docta!

I'm getting way too used to my role here. At home I shudder when someone calls me doctor, because I am soooo not qualified yet. But here, I respond to "excuse me, docta?" multiple times a day, and I'm beginning to enjoy it. Also, because the nurses here wear matching dresses and tiny little hats (like the size of a teacup), I never get mistaken for a nurse. I'm also getting used to a very different outlook on what health and healthcare means in Uganda (and much of the developing world) as compared to home. In Canada, the hospital exists for sick people to come and return to health. In Uganda, it exists for people to come when they are often about to die, and by being there they may avoid this inconvenience, and will be promptly sent home when they are no longer at death's doorstep. Returning to health is not always part of the package - there's simply not the space or resources. You may need to go home for that part. In addition, everything costs money. It's easy to forget when you go to the hospital when you're feeling a little under the weather that the painkillers or IV fluids or X-rays or CT scans or blood tests are all paid for from a secret fund somewhere. But here it comes directly out of your pocket, and when you are making less than $100 each month, this becomes a large burden.

On one of my first days here, I was hit with the repercussions of not having this nice little thing called Universal Health Care. Chronic kidney disease is a scary disease for anyone, anywhere, and the definitive treatment is eventually a kidney transplant that might take a while to receive. In the meantime, one has to undergo regular hemodialysis, during which your entire blood volume is flushed through a machine that filters out all the toxins in it, essentially making urine so your kidneys don't have to. This takes several hours and you are required to do it multiple times a week while waiting for that phone call that tells you there's a kidney available for transplant. Hemodialysis is nothing more than a intermediate treatment to keep you alive in the meantime. When our patient presented with chronic kidney disease that had gotten incredibly severe, I inquired, obliviously, "how does the transplant program work in Uganda?" To which the response was, "There is no transplant program in Uganda."

Here I was stumped. In the weeks that have followed, I have continued to be hit with the hard reality that the definitive treatments for many illnesses and diseases is simply not available here, due to lack of resources or funds. In this particular instance, I learned that the only way to get a kidney in Uganda is to either fly to India or South Africa, all, of course, at direct expense to the family. Moreover, you never know how long it will take for the kidney to become available, so hemodialysis must take place in the meantime, multiple times a week, at about $100 per session. So begin to imagine around $1500 per month, for an unknown number of months or years, followed by a flight to India, followed by the costs of actually having the surgery, then the costs of recovery, then the costs of returning home, then the costs of follow-up, then unknown potential complications for the rest of the person's life... and the patient is only 16 now. And any one of these steps might not be survived by the patient in the first place. Let's not forget that this family makes less than $100 each month. This particular situation almost made me cry.
Debt doesn't exist in the way we know it in Canada, where everyone has a mortgage, multiple credit cards, lines of credit, or families to borrow from that they will be able to pay back in a few years. This financial burden could simply never be managed. The family would bankrupt and starve themselves trying to cover the first few weeks of dialysis. We all know counselling patients is a big part of a doctor's job anywhere. Counselling takes on a whole new meaning when you're telling parents that it makes the most sense to let their 16-year-old daughter die rather than destroy their lives and their future trying to keep her alive for a few more weeks until the funds run out. Yet this is a conversation that is had by every doctor again and again for diseases that would be treated aggressively in any developed nation. Imagine chemotherapy and the decisions that must be made there. In the few weeks I've spent here, I have been present during many of these discussions, and the sorrow is massive. Very few life-prolonging measures are available or affordable. Some illnesses simply have no cure here.

It is not to say that there is no one who can afford the extensive care required for extremely sick patients. I have worked with a handful of wealthier patients, who you can generally pick out because they speak English and have been educated to high school and beyond. I use the word "wealthy" very loosely here because wealth is always relative. And many patients can afford a certain number of procedures and tests and medications, but every family has a limit of what can be afforded, and it's always a bit different. There also exists what is called the "PPF", or "Poor Person's Fund" (quite aptly named), and some desperate procedures and medications can be purchased out of that fund, but it needs to be used quite carefully to ensure its availability when most acutely needed. Just recently the doctors used the term "blanket sign", which they asked if I understood and I shook my head. They laughed at me and told me that when assessing patients and trying to determine what they will be able to afford, you can look at their blanket (patients are required to bring heir own bedding to the hospital). They said here in Africa, the patients will bring the best blanket/bedding they own to the hospital with them, so by looking at the state of the blanket, you can make assumptions about their socioeconomic status. A ratty blanket full of holes might indicate that they will not be able to afford even a blood test, while a lush, clean, quilted blanket means they will likely have the funds to pay for all treatment recommendations. This allows the doctors to plan treatment options that will hopefully be within the patients' budgets without offending them.

On the patient's chart, "occupation" is commonly listed as "peasant", which is a word that I've only heard in Canada coupled with the word "-vision", when referring to those unfortunate enough to only receive 3 channels on their TV. But there seems to be a large number of charts with this label on it. I don't fully understand what it means - "peasant" as in below the poverty line? "Peasant" as in currently unemployed? "Peasant" as in homeless? Never had a job? On sick leave? In Canada, you would usually use one of the above terms, because surely, everyone must be either in between jobs or a student. Not so in Uganda. Peasant can mean peasant for life.

I am also staggered by the number of charts labelled "NYY", which is code for "HIV-positive". This is done to keep some semblance of privacy for the patients when they are lying in a bed that is in the middle of a large room with 30+ beds lined up. Although the national HIV-positive statistic puts the number between 9-14%, it seems that close to half of the patients we see are NYY, and one doctor suggested up to 90% of inpatients at times. This is due to the major complications that can come with a positive HIV status, generally due to their immunocompromised status (much like someone on intense chemotherapy can catch any and all infections they are exposed to due to a severely compromised immune system). The worse the disease gets, the more illnesses that occur, specifically and primarily Tuberculosis. This disease is a huge jerk, and takes over all parts of the body whenever it feels like it, and wreaks all kinds of havoc. It also damages your immune function, so you can imagine that when TB and HIV get together they cause massive problems and a lot of death. I am learning so much about both diseases, which won't actually be all that helpful when returning to Canada. Both are rare, and when they do exist, there are specific clinics and specialists that are trained to handle them. But in Africa, you would be a fool NOT to know all the ins & outs of these diseases.

There are some things about practicing medicine here that might be considered "better", usually in that they're easier. However, this often also is as result of poverty and malnutrition. Never yet have I had to struggle to fit a blood pressure cuff around an arm that is too big. I don't struggle to hear audible breath or heart sounds through layers of fat, or have difficulty palpating organs through massive obesity. Many things that are internal are extremely easy to examine externally. Nutrition counselling focuses on "you need to eat more, and these are the best high-calorie foods to eat," rather than the complete opposite. Patients here also are so appreciative of the work you do and thank you for your assistance. Even in the cases where a patient sadly passes on or is faced with a difficult diagnosis, the family thanks you for your effort and your presence. I haven't yet met a grumpy or demanding patient. Rather, the people I have met here are some of the friendliest I have met anywhere, and always grateful. Also, they are sick. This may sound bad, but it is better than having a patient with a bout of gassy cramps in the ER in a panic or crying over a particularly bad paper cut. If they've come to the hospital, they really need to be there. However, this doubles as a curse, because the patients who arrive at the precipice of death have not had the luxury of a family doctor who could help manage their diabetes or run regular tests of their cardiac function. It is such a gift that we take for granted that we get to go for yearly physicals to make sure we're in good shape. (Which we all go for, right? RIGHT?!)

The way tests are done, results are received, and patients are cared for also varies wildly from home. Each patient has with them in the hospital an "attendant", someone who stays with them and is responsible for all of the above. This tends to be a family member, and people find themselves in a very difficult situation if they are without an attendant. When blood is drawn, it is given to the attendant, along with a requisition form, and they are required to take it to the lab, pay, and go back to receive the results at a later time. This also goes for sputum samples, urine samples, stool samples, etc. If the patient needs an x-ray, ultrasound, CT, etc, the attendant is also required to get the patient to where they need to be in order to pay for and perform that test. This becomes very difficult when the patient is not able to walk. Many family members will band together to carry a patient or perhaps find a wheelchair if they are lucky. We have a wonderful nurse/porter team in Canada who provide these services, making getting tests and results virtually effortless on the part of the patient and the family, but if you are without an attendant here, you are in a very rough spot. They are also responsible for feeding the patient and helping the patient relieve themselves (which usually means helping them squat down into a bucket next to their bed). Adding up all the patients plus attendants in the wards makes for a very busy, very LOUD, very un-private place to do rounds, histories, and physical exams - generally there are about 60+ people in the room, especially when you include the extra mattresses along the floor for the overload. It would be very difficult in Canada to get someone to join you in the hospital 24/7 to attend to your every need and meal - who would your attendant be? For SURE every one of you just said "mom".

Our hours vary day to day, but generally start around 8 or 9 with a case or research presentation, followed by Post-Take. This is when whoever was on call the previous night presents any new patients that arrived in the emergency department who are being admitted for treatment. Ward rounds with interns and residents follows (residencies are NOT paid positions here, so residents in Canada, be excited!!), which takes several hours, and what is left of the afternoons is spent on procedures, clinics, research, or in the emergency department. Afternoon Post-Take (whoever showed up to the ER during the day), is supposed to start after 5 sometime, so generally our days wrap up between 6 and 7. Whichever of the 4 of us is making dinner that night will take a few hours off in the afternoon to get ingredients from the street market and prepare food for when everyone else gets home. We have become quite adept at cooking with very limited kitchen equipment, one working element and a stove that only broils and has 1 temperature setting. We also make our toast over that one element and flip pancakes with a fork. (Please go thank your toaster and metal spatulas right now.) The hospital is across the street from the housing we are staying in, so the commute has been incredibly convenient (~5 minutes door to door).

The emergency department is divided into 2 sections: One is Internal (where we work), which is pretty self-explanatory, as it includes heart attacks, kidney disease, asthma, liver failure, DKA, headaches, vomiting and diarrhea, psychosis, etc. The other is anything trauma-related or musculoskeletal in nature - essentially anything you can see. Blood, breaks, bullets, car accidents, falls - basically whatever would likely end up in surgery if it was bad enough. This distinction can sometimes be very vague, and I think would be a point of stress in Canada, as so many problems could be classified by one or the other, or both, and would result in patients being sent back and forth. This happens here quite often, and it means patients aren't always getting prompt treatment. However, it allows specialists to work specifically with the patient population that they are best trained to care for. The doctors here are incredibly knowledgeable, excellent teachers, and have been so welcoming to us as we try to get our bearings and absorb all the information being thrown at us. I have a deep respect for these physicians working in an environment that is not always ideal, and giving patients the best possible care despite lack of funds and unavailable resources. I think knowing a specific treatment was available but not being able to provide it as an option would be very frustrating, but they doctors here work within what they have with grace.

Napoleon described medicine as "the science of murderers" after surviving a severe bloodletting. If you were unfamiliar with medicine and what it entails, I can understand why this might appear to be true. Medicine is, in a word, barbaric. This has become increasingly clear to me while watching, assisting, and performing procedures here in Uganda. In Canada, people are shielded from the intense violence of medical procedures - we drape, anesthetize, use numbing agents, put people to sleep, tell people not to look and perform procedures behind curtains to save individuals from witnessing the horror that is modern medicine. Sharp metal objects, blades, lasers, cauterizers, needles, wires and tubes inserted in terrible places all help form the backbone of this brilliant science that we practice in order to save lives and improve health. It's genius. It's phenomenal and unbelievable. But make no mistake, it is barbaric. Especially when the resources don't exist to numb, anesthetize, drape, or even hide a procedure from the other 50 people in the room by pulling a curtain around it. We are truly coddled in North America. Enjoy it. Appreciate it. Thank your local neighbourhood physician or nurse or lab tech or pharmaceutical researcher or the inventor of lidocaine. And while you're at it, thank modern medicine that we yell at people in Canada if they fail to thoroughly clean a region that's about to be injected or cut into. That is not the case everywhere.