Physician Educator: Health comes home

March 18 - April 3, 2017

After a lovely whirlwind tour of Uganda with mom and sister, Dennis and I were quickly back into full swing of life in Mbale.  

Malaria Think Tank with
Health Educator Jasraj

Sunday March 19th I traveled east via matatu to the town of Tororo to participate in the Malaria Think Tank Uganda Mini Boot Camp, a four day educational conference for Peace Corps Volunteers and their local counterparts.  The camp covers education about what is malaria including the life-cycle and how it is spread, prevention from mosquito bites, and how to educate each of their communities.  I gave a lecture on malaria in pregnancy (HUGE contributor to both maternal and fetal morbidity and mortality), as well as HIV and malaria co-infection.  Each year malaria claims over 400,000 deaths worldwide, with an incredibly disproportionate 90% occurring in Africa.  The key to prevention of malaria in the population, especially for pregnant women in the first trimester, are insecticide treated bed nets to prevent bites.  These have been shown to be a cost effective intervention with significant health benefits.  

How can we get bed nets to more people in Africa and around the globe?  The economics of interventions is complicated.  While in Uganda I have found the greatest challenges not necessarily from the rare cases or severe diseases presenting to the hospital, but rather from the basic supply chain or lack thereof in the hospital.  As luck would have it, Jasraj - a Peace Corps volunteer in agriculture with a degree in economics - has become more interested and involved in health education, while I have delved more deeply into the commerce of healthcare in Uganda and developing countries.  A winning team :)

During the HIV and malaria talk, there were several unanticipated questions regarding HIV and its transmission.  I discovered that there are several community beliefs and myths about HIV, transmission, and treatment.  The think tank participants talked of partner coercion with many demanding their significant other not get tested for the virus, or others paying healthcare workers to say they are negative when in fact they are positive for HIV.  Many felt that HIV could be treated by having the blood "cleaned" in the U.S. (false), while also questioning the origins of HIV through transmission from chimpanzees (true).  It was wonderful to have such an active and engaged group; I would love to continue the education in the community in the future!

Afternoon rain outside Endiro Coffee

On the matatu ride back home, the possibility and origins of so many fantastic myths was solidified when I found a fellow passenger reading a newspaper article stating that second hand clothes (a huge market of the donated clothes from all over the world) can cause cancer.  Yikes.

As the rainy season approaches, I have loved the afternoons, evenings, and middle of the night rainstorms that come pouring down on Mbale.  The days cool off during the rain, and there is something incredibly soothing about sitting at home or in one of the local coffee shops, working or reading while listening to the rain and thunder outside, or watching the clouds filled with bolts of lightning striking in the distance.  Some coffee shop work has included sending wedding cards to friends who have gotten married over the past year.  In one day we sent cards from Africa to three other continents.  So far most have arrived!

Dennis teaching effective power point presentations

The week that followed the malaria camp was full of lectures to the third year medical students, morning meetings, ward rounds, and the operating theatre.  Each day's schedule is always unpredictable, as lectures or meetings will be scheduled or cancelled at the last minute.  Tuesday March 21st a grand rounds presentation was scheduled to be coordinated by my colleagues Dr. Waiswa and Professor Wandabwa, except that Professor was out on his annual leave and even out of the country in Cape Town, South Africa presenting at an international conference.  I organized the grand rounds on ectopic pregnancy for that day, only to find out a few hours before that the course coordinator had rescheduled a written examination for that same day, interrupting the grand rounds presentation and cutting it short.  Frustrating.

On March 24th, health came home.  Dennis and I were awoken early by a fellow GHSP volunteer who needed some minor medical assistance.  As the day continued, the situation progressed to needing major medical assistance.  What happens when you become acutely sick in Mbale, Uganda?  There is no phone number like 9-1-1 to call for an ambulance.  The Peace Corps Medical Officer attempted to call a local ambulance company, however no one was picking up the phone.  We arranged a ride with a local driver, and made our way to the designated hospital in the area.  In the U.S., we are used to a team of nurses and doctors quickly converging on a patient, with an IV placed, labs drawn, and necessary medications given within the span of minutes.  In Uganda, you have to first pay the consultation fee and present the receipt for a doctor to even begin to see the patient.  Obtaining vital signs takes several minutes, with the main focus of vital signs being blood pressure.  The nurses or physicians took one look and said everything was fine, not noting a heart rate in the 120s.  Definitely not normal.  Once a treatment plan is underway, you then pay upfront for the requested cannula, tubing, IV fluids, gloves to be worn by the staff, and the cost of the labs before they will be drawn or sent.  Dennis and I did not have enough cash on us, making a run to the ATM another hurdle to overcome.  When the labs did come back, there were some significant abnormalities that were either very suspicious for a lab error or were very worrisome.  And there wasn't the correct fluid in the hospital to attempt to treat these abnormalities.  During this time we were incredibly thankful for a visit from three of our lecturers that we work with at the university, Professor Wandabwa, Dr. Tegu, and Dr. Masaba, who we dubbed the three wise men.  They were incredibly supportive, and I know made things happen in the hospital that would not have otherwise been accomplished without their presence.

During this time we were also coordinating transportation to the capital; from the time we began arranging transport it took two hours for the ambulance to actually dispatch, then another six hours before it arrived to the hospital in Mbale.  The ambulance itself was more well supplied than the entirety of the hospital we were at.  It was another six hours before the ambulance arrived at the hospital in Kampala.  A total of 15 hours had passed from beginning to coordinate care and transport to being in a full fledged facility.  This story is true around the world, as noted in a recent NY Times podcast report from Venezuela.

The following week we went to Kampala to check up on our colleague, who was doing much better and out of the hospital, however heading home for the remainder of the year.  Julia and Dennis were also shopping for items for the nursing skills lab with Julia's grant she received, which turned out to be more onerous than expected as most places did not have supplies in stock that Julia was told would be available on her arrival.

From Kampala I made my way via the Homeland bus to the town of Gulu to shadow Angie, a Peace Corps Volunteer working at Lacor Hospital.  Peace Corps Uganda created a new GHSP/PCV exchange program, where volunteers will get a chance to shadow in the hospital and at local community sites, respectively.  At Lacor, Angie is involved in a multitude of projects, including mosquito net education to the HIV-positive patients, teaching how to make re-usable menstrual pads (named RUMPS) for women who cannot afford the very expensive disposable pads, making a "big book" for teaching a large class out of grain sacks, and also forming an empowerment club for the women of Gulu University Faculty of Medicine.  She was an incredible hostess around Gulu and Lacor, and it was a pleasure meeting her colleagues, counterparts, and seeing the incredible work she is doing!

After a day of shadowing, I was off to the hotel to meet with the rest of the GHSP group who traveled from all parts of Uganda for a training design and evaluation workshop, preparing orientation for the next cohort of GHSP volunteers!  It was a great few days catching up with our colleagues, many of whom we had not seen since in-service training in November.

Once training was completed we had a lovely dinner under the stars at Elephante.  A few of us awoke early on Saturday for the Gulu Go Green 5km and 15km race on a beautiful sunny day and a perfect way to start a Saturday morning.  Afterwards to indulged in fresh out of the oven cinnamon rolls at the Iron Donkey while planning the next race - a 21km trail run through the Mpanga Forrest on April 30th!

From Gulu, Julia, Dennis, and I took the long way home via Kidepo Valley National Park in north-eastern Uganda, bordering South Sudan.  With Fred and Sandra as our guides, we traversed the red dirt roads of northern Uganda. The scenery was beautiful, with small collections of huts along the isolated roads a stark difference from the crowded and commercial roads we traverse in southern Uganda.  The landscape in and around the park is absolutely stunning, and one of the most scenic backdrops we have seen thus far.  As the sun was setting behind the mountains marking the Uganda and South Sudan border, the savannah landscape glowed with incredible colors, dotted with herds of zebra, buffalo, Jackson's hartebeest, and Uganda cob.  Once we arrived at the Apoka Rest Camp, all five of us were laughing at our change in appearance, with hair, eye-lashes, skin, and clothes coated in a red-orange layer of dust.

As we settled in to camp, a buffalo was grazing in the fields nearby, while several jackals passed by our roaring camp fire.  The night sky was filled with stars, and otherwise the amazing sounds of the nocturnal animals coming to life.

The next morning we were up before the sun to explore more of the valley and its lustrous wildlife.  Kidepo is most known for its tremendous herds of buffalo, with over a thousand members in a herd, creating a thunderous rumble as they migrate through the savannah.  Near one of the largest herds, Fred spotted three young lions sleeping in the shade of a tree, too lazy from the heat to care about the thousands of buffalo nearby.


After a relaxing afternoon reading and watching a family of warthogs chasing their piglets around the camp (Julia was in heaven), we ventured to the Karamojong village.  As part of a way to teach others about their culture, as well as raise money for their village, the tribe welcomes visitors to tour their homestead.  In the homes, we saw dried sorghum and maize hanging from the ceiling, protected from bugs by mosquito nets (unclear if there were separate mosquito nets for sleeping under).  A woman taught us how to grind the sorghum against a block of stone in the home as a way to prepare bushera, the popular fermented beverage.  

Outside of the home we were shown the hut we noted the horns of a goat; if a man marries a woman and is happy with the marriage, he will buy the family of the woman a goat to be slaughtered in a huge feast.  The family will then display the horns as a badge of honor for producing a hard working woman.  After touring the goat shed and the grain bank, we were treated to traditional songs of the tribe, as well as a dance, with groups of men and women jumping high in the air.  This is another traditional custom to show others how high one can jump and that you are a hard worker.

Back at the camp, we again enjoyed a beautiful sunset and watched the sky transition to a dark backdrop full of shining stars, while a large buffalo came wandering through the camp.  We were joined by two wonderful people from UCSF who were working in Soroti Regional Referral Hospital for four months.  As Chris, a fourth year medical student, sat down next to us, he asked, "was that a huge buffalo that just walked by?!"

The next morning we took a walking tour, walking where antelope had been just moments before we scared them away.  Highlights of the walk were seeing the small details of nature, such as the antlions that trap bugs into a conical hole in the ground, the clean bones of an old buffalo, and discovering the only the scat of a hyena is white from the calcium of eating bones.

The rest of the day was another dusty ride home to Mbale, passing through villages set against the dry mountains, and the landscape reminiscent of the Arizona desert.  Men wore knitted top hats with a single large feather on the side, with a plaid fabric wrapped around them.  The women also wore the plaid fabric wrapped around, and had large necklaces made of tiny beads decorating their necks.  The landscape then began to change to one of green atop towering rocky mountains.  Yet another beautiful side to Uganda.