Clinics and cakes

Last report - sent June 10th, 2007

Greetings all! I hope this find you well and enjoying spring (…or summer for some of you further south). It still seems to be the rainy season here as we’ve had several heavy rains here this week. Everyone here thinks that the seasons are changing – the rains are more erratic than previously - and they blame it all on global warming. I understand that Calgary had a huge rainstorm last week and unfortunately they’re not as well equipped to deal with it. (In Kampala there are no basements to flood, the roads have specific run-off gutters and there aren’t nearly as many large auditorium-like buildings with roofs that can collapse) I hope that everyone is coping OK with things. Dang global warming.

This may be my last “Uganda report” as I start my last week of work tomorrow and it depends on how ambitious I feel when I start vacation the week after. Last week and this coming week I have been and will be doing some outpatient clinics at the IDI (Infectious Disease Institute) that is just across the way from Mulago Hospital. In a sense “IDI” is a bit of a misnomer because it’s pretty much all HIV – at least the clinical side is. (Although, really, the same could be said for the “ID” wards at Mulago, and for that matter, many of the other medical wards). I really wanted to get a sense of outpatient management of HIV because most of what I’ve been seeing has been what happens when HIV is NOT managed in outpatient. (For the non-medics: outpatient = basically, people not in the hospital – they can still be quite sick though).

There are numerous HIV and other clinics that I could have gone to but I chose the IDI for a few reasons, not the least of which is the proximity to Mulago so I can go back and forth. Several people I have come to know also work there as well and finally, I am still trying to figure out just exactly what I want to do/be when I grow up (I know, it’s pathetic at my age…) and the IDI is sort of one model of a very long term collaboration/organization between resource wealthy (mostly U.S.) countries and a resource poor country that I was looking at to evaluate the setting I want to work in. I’m still not sure exactly what I want to do but I am enjoying my time in clinic. It is more of a primary care type clinic. The care is free there and therefore the patients very seldom would see any other doctor. There are lots and lots of patients (called “friends” at the IDI) to see, although not as many as at the free Mulago clinics where the stack of charts seem endless, and one has to be very efficient.


The IDI


Dr. Kalule and I at the IDI
Overall I have really enjoyed my time here in Kampala and I can’t believe it’s almost over! Time flies when you’re learning lots and having fun. Yesterday afternoon I went with some of my friends to an “Introduction”. It is the first stage of the traditional Ugandan wedding ceremony. It was quite fascinating although given that it was all in the tribal language (which happened to not be Luganda) I really didn’t understand much. They tried to translate for me but it’s hard and given I was the only foreigner there I already stuck out so tried to create as little ruckus as possible.

My friends (5 sisters) are close friends with the bride and her sister and one of the 5 was a bridesmaid so they wanted me to come. The day was very long and I was quite tired by the end of it. I had gone into the hospital in the morning for awhile and then went over to my friends’ house at around 1pm. I’m not sure why 1pm since we didn’t end up leaving until just after 3pm so that gave them plenty of time to dress me up in traditional clothing for the wedding. I seem to attract this wherever I go – I’m not sure why as I generally look kind of funny (hmmm, maybe that’s the reason): this tall awkward white girl (made taller by the heels that I’m inevitably given to wear) with traditional clothes that don’t quite fit properly and that I’m always tripping on and adjusting because traditional clothes in the places I’ve traveled tend to involve long flowing/draping styles. Ah well, at least it provides entertainment. Maybe I’ll show you the pictures at home.


Traditional clothes

We arrived at the venue by around 3:30 pm and it was good that we hadn’t gone sooner as nothing started until around 4:30. It was at the bride’s family home and they (excluding the bride and her attendants) all sat on one side of the yard waiting until the groom and his entourage (mostly family members and close friends – all male) arrived seeking entrance. Female family members of the bride and her brothers meet them at the gate and the groom’s side have to “negotiate” to come in. Once they do they sit down on the opposite side of the yard and the ceremony begins. They are served some sort of traditional drink – no one could really explain what it is (some sort of fermented sorghum drink?) and a whole bunch of speeches welcoming and receiving welcome occur. One uncle of the bride and one uncle of the groom do most of the talking (the bride and groom and their immediate family say very little the whole day) and those who are funny and good at speeches seem to be preferred. (Hmm, I’m not sure who I would choose of my uncles – it has to be one of your father’s brothers so couldn’t be Uncle DeLoss – he’d be good but then, so would all Dad’s brothers too, I think they’d get into it).

Once it’s been established that the groom’s family came seeking a wife for one of their members (more speeches), girls start coming out. First they send out a bunch of young girl cousins between 10 and 14 years and the groom’s uncle makes a big deal of the fact that these are too young. Then some of the bridesmaids are brought out and the uncle make another big deal comparing them to a picture he has of the girl and deeming them not right. Finally another group of bridesmaids come out this time with the bride and her aunt (mother’s sister) and the groom’s uncle proclaims that he’s finally found her. At that point they have to “find” the groom so the aunt and the sister (sort of like the maid of honor) go over to the groom’s side and “identify” the groom. He then comes and they are “introduced” and he gives her a small gift (necklace in this case). I guess traditionally these would have been arranged marriages made by your aunts and uncles and you wouldn’t meet until the actual day, hence “introduction”.

The next part was…interesting: the negotiation of the bride price. They finally settled on 6 cows, which is apparently quite a lot. It kind of gets my feminist ire up a little bit (I was never a great fan of “Johnny Lingo” like many were – sorry, inside joke for those of you who didn’t understand that). One of my friends was sitting beside me and explained that it is still traditional, especially amongst this tribe, although many feel it’s quite archaic and should be done away with. (Mormon comment here sorry) She told me they’ve been very strongly counseled by Pres. Hinckley and other leaders to celebrate as much of their culture as possible that is positive but to not participate in things that denigrate people and the bride price is a commonly cited example. It equates woman to property and encourages a negative unequal marriage partnership.
Anyway, after that, more celebratory speeches and a tradition that I think we should emulate. A cake was brought in to celebrate (not a true wedding cake as I guess that’s for the next ceremony) and the bride and groom cut it along with the aunts and uncles. Then the bride, groom, bridesmaids and groomsmen handed out cake to everyone. Great tradition I thought! Not only do they get to move around and quickly greet people that they might not otherwise, they also get rid of the wedding cake. Not that they would have had troubles getting rid of it – it was very good chocolate cake! It just seems like most North American weddings have massive amounts of excess cake left over which wouldn’t happen if you actually brought it around to people.

There were more speeches of celebration at this point and then introduction of the family members (although only the males on the groom’s side as the females don’t participate in this part I guess). I didn’t really understand much of this and I was getting quite tired by this time. It was about 8pm by the time they finished all the speeches. Then we got to eat (Hurray!!) traditional food, which I have come to really like. The “give away” is the next ceremony, in a couple of months I guess, which is the actual traditional wedding and nowadays is usually accompanied by a church wedding the same weekend.

I had brought my camera and had taken a few subtle pictures prior to this but then took a whole bunch of all the bridesmaids and my friends, which they were very excited about – very few people have cameras here. In fact, I burned them a CD of all of the pictures and gave it to them today because they were so keen on having them. We came home late and I was very tired but it was a really great day.






Once again I’ve blathered on a long time so will sign off. I hope you are all doing well and I’m looking forward to seeing you soon.

Love Jo

Uganda Report 5: Gorillas in the Mist

Next update: originally sent out May 31

I apologize for sort of being missing in action the last few days. I actually took a spur of the moment trip to Rwanda to go gorilla trekking and also have had some internet connection troubles. It seems to go down with unpredictable but frequent regularity. I wonder if it’s like the electricity problem where I think that too many people are trying to use it. I’m not very technologically savvy and don’t really understand internet access all that well. I’m just happy when I can get on. (It’s frightening how accustomed and even dependant I’ve become to my luxurious cable-line access at home).
Things are going along as usual on the ID female floor. I am trying to learn as much as I can and to help as much as I can without getting too upset about the inadequacy of the care we are able to give most of the patients. I think one of the reasons a lot of the staff people are just not around on the ward is that they realize this as well and probably get burnt out dealing with it so just don’t. Somehow ID female has also been saddled with the next rounds (next Tuesday), which happen to be the last rounds of the semester as exams start the next week. No one wants to have anything to do with them of course because of all their exams and trying to finish up work. We also can’t find a good case on a topic that someone hasn’t recently just done a presentation on. I think we are going to actually revamp my old Primary CNS Lymphoma talk as an “Approach to CNS lesions in HIV” as 75% of the work is already done. I hope it turns out OK as they tend to be a very hard crowd and like to nit-pick even more than some of the more famous nit-pickers in our program.

Speaking of nit picking, that reminds me of the gorillas last weekend and their grooming habits. I was feeling very burnt out and frustrated and after having worked everyday since I came here I was encouraged by numerous people (including many of you) to take a weekend off and do something. The opportunity came up to go gorilla trekking in Rwanda so I took it and loved it – despite the 10 hour bus ride each way (yuck – I won’t dwell on that much, only to say that loperamide is a good drug in a desperate situation), and the very random border crossing procedure which involves all passengers signing out of one country and trekking 500 metres through the mud to sign into the other country. I went with Victoria, a recently graduated medical student from the US. She is a very interesting girl.
Kigali (the capital of Rwanda) is absolutely beautiful (more beautiful than Kampala actually). All of Rwanda that I saw is really beautiful, it’s hard to believe that the genocide could have happened in such a beautiful place with such nice people. It’s such a small country that all of it has to be under cultivation so you see all these fields straight up all these very steep hills. I took a million pictures of it because I thought it was so nice.
We arrived in Kigali at about 1pm and were met by Isaac, the brother of a travel agent that we’d been in contact with. He was very nice and drove us around Kigali quite a bit. Nothing was open until 2pm as it was the last Saturday of the month (and that’s national clean up day in Rwanda so everything is closed while everyone cleans the country – great custom) so we ended up going to the nice mall and eating lunch in a coffee shop there. So, after lunch we went and picked up our gorilla tracking permits and then we went to the genocide memorial. It’s a lovely building and tells the story of how the genocide actually happened and some reasons why. It is very well done and completely heart wrenching. I was quite upset at some parts and I think Isaac felt bad for me. The only place I’ve been like that before is Yad Vashem in Jerusalem. There were two particularly bad parts, one was some commemorative biographies of children that were massacred in the conflict and the other one was in the clothing room. They’d saved some of the clothing that was found on some of the corpses and one was a little boy’s t-shirt that said “Ottawa, Canada” on it. It made me feel awful, we could send all our used clothes over to Africa but somehow none of us could do anything to stop the horror of the genocide from happening. Outside the building there is actually graves of victims and beautiful grounds. I guess whenever they find a mass grave (and there are lots) the bodies are coffined and brought there for formal burial services. It’s a peaceful place with lovely gardens.



Kigali, from grounds of genocide memorial


Anything after that is a bit anticlimactic but I must say the ride up to Ruhengeri (the town close to the Parc National des Volcans – where the gorillas are and where Dian Fossey did her work) was stunningly beautiful although a bit frightening because of the drop off. It was akin to the “Going to the Sun” highway between Waterton and Glacier National Parks but obviously more tropical. We got up early the next day in order to get to the local park office and there we were split up into groups of 8 (the maximum number of people they allow to visit each family group of gorillas). We had a bit of orientation with our guide, Placide, who told us about things and then we got to know each other a bit.

Road to Ruhengheri





We drove on abominably bad roads for a while out to a little village nearest to where our trek would start and then walked through fields for about 40 minutes to the edge of the park. Then it was pretty much straight uphill, although after about 10 minutes we had to stop, turn around and go back down and around to another point as the gorillas had moved. We went uphill then for another 30 minutes or so and then, all of a sudden, there they were, sitting contentedly and resting. It was an amazing experience! You understand while people get into studying fascinating animals in the field for years on end although at the same time you wonder how appropriate it is to sit there and stare at them – although they often stare right back, probably wondering why in the world there is an odd group of awkward, funny-looking animals that come to look back at them for awhile everyday.
The group we went to see has 9 members. The silverback was the first one I saw, just sitting and leaning over. I didn’t realize how big he was until he got up and started to move towards me – yikes. Then there were three females (although I think we only saw two), one blackback (a male, not yet mature), a juvenile female who sat grooming her mother the whole time, two young ones (a year or two) who were hilarious and very active – rolling around, climbing and falling out of trees, and rough-housing with one another. The last one was a very cute little baby that is apparently only 1 month old. She (they know it’s a female) sat in her mother’s arms the whole time, every so often peering out at us. I probably took about 100 pictures. You’re not allowed to use the flash so some of them didn’t work that well but I think I’ll save all of them to show to Alita – she’ll be really jealous as she really wants to see gorillas – maybe we’ll see some chimpanzees instead.





Gorillas


Mist

Anyway, it was a great experience but we eventually had to leave and walk back down the slippery, wet mountain (yep, everyone landed on their bum at least once) - it was fun. We then drove back to the main park centre – or I should say, we attempted to drive back to the main park centre but had a bit of trouble i.e. running out of gas. (I wonder if that terrible road we’d been on put a hole in the tank – I wouldn’t be surprised). All’s well that end’s well though and we made it. Two of our group members actually offered us a ride back to Kigali with them as they were going anyway and as we were nervous about the mini-van we’d been in (that had run out of gas) we paid off the driver and took them up on their offer.
Well, this posting has not been much about Mulago or the ID service but as it’s getting pretty long I’ll stop now and write more next week. I’m looking forward to seeing those who are coming in a couple of weeks!!

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

More from the crazy mzungu…

Beautiful Uganda


I had written another dispatch previously but I decided that it was too negative and so filed it away in my journal. I just started venting and decided that it wasn’t appropriate to send that all out. This has been a frustrating week though – probably one of the most frustrating of my life! I have switched over to ward 4A, which houses all the Gastroenterology as well as infectious diseases patients. Unlike all the other specialties, ID is split into two teams – male and female. For some reason, the female side tends to run at about 30-35 patients and the male side more like 20.

I guess I am enjoying ID as I am seeing plenty of pathology – most of it related to end-stage HIV. The stuff I saw on the HIV ward in St. Paul’s in Vancouver was nothing compared to this. It’s heart wrenching, I’m not used to losing so many patients. And I feel like what I can do to prevent it is very limited. I know what to do and I know what would make a difference - at least in some cases - but getting it done is another story. Inadequate numbers of nurses, inadequate nursing care, inconsistent (or nonexistent) access to medications or even basics like IV fluids, very little access to diagnostic services and my struggles with procedures all combine to make things difficult.

The worst was the LPs this week – I was so frustrated with myself. I basically HAVE to get the LP because it’s the only diagnostic test that’s possible or with in the means of the patients (i.e. it’s free) and when the interns can’t get it – I get called. Well, trying to do them on a concave bed with a confused patient, one set of sterile gloves, no drapes (I use the inner glove cover paper as a sterile sheet), sketchy chlorahexidine scrub solution on (maybe) sterile cotton and an IV catheter as my needle (the 18 gauge is just barely long enough in the slender Ugandans) is quite difficult. On top of that, the wind then comes in and starts blowing everything around (ie patient’s clothing/sheets, cotton, sterile piece of paper etc. Great. ….I made one girl move onto this flat gurney because her bed was positively a valley in permanent reverse trendelenberg and prayed really hard – miracle occurred, prayer answered – got the tap.

Actually I’m not sure what this experience would be like without the HIV. It’s so pervasive. They say the statistics are that the prevalence is 10% in Ugandans but it’s probably about 75% in the patients admitted to Mulago. I’d read about the effect of HIV in Sub-saharan Africa but you really don’t understand until you’re here and you see the absolute devastation this virus has caused. And it’s usually in people who don’t really have huge risk factors like we would twig onto in Canada, frightening.

I should say that there are positive things too. For the most part people are very kind too me and I have made more friends amongst the residents – it’s hard because their agenda is very much educational based (they don’t get paid to be on service) but I feel I can’t just leave the poor intern to run the ward herself so I spend much more time on the wards than the rest of the residents. Also, patients are always so grateful – even though I feel like I’ve done nothing for them.

Uganda is a beautiful place. It has rained a lot this week so it’s very green and humid. It rains very hard at night and I often will wake up and listen to it drumming down on the metal roof. The birds are nice too – although there is one black, iridescent species with a long curved beak that makes a terrible noise: a kind of cross between a frightened cat and an angry crow. And then there is the Maribou, a large stork. They are very ugly, large birds that all congregate in tall trees. If you’ve ever seen Walt Disney’s Jungle Book it totally reminds me of those vultures that sit in the dead tree and ask each other “So, what do you want to do?” “I don’t know, what do you want to do?” (Alita – I will try and send pictures so you can look them up in your book).

(This next paragraph is church/Mormon related so those of you not interested could skip it) It was a hard week for the church here too. As some of you may know, President Duke, the mission president for the Uganda mission was killed in a car accident on the Entebbe road early Thursday morning. His wife was injured but is recovering well, at least physically. I forgot to ask about the driver, but should have. They had a memorial service for President Duke so that all the members here could attend and it’s been very hard on all of them. So many of them are new and felt very bereft at his death. One of the other couples that are here (there are several couple missionaries) has been asked to step in for the interim until they call a new president. The missionaries are in shock but coping OK as well.

I have been working pretty much everyday but everyone keeps telling me that I need to see some of Uganda besides the 5 square kilometers that I pretty much have seen. I have been taking walks in an attempt to get more exercise and it’s pretty good as Kampala is basically built on a bunch of hills. The Ugandans think I’m crazy, why walk when you have money to ride somewhere? Whenever I go out walking I’m sure to get honked at every 30 metres or so by either a taxi driver or a boda boda driver (motorcycle for hire) checking to see if I want a ride. I guess most Mzungu (foreigners) are into conspicuous consumption here (at least it seems like it as they have the most gorgeous houses, SUVs and gardens ever) so it’s hard for others to see a Mzungu who’s on a bit of a budget. I don’t think it’s necessary to take a special hire (taxi) everywhere – especially when I want some exercise. Don’t worry though, I don’t go walking around after dusk.

Yikes, this is ridiculously long already so will sign off. Thanks for your letters and support! More next week.

Uganda Report 2: Ah….the starch

(Here's the second posting - I think from about May 4th.)

I may be belated in doing this but I should clarify for some people what exactly I’m doing. Some of you didn’t really know that I was even coming to Uganda. (Sorry, sometimes I’m not the greatest at keeping in touch with people…). I’m here for two months on what’s basically an exchange program between the division of internal medicine at my university (University of Alberta) and the university here (Makkerere University). I’m working as a senior resident here at Mulago Hospital, which is the referral centre for Uganda and some of the surrounding area. Having lived in developing countries before some things are not as shocking as they might be for someone experiencing all this for the first time but some things are eye opening, that’s for sure.

In keeping with family tradition, when living abroad I must make at least some detailed comment early on about the food. (Sorry – inside joke for immediate family members, if you’re not interested in food you can skip this paragraph). That is why the title of the email. I was never a fan of the low carb craze but after this trip I may decide to take it up as I feel like I have seriously overdosed on the starchy foods already. Let me explain what a daily diet is – at least for me. In the mornings, I eat a banana (if I’m lucky), which is great, some toast (on white bread – yep, jo eating white bread as that’s what there is) and sometimes an egg – although as mom could witness, I’ve never really loved eggs. At lunch time I usually eat at the “Doctor’s Canteen”, which is on the top floor of the hospital and as far as I can tell has the best food of all the places at the hospital – as is evidenced by the fact that a lot of the staff eat there and not just the doctors. This is good traditional Ugandan fare (i.e. starch-o-rama) you get “the mix” or selections from “the mix” plus “sauce”. The mix is a big huge plate of: white rice, posho (ground white corn flour made into a loaf-like texture), matooke (plantains boiled and mashed), sweet potato (more like our regular potato) and yams (purple and very starchy, not like North American yams). The “sauce” is brought in it’s own little bowl and can be beans (which I like and always get if available), groundnuts or g’nuts (actually peanuts ground up into a sauce – quite tasty), fish (always fried tilapia from Lake Victoria, with a tomato/oil sauce), or some kind of meat (chicken, beef or goat boiled in a tomato/oil sauce). The alternative is to get chips (i.e. French fries for you Americans) plus “sauce” or sausages. For supper I either eat out (vegetables preferably) or eat some fruit and crackers, as I’m not usually that hungry after such a big lunch. I haven’t solved the dairy deficiency problem yet but am working on it. I have made friends with the couple staying in the little apartment next to my room and they have a fridge that they say I can use.


Fruit Market


Lake Victoria







Whew, long section – as per usual, I got a little carried away when talking about food, my apologies. I am now well settled in at the guesthouse and am enjoying it. Kampala is a beautiful city (when you live up on one of the hills) and I have enjoyed walking around and exploring a bit. I haven’t been very far really as it isn’t wise to be out after dark but hope to do a little more exploring this weekend with some new friends. Two of the girls who work at the guesthouse and I are going shopping tomorrow. We’ll see how it goes.

I went to church last Sunday and enjoyed it. It was in English so that was really great. They were very kind and I made some friends who were so kind as to invite me over for dinner on Sunday afternoon. They live just on the other side of Mulago hill (Kampala is divided into neighborhoods that are roughly based on the hills). I also met a girl who is an intern at the hospital and lives just next door to me. I also met all the missionaries (who were the only other foreigners at church besides me) and actually took the two elders who work in this area out for dinner once this week. One is from Botswana and the other is a farm boy from, you guessed it, Idaho.

I haven’t mentioned much about the medicine this week. A few people said that my last posting was too medical. It’s kind of hard since that’s really what I’m here to do (and it’s taking a whole lot of my time!) but I’ll try not to make things too unintelligible for the civilians. I’m kind of a little frustrated actually. I feel like I’m not really contributing much. I’m not sure if it’s because I really don’t know very much or that I still sometimes can’t figure out what exactly is supposed to be happening and the language and culture are huge barriers. Maybe it’s a combination of everything.

Part of the problem is that cardiology was never one of my strengths – I’ve probably learned more in the past 2 weeks than I ever did in my 2 months of cardiology rotations at home. I realized how well I know my acute coronary syndrome stuff and what to do (I didn’t realize that I actually knew it so well) BUT how poorly I know the rest of cardiology. Who knew that dilated cardiomyopathy secondary to blown out hypertensive heart was so common? I am seeing a lot of rheumatic heart disease (with lovely mitral stenosis and regurg murmurs) as expected but there’s lots of other stuff. I’ve really had to study pulmonary hypertension and other valvular heart disease. I am looking forward to starting infectious diseases on Monday – although my knowledge will probably be sadly lacking there as well.

Another part of the problem is that the approach to things is quite a bit different here. They are interested in slightly different things and don’t get worried about the same things. Maybe it’s because they can’t do much about them so there’s no point. For instance, there was a gentleman today who’s oxygen sats were 75% (99-100% is normal expected) yesterday and it had been suggested that he move to where the oxygen tank is (there’s only one so all the people who need it have to be clustered around it) but it wasn’t done. Today his oxygen sats were 66% and he was very cyanotic looking and the comment kind of was: “well, when we finish rounds we’ll get the sisters (nurses) to move him to the oxygen.” It’s hard, because at home we’d have called the ICU long ago. I don’t know, the problem is that he’ll probably only get a maximum of 3L of oxygen /minute anyhow so I’m not sure how much the oxygen will help anyway.


Oxygen Tank

I also didn’t realize that all that “patient-centered” stuff in med school sunk in as well. I realized at home that I spend an awful lot of time explaining things to patients and their families. Here I can’t because I don’t speak the language (they laugh when I try to say things in Luganda). I don’t think it’s really done here either, mostly we just write in the chart and on the treatment order sheet and move on – except for telling the patient that they need to take more of that or this pill (Captopril, Furosemide, Propranolol, ASA, Spironolactone, Warfarin and Digoxin are pretty much the only drugs I’ve ordered this whole time). I think it’s a cultural thing – I’m still getting used to it.

I do enjoy the on-call nights (ha ha), mostly because I feel like I’m actually doing something. I don’t pick up on everything (apparently, despite much reading I know nothing about Sickle Cell anemia). I do know some things though and with help can manoeuvre through the intricacies of the system. It’s hard though. They expect me to be an expert on things like stroke and I have to really think. They ask, so, what would you do now and I think to myself: “ummm, page the Stroke Fellow…”. For instance, do I or do I not try to lower a blood pressure of 210/110 when I don’t know if it’s hemorrhagic or ischemic (no CT scan).

Anyway, this is ridiculously long and probably getting boring so I’ll stop. I wanted to talk about the animals - Maribou storks and the monkeys that live next door just for you Alita but I will save that for next time and maybe will be able to send pictures as well. Talk to you later.


Monkey!!


Maribou stork (eating garbage)