Today

Today, I woke early. Made my morning cup of tea. And read over the lecture I was scheduled to give at 8am. The main road between our house and the university was quiet and easy to walk across, and I arrived on time. Over the next 10 minutes the classroom slowly swelled, filling with 3^rd year medical students ready for a thrilling (?) lecture on cardiomyopathy, part of their core medicine lecture series. As usual, their interest and enthusiasm made being the lecturer enjoyable. We ended on time, and I wished them good luck on their upcoming exams.

After my lecture, I wandered home and had my second cup of tea and a quick chat with my lovely hubbie. He had been up very early himself to complete a project related to his thesis in development studies. The question of cause regarding Mbarara’s litter problem was to be tested by Danny, who placed a large, obvious rubbish bin in the middle of the busy bus park very early in the morning to see whether, if given access to a bin, people would elect to use it. Does the fault for litter lie in the hands of the local government who don’t provide adequate bins, or in the local culture where littering is acceptable? We shall see…

After a cup of tea, I was off again for my daily ward rounds, and walked across the now slightly busier street, dodging bodas, matoke trucks and, perhaps most dangerous of all, SUVs belonging to international NGOs. Upon reaching the ward, I met with the PG, Obayo, who works on my firm. Together we are currently responsible for half of the female ward (~16 patients). We gathered the medical students who are currently working with us, and began to sequentially see and evaluate our patients. The general format includes a brief (hopefully) presentation by the medical student responsible for each bed, followed by a focused physical exam by either myself or Obayo and a group discussion and decision regarding the plan for the day for each patient.

The first patient of the day was a 70-year-old lady who would be called a “frequent-flier” by residents in the US, and while she is now well enough to leave the hospital, the tragedy of her situation reflects bigger problems for Uganda. Due to both culture and a lack of government-funded social services or nursing homes, people in Uganda expect to care for their elderly or ill family members at home indefinitely. Indeed, this attitude is carried inside the hospital itself where medical care is provided but all ancillary services, such as toileting, cleaning and feeding must be provided by a patient’s attendant (usually a family member). The assumption that the health of family comes above all else, and the expectation that your family will care for you, is a beautiful part of the culture here. The problem, however, arises when there is no family, as in the case of our patient. Every day for the past week, as well as every day of the last 3 admissions, she has had a new symptom or complaint which we have diligently investigated, with little to report except mild, chronic hypertension. She finally revealed that she has no family and at an ancient 70 years of age (life expectancy in Uganda is 46), has found herself alone with neighbors who are tired of her asking for money or help. While I understand the comparable attractiveness of a private room and TV at Santa Barbara Cottage Hospital over returning to the homeless shelter, the fact that this lady would prefer to sleep in a TB and HIV filled ward with 36 other women rather than return home reflects the real heartbreak of her situation. Today we finally discharged her, but I suspect I will see her again soon.

The other cases were as diverse, interesting and frustrating as always…

• A 65 year old lady with a severe heart valve problem, now in heart failure. Diurese, diurese, diurese!
• A 38 year old, HIV-positive woman with TB meningitis. Nearly always fatal without treatment. Due to a problem (i.e. complete absence) with the national supply of TB medication for the past 6 weeks, she and many like her have been without ANY treatment for several weeks.
• A 23 year old woman with end stage kidney failure. Reason not known. Dialysis unavailable.
• A 28 year old woman, also HIV-positive, with septic shock and a chest X-ray revealing military TB. Thank god the TB drugs finally arrived last night.
• A 30 year old woman without HIV, admitted with severe wasting. She is disappearing before our eyes. With her vomiting, we are worried about stomach cancer, but the endoscopy needed for diagnosis is prohibitively expensive. The differential diagnosis is short: cancer which we can not treat or disseminated TB which we can. Today she will begin TB treatment, but I suspect she is not long with us.
• A 20 year old, HIV-positive girl, on TB treatment but not yet on ARVs. Weight 65lbs.
• A 45 year old, HIV-positive woman with anemia due to her HIV medication and pneumonia. Got blood, got antibiotics. Got better. Going home. Yay! Victory.

After my rounds on the ward, I walked into town with a friend (a visiting resident from Boston). Hit Pearl supermarket for the typical juice, cheese and canned food. Moved on to the Central Market, where I visited my usual three stalls and picked up eggplant, carrots, onions, chili peppers, green beans, tomatoes and bell peppers. A steep $4 gone. I’ve become picky about the size of our eggs, so made a special stop at a shop that sells the big ones. After a quick visit to the DVD rental place, we jumped on bodas and headed home.

And, yes, as I walked in the door of our little apartment on the compound, I put the kettle on for another cup of tea.