George passes the chart for me to review. There are two plain white pieces of legal paper stapled together with a short note scribbled in blue ink. “34 year old with four days of weakness. Fever and vomiting. Feels cold. No medical problems suspect malaria.” Below the note, orders for five medications are written – an antibiotic, antimalarial medication, a steroid, and two medications for stomach ulcers. The note was written two days ago. I ask George why a steroid was ordered, but he doesn’t know. The patient is thin and pale as she looks up at me from the hospital bed, her child sitting quietly on the floor next to her. A clinical officer initially evaluated her in the outpatient department, wrote the initial orders, and admitted her. Clinical officers have two years of formal medical training and are similar in equivalency to physician’s assistants in the United States. No one saw the patient on rounds yesterday and she has not seen a physician since she came to the hospital. George leans over the patient and says something to her in Swahili. She doesn’t understand. George is a clinical officer employeed at the government district hospital but he is not from this area of Uganda and doesn’t speak the local language.
We moved down the long line of patients, one by one. An elderly lady with an acute stroke did not respond to Lasix well to treat her high blood pressure. Her blood pressure was dangerously low two days ago when she was seen on rounds. At that time, the medication was stopped and she was given a bolus of IV fluids. Her blood pressure has not been checked since. George inflates the blood pressure cuff and listens intently with his stethoscope pressed to her upper arm. Luckily, her blood pressure has improved today. We move on to the next patient, a young woman badly beaten by her husband five days ago. She complains of abdominal pain. A complete blood count had been ordered but has not been done, the machine in the lab is broken again. George presses on the patient’s abdomen as she winces in pain. He decides to send her to another medical center to get an ultrasound. The ultrasound and xray machine at the hospital have been broken for weeks. We review the patient’s orders. George asks if the pain medication has been helping. She states she hasn’t been given any medications since she arrived yesterday evening. Dr. Kayumba joins us, finally free from an emergency c-section case in the operating theater. We move on to the next patient.
This is how I spent my morning at the district hospital in Masindi, Uganda. It has been a few years since I had visited an African district hospital. I have been spoiled by NGO sponsored hospitals that boast modest but available staff and supplies and had forgotten how dismal the conditions can be (and usually are) in the district hospitals. Broken equipment, drug shortages, and inconsistent training frustrates the already overburdened and poorly staffed health care providers. Physicians and nurses choose their occupation based on a desire to help, to take action, to intervene. Instead, these providers are forced to stand by and watch as patients die of curable diseases for which they have the knowledge, but not the ability to treat. Their hands are tied. There is nothing more frustrating. Expect, possibly, knowing that they will most likely one day be patients in the same system, helplessly stuck and powerless.
The last patient on rounds today was an elderly lady with sepsis secondary to a tooth abscess. One of the pharmacy students who came along with me asked Dr. Kayumba if the hospital had the antibiotic clindamycin as it would cover the most common bacteria that might be causing her infection. Dr. Kayumba smiled and then laughed as he said, “In Uganda, we survive.” I am amazed by how much Dr. Kayumba and the staff of Masindi District Hospital have been able to do with so little. And more so, I am amazed by the generous, optimistic attitude the staff has managed to maintain despite their working conditions. As I was leaving today, I shook Dr. Kayumba’s hand and said the only thing I could think to say. “Keep fighting the good fight.”