these skills developed in the first week into practice in 4 weeks in the community. Having taken most of the material before, I feel slightly de-motivated to participate. The semantics are different from what I learned in the last school year but it is easy to follow save for some difficulties with the vernacular and accented English.

Most of the presenters were clear and our groups completed exercises well enough. One coordinator, from the college of Nursing, had a harder time than the others. She has heavily accented English which even the Ugandan students had trouble following. She did not seem particularly prepared and often mixed up her words or the order in which we were supposed to complete exercises which made the sessions confusing. One would think that I am accustomed to broken English because of my parents but they speak with a different accent and break the language in different aspects. Still, the students are much easier to understand than some of the coordinators.

Students from Medicine 4, Pharmacy 2, Nursing 3, and Medical Lab Science (MLS) 3 participate in the summer program as an elective worth 5 CU. My group has two Med 1, one Vet Med 1, and myself (Pharm 3). It costs $500 USD which covers the course, community allowance for food and supplies, lunch during class, and accommodations at the rural site. The tuition also covered our stay at the MUST international apartments. We are covered for the entire 6 week duration as promised before they shortened the program. My group has one Med 4, one Pharm 2, three MLS 3, one Canadian Med 1, and myself (Canadian Pharm 3). The other group has two Med 4, one Pharm 2, one MLS 3, one Nursing 3, one Canadian Med 1, and one Canadian Vet Med 1. This may just be my bias, but I feel that there is a great disparity between the level of education of the different health students. The Med students have the most experience being the furthest in their academic education as well as clinical experience. Perhaps I'm being overly sensitive because I'm in Pharmacy but one cannot deny that the pharmacy students in this program have the least clinical experience. I asked and learned that this is the first instance of clinical experience the Ugandan pharmacy students have in their program.

We are headed off to Rugazi on Sunday which gives us time to buy our supplies before heading off. We will be better off than other groups as Rugazi Health Centre IV is one of the most developed rural health centres (not quite a hospital) having electricity, a fenced and guarded perimeter, running water, and mobile phone signals (for cellular phone use and internet access). Some other sites lack even beds for the students; they are given a slightly higher allowance if they must buy more supplies and amenities like water. I think the administration didn't want to shock the Canadian student too much by throwing us into the truly rural areas of Uganda.

Posted by stt100 at 03:07 AM | Permalink