Uganda report 4: HIV is a bad disease!!

(Next update - originally posted May 22, 2007)

Yep, HIV is a really, really, really bad disease – most especially if you’re poor and you live in Africa (or probably anywhere in the world besides North America, Western Europe, Japan or Australia/New Zealand – i.e. anywhere there is high or soon-to-be high rates). Despite improvements in the educational aspects as well as treatment aspects there is still horrible outcomes here, everyday in fact. I’ve been on the ID female ward now for 2 weeks and I think we are unfortunately averaging about 2 deaths a day. The vast majority of them are patients with neurological complications of HIV. (Most often proven or presumptive cryptococcal meningitis, followed closely by proven or presumptive cerebral toxoplasmosis for you medical types). I think in saying that I’m a bit biased because most of them with respiratory complications (probably the next most common) go to either the pulmonary ward or the TB ward. I was concerned that it was me (as I’ve been the most senior person around the vast majority of the time) but when I expressed that concern all the rest of the house staff started laughing hysterically. I guess it’s always this bad.


What end stage HIV/TB looks like (permission granted to take picture)

Anyway, we do have successes, ones we do catch in time and ones that make a stunning recovery – it’s just hard to see the ones that don’t. TB is the other thing. Right at the moment several of our patients are on dual treatment for TB/HIV and we are not able to monitor them nearly as well as I’d like. For those of you non-medical types - TB is a bad disease but TB on underlying HIV is a terrible disease, it may present differently and be difficult to diagnose and it’s hard to treat. Maybe this isn’t quite so bad in Canada where we have access to much better diagnostic measures but it’s a problem here.

Actually I must say one of the most frustrating things here is the inadequacy of the ability to appropriately diagnose. I do think that my clinical diagnosis skills have improved greatly – not as good as some of the others here but much better – but still, you can only get so far with your ears, eyes, hands, stethoscope, reflex hammer and penlight (especially since my penlight has vanished). We end up treating empirically a lot of the time and that’s frustrating.

Case in point: 37 year old lady, known HIV positive comes in with right sided weakness and confusion. She’s not on anti-retrovirals (anti-HIV medications) and there’s some question about TMP-SMX prophylaxis. Probably cerebral toxoplasmosis but could be any number of things. The family cannot afford any investigations (they finally scraped enough together for a blood count, CT Scan? ha ha ha ha ha) and so we’ve been treating empirically with high dose TMP-SMX (forget Pyrimethamine etc – although, there is one study that shows high dose septra may be a good alternative…). I could and have been very, very tempted several times to pay for investigations myself. I haven’t yet because I don’t think it’s really fair. None of the people I’m treating have much money (that’s one reason they end up in Mulago Hospital) and to be fair I’d have to pay for all – how could I choose? We’ll see – I know that if it’s one of the young ones (the adult ward starts at age 13 here) I’ll probably not be able to resist the temptation to help out but thus far on our ward we haven’t had any of the really young ones that have been acutely unwell.
Hmmm, ethical dilemmas all the time.
OK, I know the last bit was super medicalized and I apologize to those of you who couldn’t follow it. On the lighter side of things – I have noticed that I am starting to talk Ugandan English. There are some definite differences and some figures of speech that are creeping in. One example: Somebody drops something, bangs their head, tells a story about not being able to sleep well the night before etc etc: Ugandan English: “Sorry!!” They say “Sorry” in a very sympathetic way when anything bad happens, all the way from a family member dying to me accidentally drawing on my lab coat. (Yes Martina, I will probably come home apologizing more than I already do hee hee).

Another example: Someone needs to use the washroom (toilet for you Americans): Ugandan English: “I am going for a short pass” or “I need to take a minute for a short pass.”

Another example: Someone is explaining something and trying to emphasize a point – Ugandan English: “He was very sick and we took him to the what?..To the hospital” or “She had meningitis and we gave her what?...the Ceftriaxone” or “She is losing her place to stay so she talked to who?...to the Branch President.” This one is my favourite and almost any conversation longer than about 30 seconds contains at least one example of this. I totally love it actually.

My Luganda (the most commonly spoken language in the Kampala District I think) is not coming along as well as I would like. Although today in fact there was a moment when we were asking about somebody’s pain (Kalooma) and I totally understood: it was very bad (nya nya nya) when she coughed (koloofa). I also can understand words like bowel motion (afluma) and breathing (sanyo) and ask about them. (NB I’m not sure of the spelling of these words). I also know the standard greetings and thanks etc but that’s about the extent of it. I’m not sure if my accent is terrible either because sometimes when I say what I think is the correct word they just look at me funny and my intern has to repeat it. Sigh, the one book I have does explain some things but it doesn’t really help in the medical setting (“that is the goat of my sister” and “please pass me the posho” aren’t terribly useful unfortunately.)

Uganda is a great place. Some of you have expressed concern that I am working too hard and I may be. I have worked every day since I’ve come and I’ve decided to try and take one short trip to at least see a little of the country. My social life has been extended slightly. There haven’t really been many people at the guesthouse at all so I’ve had to find people to do stuff from work. There was a visiting resident here from Yale University and his girlfriend was also here volunteering so I went with them to this orphanage one evening last week and played with the kids for a little while. We were supposed to be helping but I think we pretty much just got them all riled up. We had a fun time though!!


Fun at the orphanage


Some of the girls took me out last Friday night as well (other residents) and I have now confirmed my suspicions that most of the restaurants that the mzungu (foreigners) frequent are highly overpriced. We had a huge meal including soda for 3500 USh each and they thought that was a little on the pricey side. We had fun though and played snooker/billiards.


Billiards (bad picture of my friend though, she's much prettier in real life)


I also went to the Uganda Museum on Saturday after work. The people that were supposed to go with me bailed so I went by myself and spent about an hour and a half (and saw the museum extensively – it’s not an extensive museum). Highlights included the bark cloth exhibit and the traditional musical instruments with someone to play them for you. I actually bought a CD of traditional music for a souvenir because it seemed kind of more original than the other stuff (although I was slightly tempted by the T-Shirt that said: “Mzungu”).



Musical instruments in the museum





(Next paragraph is Mormon stuff) I really enjoy church here immensely, it’s a nice branch. I also went to institute class last week and enjoyed that. It turned out to be the last class of the semester but they will start up again in two weeks as well. I thought it would be fun and it’s nice to go mid-week sometimes to get a different perspective on life. Anyway, I’ve been so impressed with people here, they’re mostly very young – but very devoted. The District President has moved into the branch I go to so he spoke last Sunday. Fabulous talk about respect and reverence – I kind of wish my ward back home could have heard it. Great guy with a great little family.

Anyway, I need to go and this is getting very, very long – the longest yet! You all keep telling me it’s fine though…and I guess if you don’t want to read it you can delete. Keep well!

Love Jo