Mulago hospital (as told by YM magazine)

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

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3 Responses to “Mulago hospital (as told by YM magazine)”

  1. Amanda Says:

    YM Magazine is a teeny-bopper publication for 13-year old girls! I assume you mean Yale Medical?? 😉

  2. non hodgkins Says:

    Having overcome non-hodgkins, this was good to see. Thank you for this.

  3. Durham Dentist Says:

    It’s nice to read articles about this. Thanks for sharing such great information!

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