Archive for August, 2008

One day: botanical gardens, a wedding, and pizza part 2 in Kampala

August 27, 2008

As we walked passed the gentleman with elephantiasis, we stopped and turned at Nakasero Market, a place of spice, fruits, vegetables, and some crafts. I cannot wait to get local vanilla, cinnamon, and nutmeg, the last which is endemic to this region. And then Matt and I came across a sight to behold – the old taxi park of Kampala. We found it relatively easy to navigate the park to get to our matatu heading to Entebbe. The vehicles were densely packed, though.

Old Taxi Park Kampala

Old Taxi Park Kampala

 

The botanical garden tour was excellent. Vervet and colobus monkeys played around while we heard smelled aromas from the nutmeg, mango, orange, and cinnamon trees. One of the vervet monkeys had twins the day before we arrived! I took many, many pictures, but here are some.

Vervet monkey with baby at Entebbe Botanical Gardens

Vervet monkey with baby at Entebbe Botanical Gardens

The Colobus monkeys are shyer, here is one:

 

Colobus monkey in the center

Colobus monkey in the center

 The “yesterday, today, and tomorrow” bush/tree has three different colors of its flowers: blue, white, violet. These change colors within 3 days, hence the name.

 

Yesterday, Today, Tomorrow

Yesterday, Today, Tomorrow

And then like a ray of light blinding my presence, I paid homage to the coffee bush. Oh, caffeine and that dark brew I long for and yet the ensuing triggered anxiety attacks. and sleeplessness. Here is Matt also adoring said coffee bush:

Coffee bush

Coffee bush

And what’s a visit to the Entebbe Botanical Gardens without a swinging session on a vine.

Tarzan List

Tarzan List

Yes, legend has it that the original Tarzan was filmed here in this forest. This has not been confirmed or negated supposedly.) Matt and I then posed for a Lake Victoria vista:

Matt and I at Lake Victoria

Matt and I at Lake Victoria

 

After lunch in Entebbe – they don’t start serving until 1PM on the dot in many local restaurants here – and an unfortuitous experience at a bank there, we headed back by matatu so I could meet Willem for my first Ugandan wedding.
Meet Willem:

Willem on the boda-boda in front of me en route to wedding

Willem on the boda-boda in front of me en route to wedding

So Willem asked me to go to the wedding the previous day. He met the bride’s sister on his plane ride over to Kampala. She invited him to the wedding (and incidentally she showed up about 40 minutes late to the ceremony which appeared to be no big deal). Before the wedding, though, he and I were able to get to know each other. We hit the big ones — religion, health care policy, relationships – and then I accidentally gave a vendor outside the church a 10,000 USh note (~$6USD) instead of a 1,000 USh note for a 500 USh bottle of water. But I didn’t catch it, and I’m not sure she did either until after I left.

 

Anyway, the wedding:

Wedding photo

Wedding photo

I don’t know the bride’s name actually. But I did recognize much of the Catholic wedding ceremony and even sung along to “How Great Thou Art” which somehow is a popular song here. Willem is Dutch and Christian – the first European Christian I think I’ve met – and we talked about some common beliefs as progressive Christians.

 

After the wedding, we taxied to his flat to have some good Gouda cheese and sweetbread. (Cheese, an epicurean passion of mine in line with coffee.) We spoke with some people on the street (incredibly friendly people here) as we walked to my new place, where I gave him the tour and enticed him to be my roommate for 2 months starting in mid-September. And perhaps I can develop the 25% Dutch I have in my ethnic heritage by learning some words. We then met Matt at the guesthouse and the lot of us had dinner at Italian restaurant per yet another excellent recommendation by Matt where the pizza was ce magnifique.

Oh the monkeys. Talk about massage therapy…

Friendship

Friendship

Things you shouldn’t see

August 27, 2008

Elephantiasis, for example. Although this (http://en.wikipedia.org/wiki/Image:Elephantiasis.jpg) isn’t the person I saw, it looks like the leg of a person I did see on my way to the old taxi park where the matatus reside. A picture like this represents a “I can’t believe it” slide in US medical schools but unfortunately can be found on the street in the main part of Kampala. And then you feel paralyzed walking by and just want to hand out a referral to the hospital. You just want to see a healthcare infrastructure of some sort take care of him. But you keep walking. Could have. Should have… 

 

 

Zen in the big city

August 27, 2008

Friday evening I met up with Sarah who is an American student here for 10 months on the NSEP Boren scholarship. A fellow Midwesterner, I felt a little bit of home here. Matt, sage of all places culinary, took us to a Thai restaurant in Kololo. One word: zentastic. Hidden away from the road, dust, and noise, I enjoyed a good Thai dinner with them under a great open air thatched structure and peaceful music. I appreciated the moment since the previous day, I had spent 6 hours meeting “brokers” on the street with the help of Ali. Trying to find a place to live has been one of the bigger logistical ordeals I’ve experienced to date. One broker sped away on a boda-boda swearing at Ali, and we thought he was inebriated. We talked to a few more that didn’t show up but said that they would. (Ali thinks this is because they want to say that they are closer location-wise to meet so one doesn’t call someone else.) We then met a nicer broker, who eventually found me the place I have now. He was late to our appointment with the landlord-by-proxy (the “real” one is in South Africa) and apparently my place was almost sold to someone else. I’m going to say this now that I cut out about 75% of the story and frustration that went along with Thursday and Friday’s events as I just told them. These are best saved for discussion over a drink! But by the end of Friday, I had paid a month’s rent with an expected move-in date of Sunday morning.

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August 27, 2008

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Research and lab time

August 22, 2008

As the orientation has continued on, I am gradually getting a better picture of how I can be involved in different studies. I will briefly describe the major studies here in light of my knowledge of them thus far.

 

One study is examining the use of punctuated anti-retroviral therapy (HIV/AIDS treatment) in patients with tuberculosis with CD4 counts (a type of white blood cell targeted by the HIV virus) ABOVE the range normally necessitating HIV/AIDS medications. Tb and HIV exacerbate each other. In light of this dual relationship, one of the central questions for the study is: can you more effectively treat Tb in an HIV positive person if you treat the HIV at the same time as Tb treatment while preventing the worsening of HIV due to the Tb infection? (Hence “punctuated” HIV anti-retroviral medication given only during Tb treatment since her/his CD4 level is higher than the “standard of care” level when medications are usually started.)

 

One of the studies I am most likely going to work on will look at cost-effective ways to diagnosis tuberculosis in a community. In this study community health workers are going out in a community in Kampala known to have a high prevalence (cases) of Tb. Rather than wait for someone to come to the doctor sick, this study seeks to actively seek out the sick as diagnosed by “chronic coughing” for more than 2 weeks. There is an extensive work up consenting individuals, household contacts, and first degree relatives then undergo if they are “chronic coughers.”

CWRU/UGa Tuberculosis Research Unit (TBRU) clinic at Mulago

CWRU/UGa Tuberculosis Research Unit (TBRU) clinic at Mulago

 

Related but reversed, is another study that examines known index cases of people with Tb and studies their household contacts and first degree relatives in a particular community. This study has been going on for many years and has gathered much data covering many issues that may impact Tb. This study also takes into account genetics, immunology, and other laboratory-based investigations.

 

The last study about which I know the least but am increasingly drawn to is studying the relationship between HIV and alcohol consumption. There are social and immunologic/genetic dimensions to this study’s analysis. I hope to get involved in a psychiatric issue (e.g., alcohol use) in addition to my involvement in one of the Tb studies.

 

We spent 2 days in the Joint Clinical Research Centre  this week, which is a 15 minute drive from Mulago. Here is a traffic jam that we caught on our way there:

Goats en masse while we were driving to the JCRC

Goats en masse while we were driving to the JCRC

Ali and I hitched a ride with the driver who brings over sputum and blood samples three times a day. Karen Morgan, PhD, a US microbiologist working there, gave us a phenomenal tutorial and tour of her work with Tb in conjunction with the studies. We learned different diagnostic techniques for Tb in patients and viewed cultures where Tb was growing. We also spent some time with the microscope looking at acid-fast bacilli (e.g., Tb) and its characteristic cording. We also received a tour of the different projects other institutions are conducting. The technology and types of machinery in the lab were impressive and many were completely new to me! I can readily say that there is some amazing laboratory bench science being done here that builds upon the clinical research in the field.

Pierre at work

Pierre at work

 

One example of the lab projects that I can explain is an aspect of the aforementioned studies. For those without an immunology background, let me try best to explain as simply as possible. When a person is infected with tuberculosis, the immune system reacts by attacking the Tb bacteria (called mycobacteria). Some of the body’s immune cells “present” part of the Tb bacteria to other immune cells that in turn help contain/destroy the bacteria. In order to make better treatment and vaccines, it is thought that targeting what is “presented” on those cells may be the future of Tb therapy and prevention. So how does one know which bacterial part causes the immune system to react? One of the chemicals the human body releases when Tb antigens are “presented” is IFN-gamma, a “marker” in the blood that infection has been recognized. So in one of the laboratory studies, the researchers are looking at which Tb antigens – the parts of the mycobacteria “presented” to the immune system by other “defense” cells – cause the release of IFN-gamma. IFN-gamma levels in the blood can be measured with the current technology so the researchers are limiting which antigens are possible candidates in the future for targeted, more efficacious Tb therapy.

Andrew and Joy decanting supernatant at JCRC

Andrew and Joy decanting supernatant at JCRC

 

I have to admit that FAR more things are going on in the laboratory than I can remember or explain, and I really parsed down the explanation of that one particular lab research project directly above. I’m not doing the lab justice! After two days at the JCRC, I came away with a deeper appreciation for laboratory bench science in general and Tb microbiological and molecular genetics in particular. Such science is a cornerstone of modern medicine and will certainly be even more in the future as we better understand molecular genetics of human disease. Continued and increased research in these areas in general is CRUCIAL!

Ali’s Saturday *Warning*

August 22, 2008

*I am providing a short forewarning about the next story for those who do not want to read further. It’s a tragic story involving abortion. Because I know my blog readers personally vary across both ends of the abortion spectrum and also because I was not witness to the events, I will only tell the story as it was told to me. I was not going to share it at first, because if done for only shock value then I’d be merely sensational. I think people from both sides of the abortion issue and in between can take something away from this for their perspective and yet see other dimensions about other perspectives with which they disagree. It stunned me when Ali told me.*

 

Ali asked about my weekend, and I told him about the fun things I did. He did not report the same. On Saturday, he was called into the hospital to help care for a woman who had an incompletely performed abortion. She had gone to a questionable doctor who performed the abortion but incompletely without telling her. She had signs of sepsis (basically a body-wide infection stemming from the unsanitary performance of her abortion) and vaginal bleeding when she was admitted. As part of the examination, Ali used the Doppler to examine the fetal heart tones which he found in the *normal* range. The abortion had not caused frank fetal death. However, the woman had evident crude mechanical rupture of membranes meaning she was not going to be able to continue the pregnancy, even if she wanted to. Additionally, fetal gestational age was at 20 weeks. So there is a woman 20 weeks pregnant with life-threatening septic infection, bleeding, an unsanitary, incomplete abortion, and fetal life that is non-viable given the scenario. Neo-natal hospital units in a resource-rich setting such as in the US could care/incubate a neonate baby with some chance of survival at 22 weeks at the earliest, but Ali said it is considered to be 28 weeks here. The woman was induced to deliver and then started on IV antibiotics to try to help stem the septic infection threatening her life. Her current status – physical, mental, emotional – I do not know.

Can you dance with 7 clay urns balanced on your head?

August 22, 2008

Because she can…

Ndere Centre - Feat of Wonder

Ndere Centre - Feat of Wonder

 

Ndere Centre is a Ugandan arts theatre that hosts different dance troupes from around Uganda and sometimes the world. A moderator led us through the different regions and intended meanings of various dance movements. For example, the dance group from the West Nile region (upper northwest) of Uganda emphasized full body movement in a way conveying “respect for the whole body” be it the hips or the elbows or the torso. The dancers from Acholiland had a visually appealing dance that paid respect to the cow. One of the women used a certain form of throat singing that had both ethereal and eerie dimensions to it. Some of the Kampala children in the audience came up at one point for storytelling and dancing. Some of them were particularly amazing dancers. The moderator gave some empowering “they are the future” moral storytelling, which I think many of their parents appeared to appreciate. So much joy and song filled the air on a very pleasant evening. Troupes from the US, Burundi, and Rwanda are coming later this month and early September for an international workshop and dance shows. The movie War Dance (http://www.imdb.com/title/tt0912599/) which I still have to see, ends in Ndere Centre apparently. I look forward to going back there and learning more about it and its influence in society here.

“Metro” males in Kampala – The First Weekend

August 22, 2008

Writing on the eve of my second weekend, my first weekend in Kampala went pretty well. Matt and I watched “Get Smart” Friday night. I laughed more than I thought I would. I enjoyed finding certain parts of the movie funny that didn’t universally translate into humor due to political or cultural references to which Americans would be more attuned. Basically, I laughed at parts others did not so I was either that strange American or Mr. Gigglesworth. Oh well.

 

Saturday I started the morning at the guesthouse with a good 2 hour discussion with Hans, a German-born and trained pediatrician from the UK most recently, working in a hospital up north-country and also working with the Malaria Consortium (http://www.malariaconsortium.org/). Both lithe and sinewy, he had a youthful appearance and was quite engaging. He conveyed a nourishing optimism despite obvious setbacks and resource limitations where he practices. I shared some of my recent findings with the children’s cancer ward (to be discussed in another post), and he ameliorated my frustration a bit with his outlook. It became evident that his dedication up north is probably rarely matched, and his heart was in clinical medicine to the maximum.

 

Dennis from Case Western picked me up in his vehicle, and he gave me tours of some areas of town while doing errands. I discovered my now favorite grocery store that I can’t wait to get back to named “Payless.” Dry cleaning is much more expensive here than in the U.S. I came to find out. And I witnessed my first teenager male giving teenager male pedicure in my life. Just at a shack storefront along the road. Why not? And also, why not find a 17-year old gent in roller derby style roller skates holding onto the back of the matatu as it speeds away?

 

Dennis and I hit a traffic jam and told stories – he gave me some examples of TIAs (“This is Africa” moments). TIA is a euphemism coined by many years ago for when things don’t run smoothly or logically through a Western reference frame. I learned of it when reading “The Zanzibar Chest” by photojournalist Aidan Hartley. Dennis once was cornered by police for a potential ticket for a violation for which there was no sign saying it was a violation on a particular stretch of road. The cop retorted, “Do you think we have the money for such signs?” After what was a strange prolonged conversation, Dennis asked, “So are you giving me a ticket or not.” To which the officer decreed, “I have decided to give the ticket to someone else.” TIA. (Side note: my whole search for a flat in which to live has been a giant TIA!)

 

We went to Dennis’ place in Bugolobi – gorgeous open-air home. He has a housekeeper and guard. The thing is, he pays about $100 more per month for all that than I do for 1/3 of apartment rent in Chicago. After awhile, I randomly came down with food poisoning or some such thing and went home. I was supposed to meet Hans to watch a soccer game, but work detained him and I felt ill. I just had some rice and headed home from the Kisimenti area.

 

Sunday I discovered the oh sweet joy and missed high speed internet and excellent coffee at Café Pap in downtown Kampala. I took my first matatu ride to get there for 800 USh ($0.48). I read research protocols and wrote emails for 5 hours. Matt joined for most of the time, and we had lunch there. I satisfied that American productivity urged in a pleasantly high-caffeinated environs. But the main event for Sunday had yet to occur… Ndere Centre

Caring for dad (short addendum)

August 19, 2008

Alex, the 10-year old boy caring for his father that I saw last week, happened to be in the office yesterday when I checked in at one point. Dr. Luzze (one of the Ugandan physicians and co-principal investigators on some studies) had finished getting an update from him. Dad was unchanged from the last visit. I spoke with Dr. Luzze and his administrative assistant Alice after Alex left. Dr. Luzze is looking to help fund Alex for schooling (30,000 USh/per month = ~$18 USD) for now and when his dad dies. Alice, like Ali and I, commented how particularly innocent Alex seems as this all happens. Hopefully we’ll see dad in the Tb clinic soon. Please keep them in your thoughts and/or prayers.

Mulago hospital (as told by YM magazine)

August 18, 2008

The following are excerpts from the Yale Medicine magazine that I found in the Yale-Mulago office. Through my thus far limited time at the hospital they capture some things I’ve seen pretty well from my vantage point. My Ugandan counterpart scholar, Ali, was interviewed for the article as well as I came to find out and unbeknownst to him! The full article is available at: http://www.med.yale.edu/external/pubs/ym_wi08/feature1_uganda.html.

On the Wards in Uganda

For Yale physicians and medical students, a few weeks at Mulago Hospital in Kampala become a life-changing experience.

Story and Photographs
by John Curtis


In the infectious disease ward at Mulago Hospital in the Ugandan capital of Kampala, a woman in her early 20s lies on a bed with only a thin sheet to ward off the morning chill. Alone, suffering from complications from AIDS, her few possessions in a cardboard box at her bedside, she has no family to bathe her, bring her food or give her medicine. These are what doctors here call poor “blanket signs.” The mere presence—or absence—of a blanket speaks volumes.

Even before they measure the blanket signs, however, the doctors know several things about their patients. They know that as a national government-run referral hospital, Mulago receives the sickest of the sick. They know that more than half the patients in the hospital are infected with HIV. They know that two-thirds of their patients will die in the hospital or within two months of leaving it. And they know that most of their patients are too poor to afford more than the most basic tests and treatments.

Blanket signs will tell them more. The hospital provides patients with a bed. Patients must bring sheets, blankets and pillows, as well as “attendants”—family members who care for them. The doctors have learned that just having a blanket reveals much about a patient’s economic status. Of necessity, the patient’s ability to pay will drive the treatment regimen. If the patient has no resources, the doctors will prescribe only the drugs that come free from the pharmacy and order only the tests that the hospital provides at no cost.

“Medicine is not all about what you have learned in medical school,” said Robert Kalyesubula, M.D., a Mulago resident. “You prioritize. In the context of the limitations you have, what can you best do for this person? What is going to help my diagnosis best? You talk to them so they find a way to get the money, sacrifice a few things. You save the most expensive tests for last, when you really need them.”

The Mulago rotations bring into question basic notions about medicine and the very concept of what it means to be a doctor. This soul-searching begins on the first encounter with the wards at Mulago.

At the 1,500-bed hospital Yale physicians have few of the tools they take for granted in the United States. Patients in Mulago are often in a hospital for the first time in their lives and little or no medical history is available. They arrive in an advanced stage of disease. The hospital pharmacy may have run out of basic medications. No one is available to take a patient downstairs for an X-ray. Test results may take days to arrive. One Yale student took to carrying a blood pressure cuff with her on rounds since none was available. During a teaching session the students wandered the wards in search of a working light box so they could look at X-rays. And it’s not always clear who’s in charge of a patient, making sure that tests are done and medications are administered.

“When people come here they can really feel bewildered,” says Sam Luboga, M.D., deputy dean of the Faculty of Medicine at Makerere University. “They find a hospital full of patients without drugs, without supplies.”

That brings them to a new appreciation of the basic skills of medicine, says Christophe K. Opio, M.D., an internist at Mulago. “You have to make a diagnosis from the little information you have,” he says. “You become an investigator. You use all of your senses to identify a problem and then know what to do about a problem.”

From their Mulago colleagues Yale doctors learn to rely on the most basic tools of medicine—a rigorous physical examination, whatever history can be gleaned from the patient and their own knowledge of disease. And that is the main lesson. “You’re not a doctor if you can only function in a certain milieu,” Sadigh says. “Sometimes there’s just you and the patient.”

The Harvard of East Africa
Any discussion of health care problems in Uganda starts and ends with money. Uganda is a poor country; annual per capita income is about $280. Foreign aid accounts for half the national budget revenues. The country has dismal health indicators—life expectancy, 52 years; infant mortality, 67 per 1,000 live births. The risk of bacterial diarrhea, hepatitis A, malaria and African sleeping sickness is very high.

And the country is still recovering from the turmoil that followed independence from Great Britain in 1962. Nine years later, when General Idi Amin seized power in a coup, Ugandans welcomed him as a relief from the autocratic President Milton Obote. Within a year Amin began to expel the country’s Asian population—brought to Africa as civil servants by the British—who, Ugandans felt, unfairly dominated the economy. The Asians also made up a significant portion of the medical school faculty.

“I had just started medical school when Amin came to power,” said Nelson Sewankambo, M.D. He is the sixth Ugandan dean of the Faculty of Medicine, a post he has held for almost a decade. “We saw the exodus of expatriate staff at the time. Ugandans and Africans also left.”

As Amin targeted his enemies, real and perceived, Sewankambo said, academics “became suspect.” Several doctors at the medical school were murdered, including one who was snatched from the operating room. By 1979, when neighboring Tanzania invaded Uganda over a border dispute and Amin fled to exile in Saudi Arabia, Mulago Hospital had no working X-ray machines, no running water, no refrigeration in the morgue and no sewage system. The General Medical Council of the United Kingdom no longer recognized Makerere medical degrees.

This loss of recognition was a stunning reversal for both the medical school and the university that had been known as the Harvard of East Africa. Makerere University opened in 1922 as a technical school. Over the next few years it added courses in agriculture, veterinary medicine and teacher training. In 1924 the precursor to the medical school, the School for Senior Native Medical Assistants, opened at Mulago Government Hospital. Even the school’s name reflected the colonial view that Africans were incapable of becoming doctors. By 1929, however, the school for medical assistants had become the Faculty of Medicine, graduating not assistants but fully qualified physicians. The university advanced in other areas after it affiliated with the University of London in 1949. By 1962 Makerere was East Africa’s leading educational institution, producing several presidents of new African nations, including Julius Nyerere of Tanzania. In 1963, following Uganda’s independence, Makerere joined with universities in neighboring Kenya and Tanzania to form the short-lived University of East Africa.

Makerere, like the rest of the country, fell on hard times during the Amin era and the civil war that followed. Fighting ended in 1986, when Yoweri Museveni’s guerrilla band took power. Museveni has ruled ever since, providing stability in Uganda if not true democracy or transparency.

As peace came to the country Makerere University sought to regain its former prestige. An opportunity emerged for the Faculty of Medicine in the early 1980s on the shores of Lake Victoria, where a mysterious ailment was plaguing the fishing village of Kasensero, about 60 miles southwest of Kampala.

In 1982 people in the village began dying of a disease the locals called “slim” because of its wasting effect. The disease was AIDS but no one knows how it reached the village. HIV had made the leap from monkeys to humans years earlier in Cameroon on Africa’s western coast. Some speculate that the AIDS virus crossed the continent with the construction of a trans-Africa highway. Others blame its arrival in Uganda on the invading Tanzanian army. However the virus arrived, it turned this village and its brothels into the epicenter of the Ugandan AIDS epidemic. Since then much of the leading research on AIDS in Africa has been done at Makerere.

“From the beginning the medical school has been the flagship of Makerere University. There is good research on HIV. There is groundbreaking research on malaria as well. Burkitt’s lymphoma was described by a professor here,” said Sewankambo, a prominent AIDS researcher. Yet problems persist. “Makerere continues to struggle in raising resources. … The salaries are awful, for example. Laboratories are rundown. The equipment is old.”

The medical faculty at Makerere has long enjoyed help from abroad. Before implementing a new problem-based curriculum in medicine, faculty members visited 14 universities around the world. And international collaborations don’t end there. Makerere’s medical school has many foreign partners—Case Western Reserve University; Johns Hopkins University; the University of California, San Francisco; the University of Medicine and Dentistry of New Jersey; McMaster University in Canada; the University of British Columbia; the University of Dublin; and the University of London…

Ali Moses, one of three Ugandan trainees to come to Connecticut, spent four months at Waterbury Hospital and Yale-New Haven Hospital learning about evidence-based medicine, diagnostic skills and patient management protocols. “The Yale elective provides an opportunity to appreciate the practice of ‘ideal’ clinical medicine, which can be used as a standard or benchmark for and basis for improvement in general clinical care,” he said in an e-mail from Kampala.
Full article at: http://www.med.yale.edu/external/pubs/ym_wi08/feature1_uganda.html