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.

Pictures and video

Jim and I forgot the camera connection cord for the computer, so no photos available as of now.  We will try to find I card reader and upload some still shots at a later date.  Also, we have video and will try to upload from that once we settle in a bit more.

We arrived in Gulu yesterday evening and I started my course today.  It's going to be super informative and I'm very excited to learn more about the social determinants of health (of which I will write more later).

...More later.

UGANDA!

 

Welcome to the Pearl of Africa!!!  I think I am going to LOVE it here.  Jim and I are both very excited about our upcoming adventures.

We arrived in Uganda yesterday afternoon and were met a the airport by Walter, who is the driver for the Green Valley Hostel in Entebbe.  The owner of the hostel, Frank, actually lives in Gulu and owns one of the bars up there.  He also used to be a tour/safari guide and was so pleased to learn that we will be in his town and plan to explore Africa after the course.  His eyes lit up when we told him of our “plans” to travel and he started rattling off various itineraries and cost-effective travel means and places to stay.  I think he’ll end up being a great connection for us.

Uganda is BEAUTIFUL!  It is very green and lush.  It’s a much cleaner and quieter (so far anyways) country than India.  It reminds me a lot of a cross between India and Costa Rica.  The people are genuinely nice.  Everyone greets you with a, “hello, how are you?”  and they are genuinely curious how you are doing.  If you don’t ask the same question of them, they are a little offended, actually.  It feels very safe here as well. 

We had a nap yesterday and then a very restful sleep all through the night.  I think we are finally getting our clocks “reset”.  After all the flying, touring Egypt, and big layover in Ethiopia (which Jim is now referring to as purgatory), we were exhausted.  I think I slept 5 hours in three days and felt WAY worse than I’ve ever felt on a post-call day.

Today we walked around Entebbe with one of my classmates, Sara Jane, from Galvatin, Texas.  We sipped Ugandan beers and had lunch on the shores of Lake Victoria (not good water for swimming), went to the Saturday market, changed money, and bought bananas for 60 shillings (<10 cents each) from cute little boys.  At the market, Sara Jane was looking to purchase sun glasses and I started wondering away looking at what else there was to offer.  Jim came and grabbed my arm, “please stay closer.  I can’t watch out for both of you if you wonder away.”  It was very sweet of him.  I didn’t even think that it might have been stressful for him to watch out for the both of us…he’s so good that way.

A few more of my classmates arrived this afternoon and we chatted with them over fresh tilapia (entire fish) and chips (French fries).  Leslie goes to school at Ross University in the Caribbean, Kirsten is from somewhere in Georgia, and Leslie goes to UC Irvine.  We also met two of the course instructors, Mike the director and internal medicine physician from Brigham and Women’s College in Boston, and Amy…don’t know her title yet. 

Everyone seems very nice and excited.  The rest of the Americans arrive tonight (I think there are 12 American students, 15 Ugandan students, and 3-4 instructors total) and we will pick up some Ugandan students in Kampala tomorrow before driving to Gulu, which will take 5-6 hours from Kampala.

“Egyptians: very tricky, tricky, tricky…be careful!”

We arrived in Cairo on the afternoon of the 5^th and were quickly inundated with taxi drivers asking to take us to town for a mere 80 pounds ($16).  Jim is quite the barterer, or at least he likes to think he is.  I want no part of dickering for the price of things, so it’s good to have him along to negotiate prices (to a certain point, or at least not in Egypt as you will soon see why).  He kept telling them that he was told that a cab from the airport should only cost 40 pounds; they quickly laughed mockingly and he eventually talked them town to 60 pounds ($12).  But that wasn’t good enough for us (Jim).  After talking to several drivers, we decided to take the bus into town, but then learned (from the taxi drivers) that there are is no public transportation and that only poor people ride the bus.  So we were tired at this point, it was getting dark, and we caved: we paid 80 pounds for a cab to the Youth Hostel in downtown Cairo.  When we finally arrived, Ramadan, the Hostel manager, “hooked us up” with a “very good price” for dinner of kabobs (chicken, beef, and an American hotdog with diagonal cuts to make it look very fancy and delicious), tea, and shi-sha (a bit like hookah in the states).  This was 100 pounds ($25).

Ramadan then arranged for us to have a private taxi driver tour us around Cairo the next day to take in all the sites.  This was to cost 400 pounds ($80), which we took as reasonable.  The driver would be at the hostal at 6:30 am to pick us up, which we were too tired to realize was NOT reasonable.  I didn’t sleep a wink all night until 5 am, just in time to be woken by a knock on the door at 6am. 

Touring Cairo (all of it) in one day was a mistake.  First our driver Farris (Beuler) didn’t have the best Egyptian grasp of the English language.  Next, he didn’t know too many answers to our questions (or perhaps he did, but just didn’t know what we were asking about).  Third, there were mandadory picture stops.  The first of which was next to a garbage/human waste laden canal to take a picture of the sun coming up.  It was “so, so beautiful” because there is so much smog in the city that you can stare directly into the big pink ball of fire.  Oh, so, so beautiful.

Farris would tell us in his thick Egyptian accent where we were going each time we got in and out of the car:  “First, I take you to Bedore Pyramid, then….we go to Ramsi’s monument.  After that, we go to Imhotep Museum and Saqqara.  Next,,,ahhhhh…we go to Giza, then Spinx, then to Cairo Museum and Bazaar.  I just want to make you happy: you happy, I happy, okay?”  Wow!  That seemed like so much, but we nodded our heads and he replied, “okay, okay, okay.”

It’s difficult to recap the rest of the day, but it sort of went like this: every stop we made, Farris, would say, “Okay, you go pay teekeek (which took us not to long to realize was acutaly “ticket”) and I stay to watch car.  Go there, get teekeek”.  We would then buy a teekeek, which averaged 60 pounds/person/stop (that’s $12/person/stop), and join the rest of the European, Amerian, and Japanese tourists to see the wonders.  It was a definite site to see and we were so out of our element.  At first we were proud that we didn’t cave in and do the big group tour bus thing, but as the day went on, we realized we would have been much more “protected” from the beggers, street vendors, and scammers had we signed up for a tour.  At one stop, we had two gentlemen dress us in there turban-heads and robes and take our camera from our hands to take a picture and then demand $20 American dollars from us.  We luckily ended up giving them 10 pounds ($2), which we said was all we had.  As we walked away, an Asian family approached and the son was quickly accosted and just as he was about to be dressed in all their smelly garb, his mother grabbed him away, saying to the men, “No, no, no, no, no!”  The father then looked at us asking, “Yor furst day en Egyp?  Egypians vewy, vewy, vewy twicky!  Be careful.”

In addition to the traditional monument stops, Farris wanted us to see some other things such as a carpet “school”, papyrus “museum”, and gold shop.  The carpet school (one of about 10 that we drove by) was actually slave labor.  Authenitc oriental rugs and tapetries made of silk, wool, cotton were being made by Egyptian childrens (which is why we were told they were so special).  The papyrus museum was a shop that educated you on all the benefits of papyrus paper (which you can imagine Jim had a hayday with) afterwhich you were expected to purchase a painting on papyrus (and for just 10 more pounds, you can have your name written in script on).  At least the gold shop wasn’t disqused as a school or museum…they were flat out trying to sell us the finest Egyptian gold and silver and diamonds from the heart of Africa (of course).

Jim and I both had our moments when we hit the wall.  It really didn’t help that we were jet-lagged and sleep deprived, but for the most part we held it together quite well.  We did end up telling Farris that we didn’t want to go to the Cairo Museum or Bazaar because we were too tired.  I think he was a little frazzled that we thought he wasn’t doing a good enough job even though we tried to reassure him.  Jim’s big moment was at the first pyramid.  Just imagine Big Jim crawling down, down, down a 3’x3’ tunnel to the bottom of a pyramid’s tomb with a bunch of Italian and Japanese tourists and getting to the bottom only to find a big empty vault and the thick smell of ammonia, which sickened us and induced a panic attack in Jim.  He was giving the heismann to a bunch of Italian girls and trampling people as he tried to race his way back to the entrance 100 feet above us, letting out a big, “Huuhhh” when getting to the top.  My moment was on the way to the airport.  Farris asked is which airline (after he’d already taken the wrong terminal exit).  “Ethiopian,” I said.

 

“Oh, Sudan?” he asked.  

“No,” a bit louder and slower “Ethiopian!”

“Okay, okay, okay, Sudan”

“NO!!!  Eee-thee-oo-pee-ann”

“Let me see your paper."  I pulled out my teekeek and read “Ethiopian” as I pointed to it. “Yes, yes, yes.  Sudan.”

I didn’t know what else to do and neither did Farris.  We found a random guy in a car (which I referred to as our pilot car) and he lead us to the right terminal through some old closed and torn up roads/dirt patches.

We spent the next few hours in the airport restaurant where we enjoyed the best part of Egypt (the shi-sha!) and Jim sang John Lennon’s “Imagine” on the karaoke machine.

Finding My Calling in the House of Hope and Fear

Mr. Diverticulitis started having belly pain two days before coming to the ED.  He had the chills and a fever the night before and now he couldn't keep any food down.  The belly pain was no longer bearable.  He's a Cuban American from Florida who heard about a drug rehab program in Seattle while watching A&E.  He's been clean from cocaine for the last five months.  He's trying to start over and get his life back in order.