Just a quick one

Hello World!

My apologies for the lack of communication/updates of late.  We've been on the move quite a bit and when we weren't on the move, we were on tropical islands without internet access (which is pretty cool).  Add that to the fact that I can't do any computer journaling while on romote islands because my computer is so old that the battery doesn't work makes for a good explanation; that's my story and I'm sticking to it! 

We've had a lot of cool experiences over the last 2 weeks and a lot of crazy stories to tell, which we will when we get the time (and power and internet access) to sit down and write!  We are in Kampala now headed to Jinja to raft the River Nile, then to Sipi Falls for some more site seeing.  Here's a taste of where we've been.  It takes a while to post and so I'll probably get most of the photos posted to Facebook, but it might not be until we get home.

I know this is just a tease, but I promise to get you caught up, even if it's not until I get home and have unlimited computer access!

We miss you and are excited to get home to share more with you.  CHEERS!!

Narrative Medicine

An exercise in Narrative Medicine is an invaluable experience.  Physicians are constantly limited by time; it is rare to be afforded the opportunity to simply listen and learn from a patient’s story.  This is ironic, as it is the patient’s story and their interpretation of their experiences that shapes how they understand and perceive their illness including causes and cures, which impacts their day to day lives as well as their acceptance of western medicine.  An hour is certainly not enough time to hear, let alone fully understand a patient’s story, but it does give the listener a glimpse into the events that have shaped a person’s understanding of illness.

“Margaret” is a 49-year-old Acholi woman from Babo who was admitted to Lacor Hospital for persistent headache, right flank and back pain, and chest pain associated with a cough and several days of hemoptysis.  As I knew I was limited by time, I did not probe into the “normal” line of medical questioning regarding her symptoms.  Rather, I tried to ask questions that would allow me to understand her perceptions and beliefs regarding her symptoms.  Even this was difficult as there was a language barrier and my strong temptation to learn more about her symptoms. 

She proceeded to tell me that many of these symptoms had occurred before; this was the 4^th episode of headaches and vague body pains, but the first time she had chest pain and blood in her sputum, which is why she decided to come to the hospital.  Her prior 3 episodes (which started in 1982) were all treated either through traditional healers and herbs, or from western medications she obtained from a pharmacy; she had never been admitted to a hospital.

I have learned that like in many other cultures, the “left” is bad luck to the Acholi people.  She told me that she had left leg pain, which she was told could only be healed through traditional methods, as there was “no other option”.  I wondered if she thought this was significant.  My suspicions increased when she told me that her mother thought she was “charmed” and that perhaps someone had bewitched her with “ju-ju”.  But she did not believe this; she didn’t know of any reason for someone to do this to her and if this were true, she would be dead by now, she explained.  She told me that she believes that western medicines are effective, which is why she came to Lacor to be treated.  What wasn’t clear to me was why she didn’t seek western treatment in any of her prior episodes other than the fact that this time, she was coughing blood.  I believe her mother played a large roll in influencing the treatment choice.  Her mother was brought up a lot in conversation and then I learned that her mother is now dead.  Is this why she is for the first time seeking medical treatment at a hospital?

I learned more about her family.  She has 6 living children (with one set of twins) and 3 others who passed away as babies.  She wonders if her son, who was born in 1982 the year her pains started, also has the same affliction; he also gets similar headaches and pains.  She has had three husbands.  Her first husband was a much older man who “took” her when she was 14 and she became pregnant at age 16.  Her mother rescued her from him so that she might return to school, but that did not happen.  She was “taken” by another man who ended up beating her.  They separated in 1982 and he later died of AIDS.  At this point in the interview, it became clear to me that the year 1982 was not insignificant (i.e., this was when her symptoms started, her son was born, and she separated from her abusive husband).  I felt that she was trying to tell me more as she kept bringing up the year, but I could never get more (interestingly, she originally told me she was a widow before explaining that she had 3 husbands and that the last one was still living).  Her third husband is still living, but again, her mother “rescued” her from him 3 years ago because he also beat her. 

Just as I felt we were starting to uncover her story, our time was up.  I wanted to ask her so much more.  I wanted to know what her childhood was like and if the war disrupted her upbringing.  I wanted to know how much schooling she completed, how she provided for her children, and what role religion plays in her life.  Does she have a social support?  Any siblings or close friends who she can confide in?  What brings her joy, sorrow, and sadness? 

Frustrated that I didn’t have time, I thanked her and asked her if she could tell me anything more that she felt was important for me to know about her.  To this she responded, “Please, tell me what is causing the pains I’m having and what you are doing for them.  Also, I want to know how I can make sure my children can attend school.  What can you do for them?” 

More Pictures

I'm trying to get more pictures posted on my facebook page: embeck84.

Extra Curricular Activities

Not only is the course called “Social Medicine”, I am finding that my classmates are all VERY social.  There is actually a social committee in charge of planning events and they take themselves very seriously. Thursdays we go to BJZ (a club pronounced “B.J.’s”) for trivia night.  One of the Ugandan students was talking quite a bit of trash about his trivia skills. He is actually on a team and they are the raining trivia champions of 2010, something they are very proud of (although I’m not sure if there was a trophy involved). 

So here he is (I think there are only 3-4 people on his team) up against 2 teams of 10-12 American and Ugandan medical students (85% of which are “gunners” in my opinion).  Needless to say, his team got rocked!  What was more surprising to me was that Jim, yes MY Jim is a trivia powerhouse!  Between him and  Ugandan Lucy (the trivia “queen”) our team won by a landslide.  Jim and Lucy won us a case of beer.  Here are the celebratory pictures:

Leslie, Nicole, Natalie, Katherine, and Anna celebrating.

Lucy, Robert, Ham, and Richard (celebrating with non-alcoholic malt beverages?!).

Notice the case of beer: our prize!

1/2 the guys here have beers!

Our second social event was a “goat roast”.  Unfortunately, I missed the butchering process (during which one of my American cohorts proceeded to dissect the uterus…only a med student would geek-out during the butchering process), but snapped a couple of shots of the remains and party to follow:

Gloria, Anna, me (only one drinking...)

As I’m not a night owl, there have been quite a few activities that I have missed including dancing and concerts. Other activities include Salsa dancing lessons, American’s cooking an American Breakfast for dinner (French toast), and enjoying dinner in town at the Indian and Ethiopian restaurants (which is a huge ordeal, i.e., it took 1.5 hours to get served one night...I'll have to write more about that experience later).

We had a dual baby shower for one of the students Jackie and for Amy, our course instructor.  We ate dinner at the Ethiopian Restaurant followed by medical students’ variation of baby shower games which included Pin The Sperm on the Egg.  Lucy drew a very anatomically correct picture of a uterus, fallopian tubes, and ovaries.  The egg, of course was near the entrance of the uterus and I have to say that by far, the men in the class were most entertained by this activity.

Many of the girls in the class have had a fun time going to the market to purchase beautiful African-print fabrics and having tailor-made dresses and skirts.  I can’t exclude myself from this group of girls and look forward to showing off my new digs when I return home.

Social Medicine Topics, Part 1

We’ve learned quite a lot in class the past couple of weeks and have seen some real eye-opening things.  It’s difficult to know where to even start with it all and I am still processing much of it internally, besides.  There are a few topics that are sticking with me that I will try to share in a somewhat coherent way.  I hope I can articulate my thoughts here, so please bear with me!

Malnutrition:

This is a topic we learn about in the States, specifically in pediatric rotations during our third year of medical school.  I don’t feel like any American medical student truly knows what this means, however.  While there are always exceptions and outliers, and perhaps some of my cohorts in the US have seen malnutrition, I don’t think anyone can say they have seen the severity that we learn about in textbooks and only see pictures of.  I’m speaking of kwashiorkor and marasmus.

How does one diagnose and measure the severity of malnutrition? 

Objective measurements of malnutrition that rely on laboratory tests such as a measure of serum proteins, micronutrients, red blood cell enzymes, and urinary micronutrients are likely not available in most underdeveloped countries.  It is much better to rely on anthropometric indices including weight for age (W/A), height for age (H/A), weight for height (W/H) that most of us are familiar with.  Anyone who has seen a child’s growth chart knows what I’m talking about.  This is any proud parent who takes their child to the pediatrician and then brags to their friends that their kid is above the 50^th percentile for their height, weight and head circumference. Practically, this gives cutoff points that alert clinicians should a child fall below what is “typical” for a healthy child of the same age.  This is called a Z-score.  The ratios (W/A, H/A, W/H) are expressed as a % of the reference standard, or as a standard deviation from the mean of a reference population.  For example, if a child is 2 standard deviations below the reference value for a parameter, his or her Z-score would be -2.  Using this system, malnutrition can be classified as follows:

·      Underweight: decreased W/A (Z-score <1 mild; <2 moderate; <3 severe)

·      Stunting: decreased H/A (same Z-score as above)

·      Acute Malnutrition: decreased W/H (also called ‘wasting’). 

o      Moderate (aka “global acute malnutrition” or GAM): W/H Z-score <2 or W/H <80%

o      Severe (aka “severe acute malnutrition” or SAM): W/H Z-score <3 or W/H <50% or the presence of bilateral edema (swelling)

A less commonly used measurement in the States, but common a measure in developing countries is the mid upper arm circumference (MUAC).  This is an easy measurement around the dominant upper arm, which has useful cutoff values in children between 1-5 years old because MUAC increases slowly in children.  Here, a MUAC of <110mm (in a child 1-5 years old) would be consistent with severe acute malnutrition (see above and note that if a child has edema, this will automatically earn the label of GAM and the MUAC may be normal…this is important in kwashiorkor malnutrition), a value of 110-125mm is consistent with global acute malnutrition, and measurements between 125-135mm identify children who are at risk for malnutrition.

How do I assess malnutrition clinically?

All medical students know that 99% of the answers to our questions can be found by taking a good history (including a thorough social history) and performing a physical exam.  Questions we should ask the parents include the child’s normal eating habits (including breast feeding) and whether those have changed.  Is there an adequate food supply for the mother? Children?  Is the mother ill/malnourished?  Are there other diseases such as TB or HIV in the family?  What is the quality of the food?  Frequency of feedings?  Is the child thirsty?  Does he have access to clean water?  Does he urinate regularly?  Is the child ill?  Has the child’s behavior and activity level changed?  Are there any recent deaths in the family and if so, what from?  Was the child born at term and healthy?  Have the normal developmental milestones been reached?  Is the child immunized? 

The physical exam should include vital signs (temperature looking for fever or hypothermia, pulse and respiratory rates), general appearance (pallor, jaundice, sunken eyes/fontanelles, facial appearance, skin rashes), behavior, and mood (lethargy, apathy, irritability); assessment for signs of shock (cold extremities, weak pulses, decreased capillary refill time, decreased level of consciousness); appetite/reaction to offered food; edema; enlarged liver; distended and/or tender abdomen.

Are there certain types of malnutrition?

Kwashiorkor and marasmus are two distinct types of malnutrition distinguished by clinical differences.  Kwashiorkor is a type of severe malnutrition characterized by protein deficiency.  The child appears edematous (with only a moderately low weight), which may be misleading as an observer may think the child is “plump” and well, and also makes assessment of the child’s hydration status very difficult.  Other features include misery, apathy, and a poor appetite; pale, sparse hair with weak roots; wasted, weak limbs; pale, thin, peeling skin; and enlarged liver.  A child with marasmus, or generalized nutritional deficiencies, appears emaciated (and may have a “pot belly”).  He may look like an “old man” with thin, flaccid, wrinkly, “baggy pants” skin due to loss of muscle and fat tissue.  The child is alert, but irritable; he is hungry.

We saw two children with severe malnutrition last week.  One with kwashiorkor and one with marasmus.  The images of these boys will be forever imprinted in my mind.  The 5-year-old boy with kwashiorkor was doing well.  The boy’s skin “looked like a girrafe’s hide” as described by the father and his hair was sparce and white.  He looked small for a 5-year-old, but was eating Plumpy’nut (a high calorie food product made from peanuts, powdered milk and sugar, and enriched with vitamins; please watch the 60 Minutes article about this high calorie food for treating malnurishment in African countries) vigorously as we talked to his father.  The family was growing (there was an 18-month at home and one on the way), and he was a simple “peasant farmer” which means he works the land only to provide for his family.  He said that food is scarce and he didn’t know what he could do for his family.  The good thing was that no one in the family has HIV.

What can we do for malnutrition?

This is a bit of a loaded question.  The obvious answer is to admit the child to the hospital, follow algorithms for appropriate caloric requirements based on the level of malnutrition, and treat other contributing illnesses.  So let’s say things are pretty good here in Lacor and we are able to do that in the hospital (which is not always the case, but let’s just say that for argument’s sake).  The child recovers, gains weight, and is now healthy.  So now what do we do?  “Send him home”, you say.  “Educate the parents.”  But have we solved the problem?  What is preventing this from happening again?  What if the family does not have access to adequate food or clean water?  What if the mother is pregnant and food is scarce?  Now she has another child to feed and this child will have less attention from her.  Even worse, what if there is no mother or father because they died from AIDS and now children are raising children?  Who is responsible?  What do we do?  How do we empower people so that they can provide for their families?  Does handing out free Plumpy’nut once weekly solve the issue?!  NO!  This may work in the short-term (and don’t get me wrong, I think it’s a great product), but it is not a long-term, sustainable solution.  It does not empower people or provide them with a means to provide for their families.  There has to be something better.  Any ideas?

Eats and Sleeps

 

We’ve had a request for a description of food and living conditions.

The Guest House!

While I am taking the course, we are staying at the hospital’s guest house.  It’s definitely not a great deal…rent is borderline American rate, but it is very convenient: I don’t have to commute to class from town (6km on a very dusty dirt road), it is clean, it is safe (there are guards at the hospital gate), the water is safe to drink, our meals are provided, and they do our laundry.  There are some quirks however.  For example: (1) The first time we send some laundry in, we saw it drying on the line the next day, but then it was in no-man’s land for the following 3 days before it was magically returned to us. (2) Towels are difficult to come by.  When we felt that we had sufficiently used our towels (and they were red from the Gulu dust), we folded them nicely on the toilet seat for housekeeping assuming they would be replaced with fresh ones.  When we came home, that was not the case, so I had to ask for them.  No big deal, but since then, our towels will randomly be taken and again not replaced.  I discovered where they are kept (which is locked in a cabinet in a locked linen closet) and have been stealing (when the door is left opened) and hoarding them ever since. (3)  There are many chickens, a rooster, and a turkey wandering around the grounds.  The first few nights the turkey would wake us up with a distressing call.  We were told he was mourning the recent loss of his mate (turkey dinner?).  The rooster is especially obnoxious.  He does not know when to perform, so he announces morning starting at 3 am and continuing through to 8 am.  I swear he stands right under our window, but some of my classmates make the same claim…maybe he walks back and forth to make sure we all know “it’s morning”.  Honestly, every night when we sit down to dinner, I secretly hope that we are having chicken soup or turkey dinner.  In addition to the livestock disturbing our sleep, the past few mornings, we’ve heard a very load alarm clock from another room in the guesthouse.  It goes off around 2 am and either no one is sleeping in that room anymore and it just got left on, or that person is a VERY deep sleeper.  It just goes on and on and on for at least an hour or two.  Fortunately for me, I’m a good sleeper and can usually tune it out, but it’s been causing Jim a lot of distress…last night he actually closed the window and curtains in hopes that they might muffle the noise; I’m not sure it helped.

Having said all of that, I do realized that we are living very luxuriously as compared to most people in the area who live in huts.  The few that have houses usually don’t have electricity or running water so they must walk at least 1 km for bathing, cooking, and drinking water.  

Booming metropolis of Lacor!

Ugandan taxi: Matata

Entrance to St. Mary's Lacor Hospital

Lacor Hospital's ED and entrance to inpatient wards.

Classrooms (where we spend most of our time).

Mike (course leader) outside the guesthouse...the only spot where there is good internet access.

Road into guesthouse.

swimming pool that is safe to swim in "as long as you can see your fingers on your outsteatched hand"

Guesthouse side view.  Our room is about where the tree is (top floor).

Our bedroom.

Dining room.

Food!

Before we came, we were warned by one of my friends who was here last year that the food was nothing to write home about.  He went on and on about how bland and generally awful it was.  He said there were no spices and the meat was nearly impossible to eat and to bring A LOT of floss with us.  Heeding his advice, we purchased a travel spice kit and another roll of floss.  We were also told by MANY people that there would be a lot of “suspect” meals and to bring “a Costco-sized box” of Pepto-Bismol tablets with us to take prophylactically before one of these said meals.  After being here for over 2 weeks, I feel like I am ready to make a fair assessment of the food.

Breakfast: Ugandans don’t know what breakfast is.  As far as I can tell, they adhere to the traditional “tea and toast” diet introduced by the English.  The first morning we were asked if we wanted toast or fresh bread and we ordered toast, which was probably toasted the previous morning, but no one finished it.  So the next morning we asked for fresh bread, which was actually freshly toasted bread.  There is always “Blue Bon”, which is essentially margarine, but I haven’t tried it yet.  Sometimes we get jam and bananas.  The good thing is that the cook does make some very strong coffee, which she also roasts out front of the Guest House.  For the first time in my life, I’m actually starting to think her coffee is actually too strong, however, and I find myself adding as much sugar to it as Jim normally does at home (which for those of you who don’t know, it is quite a lot)

Tea:  Ugandans LOVE to “take tea”.  Even if class is running an hour behind schedule, we will still take tea, which seems to be getting longer every day and takes at least 45 minutes.  Tea consists of milk tea or coffee and some snack: banana, donut bread (maandazi), samosa (sambusas), or chapatti.

Lunch/Dinner: Lunch and dinner are the major meals here and really only differ in the time of day in which they are served.  Ugandans are very social and this is a very interactive process.  Traditionally the people eat with their right hand, but I’m finding that many people today use western utensils (although napkins are often difficult to find).  There are always multiple carbs/startches (I’d say at least 3/meal) including rice, potato (including yams, sweet potato, cooked potato, and chips), plantain (matoke), posho (maize or cassava flour), chapatti (essentially a thick tortilla or flatbread), and cassava.  There is often another vegetable such as cooked carrots, baked beans, green beans, peas, zucchini, “greens” (which are cooked down much like collard greens), and fresh tomatoes.  Some sort of meat is always included.  We’ve been served beef, chicken, pork, goat, liver, and “wild game” or “smoked meat” (which I think may have been water buffalo) as well as tilapia.  You can also find many different kabobs (pork, goat, beef) which are usually way over cooked, but have great seasoning.  Ugandans love their sauces, too.  I think they have to have a sauce to make all the starches edible.  The sauce I like most is called boo (say, “bo”) which is made from the ground nut or “g-nut”.  It tastes very much like a peanut.  Ugandans are not big on dessert, but there may be pineapple or maandazi served with tea. 

So far, I have only had one “suspect” meal.  The meat was cold and Jim advised against eating.  I did eat the rice and sauce in which it was served and had a bit of an upset stomach the next day, but nothing major.  We’ve actually come to the conclusion that the food here is quite good and flavorful.  We haven’t had to use our spice kit once, but we did buy some chili sauce (spicy catsup).  I think we are actually gaining weight!  This is unfortunate because I was justifying my holiday eating by the fact that I was going to Africa where I would lose a lot of weight from diarrhea.  Even though we do like the food, I can see how we were advised about how bland it is.  All the starches day after day with the same sauces are starting to get a little old.  The main problem is the lack of variety.  Every meal is essentially the same, so while it might be good, it can get old rather quickly.  I think we will try two restaurants in town for some variety this weekend: Ethiopian and Indian. 

Beverages:  You can find sodas everywhere, but the ones unique to Uganda are Stoney (ginger beer, which is my favorite), Krest (bitter lemon…the name says it all), and Mirindia (grape or cherry flavored).  Did you know that Ugandans drink the most alcohol per capita of any other nation in the WORLD?!  This really surprised me especially because you can’t find hard alcohol at most restaurants, they don’t really drink wine, and I haven’t seen very many clubs or bars.  Beer is not hard to find.  Basically if there is a town with a refrigerator, you are bound to find a cold beer!  Ugandans import a few beers, but mostly brew there own (there are 2 breweries: Ugandan Brewery and Nile Brewery).  We’ve tried most of them including Club (a light beer, which is our favorite despite every bottle tasting slightly different) and Nile Special (a bit stronger at 5.6%) are brewed at the source of the Nile, Bell (a light, sweeter beer from the waters of Lake Victoria), Moonberg, South African Castle, Tusker Malt from Kenya, Pilsner, and a few others.  The local alcohol is called waragi, although I have not tried it.  It’s supposed to taste a bit like gin, mess you up, and give you a nasty hangover.

For Darcy James: Susan and Sande

Dear Darcy,

Jim and I were able to meet Sande, Susan, Noel, and Preeti.  Our course leaders, Mike and Amy, are actually quite good friends with them.  Susan and Sande invited the four of us into their home Saturday night for dinner.  They live not too far from Lacor Hospital…I’m not sure if they were there when you were last here (Sande said he had had that land for about 10 years).  They are working on improvements to the house and land: he has planted trees and they recently painted the house.  They are waiting for 3 of their neighbors to get power before the line will reach their house.  They think that it may happen in the next year or so.  Susan is doing well and expressed her deep love for you and how she misses you.  She is working at the Gulu Hospital and as Sande is on his holiday this month, he’s been playing “babysitter” (those were his words).  Noel is about waist-high and is so cute.  He is quiet, but very polite and curious.  He loved the torch and stickers!  We used the torch for lighting as we chatted and sipped ginger tea and Noel was very proud to light the path as he lead us all the way back to the hospital.  Preeti is absolutely beautiful and healthy!  She smiles, kicks, and laughs and is not at all afraid to be passed around by 4 white strangers!  We took some video, but I don’t know if I can get it to go through; I will try (the video is not great, but I think the audio is more important).  Here are some pictures we snapped as well.

Apwoyo!

 Susan showing off Preeti's pinafore!  She had fallen asleep, but woke up for a quick photo.

 Noel opening his gift next to Mommy Susan and Sister Preeti Darcy!

 Sande holding Preeti

 Susan feeding Preeti...she's a good eater!

 Back asleep

 Noel showing off his stickers.

I tried to load a video, but had some problems.  Perhaps I'll try again anther time.

Darcy, thanks for sharing your Ugandan family with us.  They are truly amazing people who we are honored to know.

Emily and Jim

Social Medicine

This course is called, “Social Medicine Beyond the Biological Basis of Disease: The Social and Economic Causation of Illness”.  It is organized by American physician Mike Westerhaus and his wife Amy who is a sociologist.  Mike and Amy have been coming to Uganda for over 10 years to study both medicine and social determinants of health as well as learning about the conflict that has taken place in Northern Uganda.  They have developed relationships with St. Mary’s Lacor (say, “La-chore”) Hospital and Gulu University Medical School in order to organize this course. 

The goals of the course are “(1)to provide a structured global health immersion experience for medical students…, (2)to study issues related to global health in a resource-poor setting with and emphasis on local and global context, (3)to foster critical analysis of global health interventions in resource-poor settings, (4)to facilitate the development of a clinical approach to disease and illness, (5)to build and understanding and skill set associated with physician advocacy, and (6)to promote international solidarity and partnership in generating solutions to global health challenges facing societies throughout the world.”  The course is mainly composed of classroom lecture and discussion time, field visits, and clinical teaching in tropical medicine/application of social context to patient care and health determinants.  There are 12 fourth-year International medical students (11 from the US and 1 from Canada) and 15 third-year Ugandan medical students (medical school in Uganda is 5 years long). 

Each week has a different theme/topic that is addressed and is as follows:

Week 1: Social and economic determinants of health and causation of illness

Week 2: Global health interventions (paradigms of charity, humanitarianism, and structural change) and social justice in health interventions (models of community-based healthcare

Week 3: Health and human rights and the healthcare worker as an advocate

Week 4: Tools for effective application of global health experience: writing, photography, research, and political engagement

We meet from 9am-1pm every morning (except Sundays) and from 3pm-6pm Monday through Friday with some evening films addressing topics we have discussed in class.  We typically have lecture in the morning and student pairs (every international student is paired with a Ugandan student.  My partner is Kepha) take turns “clerking” patients on the wards in the afternoon.  The patients are selected based on their disease presentation and after we have presented the cases to the rest of the class, we visit the bedside for physical exam teaching, then return to the classroom for a lecture on the specific disease including diagnosis and treatment as well as how social factors impact patients with the disease.  For example, a patient with malaria doesn’t just get malaria because there are parasite-infested mosquitoes in Africa.  They get malaria because they don’t have access to a bed net, they may live next to a swamp/marsh or in crowded areas where many other people are also infected, and so on.  We are taught what questions need to be asked of our patients in order to better understand their living situation so that we can not only treat the disease with medications, but prevent reoccurrence and educate them about how disease is transmitted.  We also seek to understand their beliefs and background: do they believe in traditional healers (“witchdoctors”)? What has been their experience in the past with this type of illness (personally, or in  friends or family members)? What are their expectations for treatment?

Additionally, there are several guest speakers that teach us.  We have weekly Acholi language lessons.  We have heard from Ugandan medical students who took the course last year who grew up in the war-torn town of Gulu.  Religious leaders and local human rights activists give us their perspective on the conflict in Northern Uganda and how that impacted the health of many Acholi people.  Speakers from Partners in Health (please learn more about this amazing organization…”Mountains Beyond Mountains” by Tracy Kidder is a fantastic book about PIH and founder Dr. Paul Farmer) working in Rwanda have flown in to share their experiences and model of healthcare delivery in Uganda’s neighboring and also war-torn country.  We also visit local organizations and regional clinics to see how they provide care to citizens.

So far this has been an extremely intense class.  There is a lot of participation from all the students and at times, quite heated discussion of human rights issues as they pertain to healthcare.  I feel as there is so much for me to learn from everyone here (from students from the States and well as local Ugandans to the lecturers and patients) and at times it is a bit overwhelming.  At this point, I feel a bit paralyzed by the devastating health disparities and social/economic structures that have caused those.   I look forward to the next few weeks as I tools that will help me effectively answer difficult questions, push myself to do more, become more involved, and advocate for the underserved.

Acholiland

 

Jim and I are living in Acholiland.  This is Northern Uganda: Gulu town to be exact.  St. Mary’s Hospital Lacor (say, “la-chore”) is on the road to Southern Sudan.  Below is a summary of both Gulu and Lacor hospital I was given by the course instructors prior to coming here (I can’t take credit for the site description and am too tired to write it out in my own words…)

I'm working on a few more blog entries including uploading some photos and hopefully videos.  Perhaps I'll have those up in the next few days.  Apwoyo!

Gulu, Uganda

Gulu town is located approximately 200 miles north of Kampala, the capital city of the East African country of Uganda. It is the provincial capital and an economic and social hub for the entire sub-region of Acholiland, which is comprised of the northern districts of Gulu, Kitgum, Pader and Amuru.  For over twenty-two years, Acholiland has experienced the scourge of war carried out between the Ugandan military and an insurgency that came to be known as the Lord’s Resistance Army (LRA).  The population of Gulu town was approximately 40,000 people until 1996, at which point the war escalated and a policy of forced displacement was enacted, causing thousands more to migrate into town.  In 2002, estimates were that the population in Gulu town was over 120,000.  For nearly twenty years, Gulu town has largely been immune to the physical violence of the war yet it feels its impact through migration and the saturation of international humanitarian agencies.  Today as relative peace pervades the area, Gulu town is home to countless international NGOs operating in the region, the strong presence of religious infrastructure such as the Catholic Archdiocese, the military base of the Ugandan government’s counterinsurgency efforts, and the intellectual and cultural life of Gulu University. 

Lacor Hospital

St. Mary’s Lacor Hospital is a 480-bed non-profit Catholic hospital located just outside of the town of Gulu, Uganda.  Originally started as a small dispensary in 1959, the hospital has grown into a large referral hospital for all of Northern Uganda and a teaching hospital for Ugandan residents and medical students from Gulu University School of Medicine.  The hospital operates medical, OB/Gyn, surgical, pediatric, and malnutrition wards.  In addition to providing tertiary care services, the hospital operates numerous outpatient clinics that aim to provide preventative care for a wide range of conditions.  The hospital averages 600 inpatients at any one time and approximately 500 outpatients are seen each day.  The hospital staff number approximately 1,000.  In addition, the hospital operates three community-health centers in outlying, rural sites.  With the return of relative peace to the region in 2006, increased efforts have gone into expanding community-based healthcare.  Funding for the hospital comes from the Ugandan government, private external donors, and foreign government support.  The hospital aims to provide quality, accessible healthcare to all, with a special focus upon disadvantaged populations.

What the heck am I doing in Uganda?

After traveling to India in 2005 with Genesis World Mission I left feeling disenfranchised about medical “mission” trips.  I felt as though our efforts in India where somewhat futile and I questioned the impact we had on the people to which our care was delivered.  Was it okay to spend thousands of dollars and devote time and resources to simply placing a Band-Aid on the wounds of the people who came to the make-shift medical camp we set up?  Were we doing these people more harm than good?  Did we really try to understand their culture, society, and beliefs to understand how that impacts health, disease, and the delivery and acceptance of Western medicine?  Were our motives in the right place?  Did we really want to help these people or did we just want to feel good about ourselves and that our privileged lives were now somehow justified?  As amazing as an opportunity as it was, I was extremely frustrated and began thinking that I didn’t want anything to do with global health in my future career.  I thought that as a physician, I could do so much more good by staying in my own community and caring for the underserved there than trying to “share” my values with individuals I had no connection with nor understanding of. 

Despite these feelings, for some reason I remained interested in going abroad as a medical student.  Perhaps I thought that delivering medical care outside the US as a soon-to-be doctor would give me a better perspective on how medicine is delivered outside the US and that this would somehow make me a better physician to my American patients.  Or maybe this time I would feel better about my actions if I had a more involved roll as a caregiver. To be honest though, a not insignificant part of my decision to expand my last year of medical school in order to participate in an international elective was to justify my selfish desire to travel before starting residency.

After applying for several different electives abroad, I was chosen to participate in “Social Medicine” in Northern Uganda.  At the time, I didn’t know much about the course.  I was told that this would be a course with several other US medical students as well as Ugandan students and that we would be learning about nonbiological determinants of disease and health.  The more I thought about the aim of the course, the more I realized that this would be an excellent fit for my goals in going abroad.  In addition to seeing patients with tropical diseases and advanced chronic diseases, I would be learning about the implications of diagnosing, treating, and preventing disease in resource-poor settings.  I hoped that this course would allow my to answer some of the questions I walked away from India with and clarify my role as a physician in delivery of healthcare outside the US.