Wednesday, March 31, 2010

A Poverty Spectrum


Pouring rain again today. Kisenyi was a bog, we slipped around for the first several hours. Red mud caked in inches on my flip flops and splattered up the back of my legs. The first house we went to was the poorest I’ve seen yet. We approached the wooden shack hearing voices within. The inside room was pitch black save for a single candle, next to the empty chai cups left from breakfast. Two single beds lined the walls and the uneven dirt floor was covered with thin, ragged mattresses. The walls black from smoke from the charcoal jiko. We interviewed a 65 year old woman who thanked us profusely for visiting. She was endlessly apologetic for the pungent smell of urine emanating from the mattresses on the floor where one of her young grandsons had an accident overnight. She’s had 16 pregnancies, six children and eight grandchildren. Seven people live in this room, smaller than my own bedroom.

Yesterday we had approached a similarly crowded part of Kisenyi, simple brick buildings, the open sewers trickling by. Kisenyi has sporadic patchy electricity but no in-house plumbing. Water is collected from taps spread throughout the community at a cost of 50 Ugandan shillings per 20 liter Gerri can. As we ducked in the short doorway between curtains I stopped, confused. From dirt to a carpeted floor. A couch lined one wall, directly across from the large TV, with DVD and VHS sitting below it next to a huge speaker. In the corner was a flat screen computer monitor, keyboard and computer. But the thing that I couldn’t take my eyes off, was the massive fish tank bubbling away, spanning half the length of the room with tropical little fishies shooting back and forth. As we started the interview a stark naked 3 year-old shot screaming into the room, soaking wet from her bath she ran around oblivious to us. Finally noticing me she burst into tears and buried herself next to her mother’s pregnant belly. We all had a good laugh.

Last weekend I took off to Jinja, just north of Kampala to go whitewater rafting on the Nile with some other folks working at the hospital. It was unbelievable. Spectacular scenery and exhilarating rapids (obviously). I felt refreshed and renewed after the weekend, ready for another week of witnessing human stories. I had a mildly profound conversation with an internal medicine resident from Yale, as we sat sipping tea, and looking out across the Nile. We were discussing how we, as residents, are abysmally trained on how to be present for patients in the midst of suffering and death. We neither have the vocabulary, or the emotional and spiritual skills to respond to a suffering human being in the face of no treatment options we can offer them. And that is exactly the situation we find ourselves in everyday at the hospital here. There are no ICU beds for the gasping patient with agonal breathing, so we either go home for supper and return to an empty bed the next morning, or watch him die. Similarly in obstetrics, a woman in hemorrhagic shock, despite the medication and resucitation that are available to give her, but there is no anesthetist available to take her to the operating room. We can stay and be present, or leave. Either way the woman has passed away by morning. Helplessness in the face of suffering and death is the most uncomfortable place I've ever been.

Friday, March 26, 2010

Perspective

I crawled out of bed feeling achy this morning, my throat was parched and sore. There are these ridiculously vicious guard dogs that yowl miserably all night and I hadn’t slept well. Grumpy, tired and sick…oh and it was cloudy outside. I felt down-right sorry for myself, this was not going to be a good day. I fought myself into the crowded minivan, then onto the bodaboda swerving taxis, bumping through muddy potholes to get to Kisenyi to start the surveys with the research assistants.

It was an ‘outreach’ day, free HIV testing for kids today so folks came from all over. Instead of going to women’s homes, we talked to those who were attending the clinic. The first interview of the day was with a 39 year-old woman. Her outfit was swirls of peach, yellow and green with an elegant matching headdress. She walked slowly and appeared weary. Her voice was soft as she eagerly agreed to complete the survey with us, despite the fact that it would slow her down in getting to see the nurse. As the story unfurled, she described her painful two-hour journey on swollen tender feet. She was HIV positive and here to get her children tested for HIV. When we were finished, she gently took my hand and thanked me in her soft voice, not letting go. She said it was so good we were starting this program, because she definitely needed to be screened for cervical cancer since she was HIV positive… when our program got started, and if she was still alive, like in a year or two, she would do the screening she said. Her sincere, dark eyes spoke volumes of hope.

Perspective. My throat suddenly felt better and my heart was humbled. This was thanks I did not deserve.

As my wise slum-dwelling little sister says, "I am glad that you are having a back to the basics time in Uganda (oops, I mean, the country of Africa). I find spending some time acompaƱando a mujeres [walking with women] in a slum is good for the soul. Brings you back to what the world is about, to why you do what you do and helps realign priorities.

Tuesday, March 23, 2010

Plantains, Mud and Cervical Cancer


We started down a muddy alley where several women ran a row of cooking stalls, little shacks made from old planks and recycled car parts. Huge pots on charcoal jikos with piles of plantains steaming covered in banana leaves, beans boiling and peanut sauce simmering. Once we started doing a few surveys word spread among women, cervical cancer is all too common yet women know little about it. Confidentiality turned out to be challenging as women and men endlessly sauntered close wanting to know what the muzungu was at, could they do it too? One woman was persistent, popping back to see if we were done so she could go next. She started reeling off questions, what if she had a lot of pain, what if things didn’t smell right, what if there was this chunky foul discharge? Her symptoms could mean a dozen different things, from benign to well, terminal I suppose. Had she been to a doctor? No, there was no time, she had to work to feed her kids. Her eyes were worried and sincere. We went through the survey and found she was HIV positive. She was 38 and had never had a pelvic examination, an incredibly common situation in most of the world.

There we stood, next to an old converted container that smelled faintly of urine, mud and broken glass at our feet, in an alleyway buzzing with people, the sweet smell of steamed plantains mixing with the human odours of sweat and engine oil. She looked into my eyes, asking for help. I stared back humbled. Completely helpless, overwhelmed by my knowledge and unable to convert my skills and training into the real help that she needed. Yes, the project we’re doing will eventually provide proper screening but we’re just getting started.

I urged her to see a doctor, told her where she could go, and gave her some names of medications she could try (for the benign options, obviously).

Last week at rounds we had discussed a woman who had cervical cancer and was HIV positive. Initially her cancer was treated successfully but it soon returned, metastasized and took her life last Thursday. A combination of underlying cancer allowed to rampage through her body in the setting of an immune system ravaged by AIDS.

This isn’t fair. But this is life, in all its grittiness, that’s what I asked for, wasn’t it?

It feels like such a privilege to be able to see people in their environment. Whether it was the chai/chapatti stall girl who took a break and sat in the alley with us, the mama lishe who sorted the rice for lunch which searching our faces inquisitively wondering about this ‘HPV’ thing we were talking about, or the 60year old woman who is currently having post-menopausal bleeding fumbling nervously and with fear as she asked questions about whether she had cancer…the tethered goat in the background gently chewing on her 2 year-old grandson’s shirt in the shade of a tree. The suvey is going well, it gives me hope in the midst of such raw human need.

Tuesday, March 16, 2010

The Baby Mill's Got Nothing on This!

Mulago Hospital, Kampala, Uganda

Morning report this morning. Sixty or so residents, medical students, midwives and attendings cram onto benches as the suns rays begin to creep through the window raising the temperature by the minute. All the house staff in crisp white coats, the nurse-midwives equally crisp in their light dresses, knee-high socks and nursing caps pinned meticulously on their heads. An exhausted resident lists off the happenings on labour and delivery in the last 24 hours.

Total women in labour: 73, vaginal deliveries: 48, C-sections: 17, stillborn: 2. The special teaching case is a woman of 28 years old, gravida 4, plus 1 (apparently that means one kid), previous Ceasar. Presented in active labour for 34 hours. Became fully dilated and the fetal heart was 166 at this time. After 3 hours of pushing there was no fetal heart found and fetal parts were palpated abdominally. Uterine rupture was diagnosed and a c-section was arranged, this happened 3 hours later. The baby was stillborn and a hysterectomy was performed due to bleeding. She became anemic with a hemoglobin of 50 and was transfused two units. We are continuing to give her more fluid.

Wow. BC Women’s is a quiet country hospital compared to this. Our morning rounds include pedantic scientific details of preeclampsia for the most part. We ONLY have about 8000 deliveries a year. Of course, they ARE beating us with the c-section rate, 25% isn’t too bad…but then you have more dead babies and mothers losing a uterus they might have otherwise wanted to use again.

The discussion was stimulating and passionate. How could we not prioritize a woman who had a previous c-section and let her labour this long? We have condemened her to infection, she may get a fistula down the road, we took away her baby. What can we change for next time? They know what care they want to be giving, but are bound by the resources they have. I felt for the poor, haggard-looking resident presenting the case, having felt the wrath of attendings in a sleep-deprived state at morning rounds myself.

Next the NICU gives their 24 hour update. Eight neonatal deaths, 6 pre-term, and 2 at term. One may have had a congenital heart defect.

It all left me a little numb, and it was only 9am.

We were going to head out to Kisenyi, the community where the surveys are going to be done. As we were about to leave, Doreen, the project coordinator, got a call on her mobile. There was an emotional jabber of Luganda and she ran out of the room. She returned after a few minutes, with red eyes. “I’m sorry, it seems my brother is dead.”

WHAT?!?

There had been clashes between university students who opposed one of the candidates being proposed as the new president of Makerere University. Things escalated and a security guard shot two students. As it turned out her brother (cousin) had been shot in the neck and was now in ICU. I’m no trauma surgeon, but things didn’t sound good.

It was 11am… maybe it was just the jet-lagged, but it seemed like a disproportionate amount of death and suffering before lunch.