Making Mbale home

August 21 - September 12, 2016

Hiking Wanale Hill from our own backyard

Hello again!  After a heavy post about working at the University and in the hospital, we are lightening up the conversation and introducing you to our newest hometown: Mbale, Uganda.

Meet one of the 
animal neighbors

What is the language?

Mulembe. Mulembe.
Uryena?  Bulayi.
Kamakhuwa?  Kasila.

This is the Lumasaaba/Lugisu exchange used for greeting every morning.  The day starts by greeting, asking how the night was/how the person is doing, and what is the news.  Many people are surprised and delighted when Dennis and I are able to greet them in the local language, even if it's just a few short phrases. There are over 50 different local languages in Uganda, but most people speak at least some English, so it is used as the common language for almost everything.  The national television station (NTV) as well as newspapers are all in English.  Not to say that there aren't many side conversations in the various local languages.  Although we are learning the local language, there are many in the area that do not speak Lumasaaba/Lugisu, but rather speak Luganda, Atesso, Acholi, Lusoga, and many many others depending on the region where they are from. Even walking from our apartment to the top of the beautiful Wanale Hill (a cool 5 hour hike round trip), we encounter many people that do not speak Lumasaaba and don't understand us when we greet them.

A kitchen friend, Newton

Monkey Dennis
hanging curtains

Where are you living?

The new Mbale GHSP gang is living in a small apartment complex in a quiet area that is also a short walk to the town center, as well as to work.  Suffice it to say this apartment is nicer than any other we have lived in together in the US.  It is a 2 bedroom apartment equipped with a kitchen, living room, and large balcony that perfectly faces the sunset every evening.  While serving in the Peace Corps, housing is provided by the host organization, to ensure support for the Peace Corps Volunteers (PCVs) from the community in which they will be working.  We have running water (hot water should be installed soon :) as well as electricity a majority of the time. Combined with a small refrigerator, microwave, and a stove top we are set.  There are times when power is out for the entire community, and for us as well.  Fortunately, we have candles, flashlights, and a 2-burner gas stove to continue cooking if the power is out.  Otherwise, a delicious coffee shop/restaurant located nearby has a generator if we feel like splurging.  The guest bedroom is set and ready for whoever wants to bring an air mattress and come visit!

Who else is there with you?

Travis with US Ambassador
Deborah Malac

Bette

Let us introduce you to the GHSP team that we are living and working with over the next year:

Travis Bias is one of the "kids," a family medicine physician from Austin, Texas and traveler extraordinaire who recently spent 5 months volunteering at a hospital in Kenya.

Bette Brassfield hails from Colorado with a PhD in nursing - she will focus on nursing education this year.  She is also a former Peace Corps Volunteer (PCV) from Thailand in the 1970s.

Jennifer with some of the
Mbale Regional Hospital staff

Jennifer Lasman is a continuing GHSP volunteer who was in Mbale for the past year and is extending for another six months.  She brought an iStat machine (for quickly measuring electrolytes and hemoglobin) which she is teaching the students and lab personnel to use. She is also a wealth full of information about the ins and outs of the hospital, medication availability, and pulling strings to get patients oxygen.

Julia

Julia Taylor is a nurse from Missouri.  Although nursing is actually her fourth career, as she previously worked at the CDC on the Dalkon Shield IUD evidence, as a teacher in Iran prior to the Iranian revolution (she left the same day the Shah left), and in the department of defense as a Fortran specialist (that's an old computer language for those of you who aren't old enough to remember).  In retirement she is a nurse.  Badass.

Judith Weiss is a librarian who hails from Ohio.  She is working on building up and connecting the Busitema University to more resources. She is a Peace Corps Response Volunteer, cook extraordinaire, and is traveling with her husband...

Judith and Robert Weiss

Robert Weiss, a pediatrician and return GHSP volunteer.  He was a part of the first cohort of volunteers (with Maureen Ries), serving at Mbarara University of Science and Technology (MUST) in western Uganda.  He is a gem to have on board with a calm and rational demeanor, and always classy with an array of bow ties.

First potluck dinner

In addition to catching up on the stairwell when coming and going through the building, it has become a tradition to host a "house" potluck once a week.  It becomes a feast of home cooked food with a taste of home, getting creative with the freshly picked fruits and vegetables from the central market, as well as learning new secrets to recipes (who would have known that cinnamon in guacamole is delicious?!).  

What is the food like?

There are several options for food in Mbale town.  At the central market, you bargain and buy the local food from the families that grew it themselves.  The stalls are filled with tomatoes, onions, carrots, bell peppers, garlic, ginger, potatoes, avocados, cabbage, cauliflower, bananas, pineapple, cherimoya, watermelon, passion fruit, and even the occasional mango (we've been told mango season is in full swing near December).  Other more traditional Ugandan food is also abound, including beans, lentils, rice, peas, ground nuts, matoke, and yams to name a few.  When needing some basics, there are several grocery stores carrying milk, yogurt, butter (!), tahini (hummus is definitely happening), peanut butter, spices, and the best ever, NUTELLA!!!  This year we'll be taking full advantage of the farm to table freshness of the produce, and try our hand at creating several staple foods from scratch. 

The house is spoiled by Julia, who bought an oven and has supplied everyone with cashew and date cookies, homemade wheat bread, papaya cobbler, and of course a sweet banana bread.

Also in town is a Danish gentleman who has built his own cheese factory, making gouda, mozzarella, cream cheese, cottage cheese, and paneeer (Indian style cheese which he supplies to the local Indian restaurants). He even delivers cheese to your front door.  Amaaaazing.  We haven't had the luxury of trying out his products yet, but will keep you updated!

What can you do for fun?


Hike! 

Last weekend we discovered the local mountain, due east of the town.  Dennis and I can step outside of our house, walk to the base of Wanale Hill, climb to the very top, stand next to a large waterfall that cascades down the side of the mountain, and see the entire Mbale town below.  The hike involves climbing a wall of sticks to get to the steepest part of the path.  It looks daunting, until you see a man with a machete in one hand and a large sac of coal on top of his head scale the wall easily without ever wavering.  At the top are small pools of water where locals and hikers alike swim, alongside rolling green fields and banana trees.  Hiking down another side of the mountain leads you to the main road to town and back to our front door.  Round trip is 5 hours, easily the best way to start a weekend on an early weekend morning.

This past weekend we trekked to the beautiful Sipi Falls near Mount Elgon for a welcome weekend celebration with the eastern region Peace Corps Volunteers.  
After a packed, hour-long matatu ride to a quaint backpacker stay called The Crow's Nest, we were off for a day of hiking to the three major waterfalls.  It was the perfect setting to get to know the newest PCV cohort, as well as many more senior and seasoned volunteers.  The hike took us again through rolling hills and farmland, until we ascended to the first fall, with water crashing down and creating a mist over the area.  The power and force of the waterfall was incredible.  Nature always has a way of casting a spell through her beauty and strength.


As we trekked toward the second waterfall, we came across some locals harvesting their onion crop.  Thinking we would get a few onions to take home, we bought 2,000 ugx worth of onions.  The roughly $0.60 actually bought 2 kilograms of onions freshly harvested minutes earlier.  We are loaded with onions.

The hike continued downstream to a small waterfall that fell into a deep pool of water.  There many children were swimming and jumping off of the rocks into the pools.  Many of the PCVs joined in.  As we continued downhill, the scene became impossibly more picturesque, until we found ourselves in a large cave behind the the base of the second waterfall.  The cave created a protected area to climb down to the base of the falls, walk amongst the mist, and hear the water crashing down.


Not far from the second falls was the Sipi River lodge, where we warmed up in the sun, that intermittently peaked through, while eating sandwiches and drinking delicious hot coffee.  

In the later part of the afternoon, we descended a man-made "ladder" leading to the base of the third and lowest waterfall.  Once you were heading down the wooden rungs, you could no longer see the top from where you had started, nor could you see the bottom of the rungs where you were headed.  It felt as if you were suspended midair on the side of the mountain.  When we did reach the base of the ladder, standing on solid ground was a feeling of relief.  After hiking further down the steep path, we found ourselves overlooking the most powerful fall, complete with a rainbow at the base from the misting water and slowly slanting sun.  The view was absolutely breathtaking.  The hike ended by climbing back up the same ladder we had descended, now with our senses filled.  

Back at the lodge, we cleaned up in the warm showers while the rain played music on the tin roofs.  A rousing game of Cards Against Humanity (little known secret - this game was created by former Peace Corps Volunteers!) ensued before a filling dinner, followed by hanging out by the campfire through the evening while watching the stars and moon shine through the patchy cloud cover.  A huge thank you to Katie and Carson for organizing the weekend!

When not at work or hiking, we are usually cooking, reading, socializing with the crew, or keeping everyone updated through blogging.

Next planned trip - Murcheson Falls.  Where hippos feed outside of your tent at night.

Physician Educator - two weeks and two days

August 21 - September 6, 2016

The memory and heartache of watching a husband cry in the corner looking on as his wife lay lifeless on the examination table, dead from severe malaria at 18 weeks pregnant, is seared onto my heart. 

This 25 year old woman arrived only two hours prior with severe anemia, moaning and writhing in her altered mental status, foaming at the mouth, with the pulse oximeter showing 42% oxygenation due to her severe anemia and pulmonary edema.   She had already received the recommended first line treatment at another facility, and all we could do was transfuse, start second line treatment, monitor glucose, and hope that she would turn the corner.  There are oxygen tanks on the ward, but no regulator head in order to deliver the oxygen.

While precepting the medical students on the nearby patients who are moaning from an inevitable abortion*, bleeding profusely from an incomplete abortion, or shaking with rigors with a temperature of 41 degrees celsius and with a cord prolapsing out from another inevitable and now septic abortion, I'm called over for CPR as the patient with severe malaria no longer has a pulse and has only intermittent agonal breath sounds.  There is no crash cart.  There is no intubation, no respirator, no board with which to place under her back for adequate CPR.  After it is clear that continuing further CPR attempts are futile, I call time of death.

As I console the patient's mother, while registering the grieving husband in the corner, I listen to her words as she is coping with the shock and yet states so calmly, "the Lord gave me my daughter, and now he has taken her away."

With this I am stunned, and can't begin to reconcile that half a world away, the taking away is so much less.   

And this was the second death I attended to that day.

Fast forward to week two.  

The inner surgeon in me arrives on the unit  early to ensure that my post operative patients are doing well the following morning.  While on the ward the nurse asks for my help with a patient who was restless overnight. I see a young 20 year old who delivered a 30 week stillbirth at home, then arrived the following day due to swelling.  She is tired, breathing rapidly, edematous all over her entire body, with massive pulmonary edema, a blood pressure of 160/100, 3+ proteinuria, an oxygen saturation of 80% on room air, and a creatinine of 12.98.  Severe pre-eclampsia with multi-organ involvement.  

I have since discovered the one room in the hospital that has oxygen, giving around 2 liters by nasal cannula.  With the help of another GHSP volunteer, we are able to coordinate patient care and get the patient to the casualty (British for emergency room) resuscitation room for oxygen and carefully balancing diuresis.  With oxygen her saturation improves to 92%, not great but an improvement.  

The following morning she is still alive, with stable vital signs from the day prior, however worsening creatinine status to 16 and hyperkalemia.  She needs dialysis to remove the extra fluid and stabilize her electrolytes; the closest dialysis center is again Mulago National Referral Hospital in Kampala, 4 - 6 hours away.  The cost of transport to the hospital and a few sessions of dialysis is 500,000 to 1,000,000 Ugandan shillings ($150 - $300).  The family needs to raise the money to get her there.  

When I am next able to check on her, the room is empty and I am told she was taken to Mulago.  Whether she made it alive, and if so was she even able to be seen and treatment given, I'm not sure I'll ever know.

Week 3.  A patient with cardiomyopathy and mitral valve involvement, had previously been stabilized on the unit, was doing well when I last saw her on Friday, excellent heart rate and 98% oxygen saturation on room air.  Over the weekend she goes into spontaneous labor with a breech fetus, brewing pre-eclampsia.  She is given a large fluid bolus and hydralazine to manage her blood pressure, with her heart rate sky rocketing, oxygen saturation to 80% upon entry into the theatre for her cesarean section.  As I walk to work on Monday morning I receive a call from the anesthesiologist from overnight, asking me to check in on the patient as they were worried.  I walk on to the ward to find a woman gasping like a fish out of water, heart rate 145, oxygen saturation 39% on the nasal cannula in the room.  Ramping up the oxygen and with a face mask I can get her to 51% saturation.  There is no beta blocker available in the hospital, or even in the entire town, to slow her heart rate down for adequate filling time or decrease her blood pressure.  Her lungs are filled with fluid as her heart can't keep up.  Intubation is not an option.  There is no respirator.  

12 hours after she delivered a healthy baby, she arrests.  We perform 15 minutes of CPR while her newborn baby lies sleeping soundly in the cot close to hers.  After calling time of death and informing the family, they are so accepting of death and the transient nature of life.  They ask me what they should now do with the baby... 

**************

To compare the drastic change in environment, the US is currently grappling with the maternal mortality rate increase to 23.8 deaths per 100,000 live births, while according to the UN Population Fund Uganda has a maternal death rate of 343 per 100,000 live births. A presentation by a local epidemiologist sites the Mbale maternal mortality at 680 per 100,000 live births.  This does not begin to touch on the number of stillbirths.

**************

Mornings start with a report that takes place every weekday at 8:30am.  Every meeting begins with an opening prayer.  Nurses, midwives, and a smattering of physicians then discuss the events occurring on labor, postnatal, gyn, operating theatre, and neonatal wards over the past 24 hours, or 72 hours if it is Monday morning. Reported numbers include admissions, discharges, runaways, SVDs, cesarean sections, maternal deaths, fresh stillbirths, macerated stillbirths,  abortions (*for non-medical personnel - this is a medical term for various types of miscarriage), UTI in pregnancy, malaria in pregnancy, pre-eclampsia, and blood transfusions, to name a few.  This is followed by challenges the different wards are facing.

Challenges noted over the past two weeks:
-Lack on running water on the unit
-No urinary catheters
-Fetoscope is missing from the ward (that's right - fetoscope.  No electronic fetal monitoring here)
-One curette available for D&C or D&E
-Pitocin is out of stock (leaving only misoprostol for postpartum hemorrhage - methergine and hemabate don't exist as they need refrigeration)
-IV Metronidazole is out of stock
-Bleach is out of stock
-Lack of sutures (5 boxes of 12 sutures is given for a 3 month supply)
-No oxygen on the unit
-Lack of manpower on the unit***

The lack of manpower is a crisis across the entire country of Uganda.  This has to do with a nation wide discrepancy between students emerging from their medical training, the number of internship positions across the country, and the compensation the interns receive.  

The typical regional referral hospital includes the following personnel:
-Nursing, midwife, clinical officer, and medical students
-Nurses (usually one per unit)
-Midwives (one on duty at a time)
-Interns
-Medical officers
-Consultants

The medical education system is more British-style.  After completion of A-level (US: high school), students can go on to receive a diploma (US: associate degree) to become a nurse, midwife, or clinical officer (likened to a physician assistant), or head to nursing or medical school to receive a diploma (US: bachelor's degree).  The medical students receive an MBChB (Medicinae Baccalaureus, Chirurgiae Baccalaureus in Latin) similar to a combined undergraduate and medical school in the US.  After five years of training at their home institution, the sixth year is completed through an internship at various government hospitals around the country.  The Ministry of Education oversees the medical schools, while the Ministry of Health is responsible for the internship positions.  Completion of an intern year is required to obtain your degree, however there are currently more graduates from medical school than there are internship positions.  Not to mention that the interns are paid through the Ministry of Finance, which often does not pay interns for 3 - 4 months at a time.  A disconnect between the ministries.  Thank you, ACGME, for making sure I was able to work AND receive a paycheck every month.

This is all to complete your basic MBChB degree.  The positions are infinitely smaller for specialty masters degrees (US: residency), therefore most physicians practice as medical officers with internship level training in their field, while a select few become consultants (US: attendings) in internal medicine, surgery, obstetrics and gynecology, orthopedic surgery, anesthesiology, etc. Consultants become available to answer any questions and weigh in on tough cases that the interns and medical officers need assistance with, however don't typically see patients in the government facilities unless they are teaching the students. 

And for all of you MFM, Gyn Onc, MIS gods and goddesses out there, you are earning/have earned the equivalent of a PhD in sub-specialization.

To make matters worse, the interns were supposed to start working on August 15th.  However the institutions did not choose their interns until well after this date. And now the interns are striking as the government proposes that only students on a government scholarship will receive a stipend - to be compensated by 2 years of compensatory service in a government hospital, while those students not on a government scholarship will fund themselves through internship.  

The lack of interns means that the medical officers are shouldering all of the inpatient clinical responsibility. There are three medical officers employed by Mbale Regional Referral Hospital in obstetrics and gynecology. Two medical officers show up to work; the third is mostly MIA.  

And the ward is busy, delivering 35 babies a day, 1,000 a month.  

WHO Partogram on L&D

As a physician educator/lecturer and consultant with Busitema University Faculty of Health Science (BUFHS), I am just beginning to learn my role in university and in the hospital setting.  My first obligation is to teaching the medical students, with the first class currently entering their fourth year since BUFHS opened in 2013.  We teach them in ward rounds every Monday and Thursday, theatre (operating room) on Tuesday, Antenatal clinic every Wednesday, GYN clinic Friday, and a smattering of classroom and patient bedside presentations on the other days.  In the first few weeks, I've discovered that showing up really is half the battle.  Oftentimes consultants will no-show, arrive late, or leave early for various personal reasons (again when you are paid every 3-4 months and aren't sure when the next paycheck will arrive, you can't blame anyone for having a second job).  By just being in the place that I am supposed to be at the given time, I am able to give my group of 13 students so much on their 5 week OB/GYN rotation.  Never mind that I have to modify my thick American accent, or pick up new phrases or acronyms to adequately convey what I am trying to teach.  I am there for them to learn.

Casuality Resuscitation Room - the only
room with oxygen in the entire hospital

When teaching in the hospital, I am learning to treat malaria in pregnancy, postoperative management of patients with obstructed labor (obstructed for days - when I mentioned the Zhang curve of no cervical change for 6 hours then proceeding to cesarean, my supervisor and counterpart laughed), as well as performing a hysterectomy with 2 sutures of 2 Vicryl (not 2-0 Vicryl) skin-to-skin.  Outpatient I am wrapping by brain around the routine intermittent preventative treatment of malaria in pregnancy, diagnosing fistulas, relying on LNMP and fundal height for the estimated due date without any first, second, or third trimester ultrasound to confirm dating, and auscultating fetal heart tones through a fetoscope.  When explaining why I didn't know how to use their fetoscope, the staff thought it was because I was used to using the fetoscope with with ear pieces like a stethoscope, rather than the megaphone-like fetoscope that is used both outpatient and on the ward.  Nope, its just that I'm spoiled with electronic doppler and external fetal monitoring (AND tocometry).

Plus sides: there is a blood bank.  Fitz, I might not have methergine, hemabate, or a Bakri balloon (though I've been told how to make one out of a sturdy Peace Corps dispensed condom and a foley catheter), but I DO have a blood bank.

A huge thank you to Dennis who is always there to hold my hand, and to Drs. Bonaventure Ahaisibwe and Maureen Ries from SEED for being amazing sounding boards as I discover my role and continue to listen and absorb what the school and hospital need most.

Up next - the fun experiences with fellow GHSPers and making Mbale home.

Swearing In and Bulamu Health Camp

August 11th to August 20th, 2016

"Ambassador of the United States of America Deborah R. Malac requests the pleasure of the company of 

Ms. Sarah Lynn Lovell Frey and Mr. Dennis Frey 

at the Peace Corps Volunteers Swearing-in ceremony

Thursday, August 11, 2016."

Team Mbale

After one full month of orientation, we are officially Peace Corps Volunteers!  The swearing in ceremony was held at the Ambassador's residence in Kampala, with the ambassador herself.  The groups being sworn in included the Global Health Service Partnership team, as well as the traditional 27 month Peace Corps Volunteers in the health and agriculture sectors.  It was a beautiful venue and a fun celebration, with many of those being sworn-in wearing outfits made of traditional African cloth called kitenge, and our bosses and language trainers wearing their best.  We were even joined by many of our supervisors and counterparts for the ceremony, including my supervisor, Professor Julius Wandabwa, Dennis's counterpart Paul Oboth, as well as the dean of Busitema University Faculty of Health Science, Professor Paul Waako.  

The night out of celebrating occurred at a delicious and relatively authentic Mexican food restaurant called Que Pasa, run by an Australian ex-patriot, in the heart of Kampala.  If you ever find yourself in the area and desiring a taste of home, Que Pasa is hands down recommended for Mexican food, while Mediterraneo has some delicious Italian with TONS of different and delicious cheeses. Never to compete with any Toti-Moles creation, though!

Friday was a surprise day off, which we used to hang out at the hotel complex, relax, read, edit photos, and enjoy not being lectured to for more orientation.  

The next day we were off again! After packing up our gear once more on Saturday morning, we hopped in a matatu (popular form of transportation in Uganda and all of East Africa) and headed east toward Jinja, the area best known for being the source of the Nile River (and Nile Beer), for a week-long medical camp run by Bulamu Healthcare International.  The camp was held at the Mpumudde Health Center IV, which traditionally functions as a resource center for HIV testing, counseling, and treatment with anti-retroviral therapy.  For the week, we were turning it into a free primary care site.  Our team, consisting of eight GHSP volunteers, two Peace Corps volunteers, and the Bulamu crew, working alongside six local Ugandan physicians, saw 2,989 patients in five days.  Whew!  Dennis was working administration and kept everything running smoothly, while Sarah focused on cervical cancer screening through VIA method and treatment with cryotherapy when indicated.

What is it like to...

Miles, Dennis, and Faroq
in "Dennis's office"

Gerald and Dr. Joseph
at morning report

...run administration for an NGO camp?

Dennis: I worked closely with Gerald Atwine, Bulamu's founder and CEO, to implement systems for collecting patient information, tracking the volunteers' hours, and accounting for the equipment and medicines that were brought in by Bulamu for the camp. I created several Excel spreadsheets for these tasks and then I essentially lived in them for the duration of the camp. We distributed raffle tickets to patients each morning to track the number of patients seen each day.  The tickets doubled as the patient medical record number as well as a way for them to get some food and water at the end of their day.  At the beginning of the camp we estimated that we could see roughly 500 people per day; each morning I would tear-off 500 tickets to get us started.  By 10am, we were usually out and had to decide if we had enough supplies and manpower to register more people.  Saying "No" was not a viable option since so many patients came from far-off places and coming back another time was not feasible.  Fortunately the staff was hardworking and the system flexible allowing us to screen almost everyone who arrived to the camp.

A note from Sarah: Dennis is underplaying his role.  He was the star coordinator for the week, and the camp would not have run as smoothly without him!

...perform cervical cancer screening in Uganda?


Sarah: The World Health Organization guidelines on cervical cancer screening, cryotherapy, and technical specifications are your best friends.  When women travel for miles on foot for screening, there is no pathology department or pathologist, and you are present in an area for a limited time, the best method is visual inspection with acetic acid (VIA) and immediate treatment with cryotherapy when the patient meets inclusion criterion.  The flashcards and atlas from Jhpiego were an incredible asset as well as teaching tool for the Ugandan midwives and physicians, so keep this in mind if preparing for VIA screening in the future.

The amazing lab staff!

Patients waiting 
to be seen

Sunday was spent turning the procedure room and its adjacent storage room into a functional screening room and treatment room, respectively.  While cleaning the storage room we found boxes full of mixed medical supplies including intubation materials, old tracheostomy kits, foley catheters, masks, ostomy bags, lidocaine, epinephrine, and safe male circumcision kits (studies showing a reduction in transmission of HIV amongst circumcised men have had a large policy push in Uganda and all of sub-Saharan Africa). These supplies were located amongst rodent droppings, insects alive or otherwise, dust, and blood stained surgical gowns and drapes.  After a few hours of cleaning and organizing, we had two beautiful rooms ready for screening and treating!

At your cervix! Dr. Shambe,
Teddy, Anna, and Dr. Sarah

The cervical cancer screening team consisted of Anna P and Julia R, two amazing American midwives, Dr. Shambe who is in the middle of her residency training at the University of Toronto, the incredible Mpumudde Health Center midwives Joy, Vanisar, Margaret, Mary, and Ruth, alongside translators Teddy and Claire.  Esther became our scrub tech extraordinaire, ensuring that all instruments were cleaned and high level decontaminated to WHO specifications. 
During the week, we screened over 260 women (focusing on ages 30 - 49 or any age if HIV positive, per WHO guidelines), with 16 identified for cryotherapy and a further 16 referred for either LEEP or to Mulago Hospital, the national referral hospital in Kampala, for chemo/radiation due to outright advanced cervical cancer.  The downside?  The one (you read correctly - ONE) radiation machine in the country is currently down, uncertain when it will be back in operation.  This leaves women with cervical cancer to wait, without any other available option.  

Triage

The team also discovered during the week long camp that patients were rarely receiving a physical examination by a physician.  Ever.  Most patients who present with a complaint such as lower abdominal pain in a female are automatically treated for PID (Pelvic Inflammatory Disease) with Ceftriaxone 1g IV followed by Cefixime 400mg PO x 3 days, alongside Doxycycline 100mg PO BID x 14 days AND Metronidazole 400mg PO BID x 14 days.  It is true that PID is a large problem in Uganda, leading to tubal factor infertility; however the cervical cancer screening team were the only providers performing a pelvic examination.  There were times when PID was previously suspected and the above regimen prescribed, however many more instances when the complaints were consistent with UTI, constipation, musculoskeletal pain, or even pregnancy (which we did diagnose in someone previously prescribed the above regimen - with doxycycline being a teratogen in pregnancy) with no pelvic organ tenderness.  Combine this with automatic treatment without a speculum exam for candidiasis, trichomonas, or BV for any complaint of vaginal discharge :/ Always examine your patients!

After the long week, a recognition ceremony was held on Friday night with cake and certificates for all of the participants.  Both of these are HUGE in Ugandan culture!  We drank sodas and danced under the star-lit sky, while the kids did everything they could to get their hands on as much cake as possible.  

Saturday morning the group took a break from work to take a cruise tour around Lake Victoria to the source of the Nile River.  The lake is Africa's largest when measured by surface area. While cruising along the shallow shores, we encountered several sites. There are numerous fishing villages, where the lake front is not inhabited by the rich but rather by the poorest of the poor.  Due to weather changes, the lake has risen several meters in the past few years, leaving many houses underwater and uninhabitable.  Also due to over fishing, several fishermen have created fish farms in the lake, where they are fed a concoction of grains, including corn, to help them grow to harvesting and selling size quickly.  Cruising further along, we see a variety of birds stationed in the trees, flying over the lake, and looking longingly at the fish growing in the farms beneath the water.  As the boat approached the source of the Nile River, you could see the current picking up underneath the boat from the running water and the up swelling groundwater that contributes to the mighty river.  As we cruised along the river, the best sites were the monkeys stationed high in the trees and jumping from branch to branch.  Alongside sightings of yellow weaver birds, monitor lizards, and even an otter, it was the perfect outing after a week of camp.

Back on land we helped to pack up and record the supplies, before heading out in another matatu for Mbale.  Finally, heading to the city we will call home for the year!

Global Health Service Partnership Orientation - from Washington DC to Uganda

July 11 to August 10, 2016

GHSP OB/GYNs!

A month-long orientation to the Global Health Service Partnership (GHSP) and Uganda!

Orientation started with a room full of 59 new GHSP volunteers (physicians and nurses), 6 Peace Corps Response volunteers (spouses ala Dennis), a 4 month old SEED-ling that will be heading to Tanzania in September, and all of the Peace Corps and SEED staff.  It was incredible to be in a room filled with people about to embark on the same adventure, in Liberia, Malawi, Swaziland, Tanzania, and Uganda.  Dr. Vanessa Kerry, an intensivist physician at MGH as well as mastermind behind SEED and the partnership with PEPFAR and Peace Corps, started the day off warmly welcoming everyone, introducing the history of the program, and the tremendous growth since its inception in 2012.  The later morning included all volunteers sharing who they were, where they were from, why they joined, and what was the most unique thing they had packed to take along the journey.  The major theme was coffee paraphernalia, followed by knitting/crocheting, color by numbers, etc. However, the best was a GoGirl toilet device for almost all unknown situations (Google it!).  The day ended with a happy hour for everyone including the SEED board of trustees, a great opportunity to get to know both fellow volunteers as well as the backbone of the organization stateside. 

Tuesday followed with more sessions on what to expect in country, current teaching methods in Africa, and the start of several lectures on clinical management of not-so-common to the US but oh-so-common syndromes in Africa.  The surprise came around 5pm when Vanessa announced that her dad, Secretary of State John Kerry, was planning on stopping by shortly.  Whatever your political inclinations, it was a truly inspiring speech addressing the global need for health education and change, with an apropos quote from Nelson Mandela, "It only seems impossible until it is done."  With those words of inspiration, Dennis and I took the evening to tour the capital on foot.  From the White House to the George Washington monument, on to the reflecting pool and the Lincoln memorial.  The best surprise was coming across a large monument of Albert Einstein.  The discovery was so fitting in that my first medical journeys to Africa, inspiring a love for global health, were through the generosity of the global health program at my alma matter, Albert Einstein College of Medicine (AECOM).  Dr. Carol Harris and Dr. Gerry Paccione, thank you for your inspiration and investment in the medical students!  The night ended with a delicious meal at Founding Farmers, with an amazing fig and prosciutto homemade bread.  Yum!

The week continued with more orientation, working on the ever expanding to-do list, making new friends, and preparing the ABOG Oral Board Case list.  And of course time to catch up with the wonderful Natalie Shanks, who is working in DC at the NIH!  A fun and filled week.  The weekend was a welcome reprieve from orienting, with a road trip up the East coast to NYC.  We took advantage of the drive, with a stop in Philadelphia for the famous Philly cheesesteak from John's Roast Pork.  NYC was then filled with friends, food, repeat.  Thank you to the wonderful friends that were able to come out and see us, and to Matthew and Javier for your hospitality.  The drive back had another stop in Philly to catch up with the lovely Berger family, and finally meeting Miss Molly, a brilliant 2 year old and budding scholar.

Team Uganda

The next week flew by with more orientation, preparations to leave, and a final happy hour on the rooftop of one of the George Washington University buildings overlooking the National Mall.  The night before our departure, we were sent off with a delicious all-American cheeseburger dinner prepared by Katie and Tom, with special guest Matthew who flew down from NYC for the evening to join for dinner.  Frequent flyer miles :)

On Thursday July 22nd, with 5 checked bags packed up and carry on luggage in tow, we took off from DC for Uganda - the next chapter in the adventure!

After a weather delay in the Addis Ababa airport, we finally landed in Entebbe, Uganda near 3pm on Friday July 23rd.  As the bags finished rolling out on the conveyer belt, our team realized that nearly every person was missing a bag, or two, or four.  There is nothing like filing a missing luggage claim form at Entebbe airport to quickly immerse you into Ugandan culture.  Fortunately we got wind that the bags were likely coming on the next flight a few short hours away.  Solution?  Hang out and drink the local brew while awaiting for the luggage to arrive on the next flight.  All missing bags did show, leading us to the next adventure of navigating Kampala traffic on a Friday evening. Who knew it could take 45 minutes to drive 3km?  After all of the travel, delays, missing bags, and traffic, the whole group was happy to arrive at the Kolping Hotel in Kampala...three hours later.  Dinner was ready and waiting for us at our 9pm arrival, which we all enjoyed before quickly heading to bed.

Saturday through Tuesday involved - yes, you guessed it - more orientation to the country.  Between new bank accounts, work permits, Peace Corps telephones, mosquito net and water filter distribution, medical officer appointments, safety and security briefings, educational lectures, as well as setting up MiFi (little device that transmits WiFi wherever you go) it was a busy few days.

Wednesday July 27th team Uganda split off into our respective locations for orientation to the cities where we will eventually be living.  Team Mbale loaded up the van alongside our language translators, team Lira, a lovely Peace Corps couple heading to Iganga, and allllllll of our luggage for the 4 hour ride from Kampala to Mbale, which includes crossing the Nile River!

Orientation in Mbale was complete with an 8 night/9 day homestay with a local family.  Our host "mom" was Grace Namonyo, a lovely business woman who runs a home decorating store near the central market, in addition to keeping up her own garden and other food production.  The types of food we discovered on the compound during our stay included papaya, avocado, passion fruit, potatoes (called Irishes in Uganda), beans, rosemary, sugar cane, rice, hens for their freshly laid eggs, and goats.  While we were staying with Grace, she acquired a male goat to accompany her female goat, so she will likely get more kid goats in the near future ;)  Grace is assisted with all of the duties by her niece, Charlotte, when school is not in session.  Grace was a wonderful host, making us breakfast filled with watermelon, pineapple, papaya, passion fruit juice, toast, eggs, cereal, coffee, and ginger spiced tea every morning.  She would then drive us to the designated meeting place for the day.  On our arrival home we would prepare dinner, learning how to prepare the local dishes like posho, matoke, chapati, ground nut sauce, and even pork acquired from the market, while we also taught some international dishes like a veggie filled Italian pasta, vegetable curry, and the favorite breakfast food of French toast.  Charlotte introduced us to Ugandan style music, soap operas, and her favorite cooking television show.  

The weekdays were packed with language lessons and meetings. Each day started with a 1 or 2 hour language lesson with our Peace Corps language and culture trainers, Rachel and Silver.  They are both amazing and patient teachers, helping us pronounce and understand the Lumasaaba language and culture.  They were also in charge of our daily schedule, and deserve so much credit for taking us around to so many places and introducing us to so many people in Mbale!

Thursday July 28th we were introduced to our bosses and counterparts at a day long meeting.  There we reviewed our goals, expectations, and created action plans for the coming year.  The day finished with a large dinner at the fancy Wash and Wills Hotel and Restaurant in town, where we also met with hospital and medical school administration and staff.  Friday involved a tour of the hospital and further introduction to the hospital staff, a preview of our brand new apartments that were in the process of being constructed, as well as a trip up to the local synagogue - one of the only in eastern Africa - to meet the congregation and the rabbi turned member of parliament Mr. Gershom Sizomu.

Saturday was an adventure day, complete with a trip up to the top of Wanale Hill (the major hillside and backdrop to the east of Mbale) and a hike to a beautiful waterfall cascading down the side of the steep hill.  Along the way we were greeted by the locals of all ages.  They would laugh when we would respond in Lumasaaba.  Along the way we saw farms of carrots, potatoes, onions, bananas, matoke (plantains), and so much more.  We saw gerry cans being used in a variety of functions, from carrying water to being cut in half to make a sled to cascade down a small hill.  One little boy who was carrying his younger sibling and 3 gerry cans nearly his size quickly dropped the cans and posed for a picture once he saw the camera.  On the way down the mountain, our matatu (taxi van) encountered a large crowd of at least 100 participants who were dancing, singing, and parading to the cultural grounds - for more, read on!  Once we were back in town, it was time for a tour of the local market.  The gentlemen took a tour of the grocery store and food portion of the market, while the ladies found gorgeous fabric and visited the tailor to have outfits made for the swearing in ceremony.  While their parents were working, a group a kids were playing nearby.  The resulting picture is what happens when teaching Ugandan kids to take a selfie :)

The Sunday of the homestay was our one day off from Peace Corps duties, and a chance to explore the city with Grace.  We started with Sunday morning church, where our language and cultural trainer Rachel was also singing in the church choir.  After meeting some of Grace's extended family and friends, we were off to the market to meet some of Grace's local suppliers, including one gentleman that routinely has more rare foods including radishes, bok choy, spinach, zucchini, and other not-so-Ugandan produce.  We were then off to the local cultural grounds, that were preparing for a large festival weekend celebrating the circumcision of boys around 18 years old to mark the transition into manhood.  This is a huge local festival that occurs from August through December of every even year.  The men are caked in mud and accompanied by a large crowd from their village waving tree branches as they dance and celebrate on the march to the grounds.  At the grounds themselves, there is a carnival atmosphere with tents filled for booze, food, and games with both traditional and modern pop music blasting from all directions.  There are also traditional mud huts with grass roofs where the various clans will stay, as well as an isolated mud hut where the circumcision will occur.  The grounds were also preparing to receive both the Ugandan as well as Kenyan presidents the following weekend, who preside over the opening weekend.  Want more information?  This is a great clip of the grounds, history, culture, and events.

Monday was a busy day meeting the main participants in the regional department of health and department of education.  With each of the meetings alongside a wonderful presentation by Dr. Jayne Byakika-Tusiime, a Ugandan epidemiologist with her PhD from UC Berkeley, we discovered that maternal mortality was a priority for improving in the region as the rate is incredibly high at 680 deaths per 100,000 live births (the US is embarrassed by a recent increase in maternal mortality to 23 deaths/100,000 live births currently).  The rest of the day was shorter as all non-clinical staff were on strike as they had not received a pay check nor the promised pay raise from the government in over 3-4 months.

On Tuesday we trekked to Tororo, the site of Busitema University's main campus, in order to meet the Vice Chancellor of the University, Professor Mary Jozzy Nakandha Okwakol.  We went a bit out of the way when heading home to visit the border crossing to Kenya at Malaba.  A guard took us on a tour through the gates to "no-man's land," the area between, yet not belonging to, either Uganda or Kenya.  No pictures were allowed though - sorry!  The next evening we had a lovely dinner with all of our host families to say thank you for the week.  After sunset we lit sparkler candles and sang happy birthday to Julia Taylor, the nurse extraordinaire (with an amazing life story) who was celebrating her 70th birthday with us in Uganda.

Thursday was back to Kampala for a few more days of lecture and orientation.  The highlight was a visit to the Ndere Cultural Center on Sunday August 7th.  There a dance troop including dancers from all over Uganda, as well as neighboring Rwanda and Burundi, perform local dances and highlight the unique cultures.  The best was the Burundi drummers - 14 drummers balancing their instruments on their head while they walked perfectly down stairs and into formation, kicking high and maintaining balance while performing a riveting drum cadence.  

With orientation nearing the end, we were gearing up for swearing in on August 11th - stay tuned!