Bone Rot

Another Tuesday morning meeting. Amna and I sit side by side trying hard not to fall asleep. As Mzungu medical students, our actions draw more attention than they normally would. The minutes of the last meeting are read. The number of patients seen by each doctor is announced. Unsurprisingly, most have been seen by residents rather than fully-trained surgeons. When even the executive head of a department earns only a few thousand dollars per month in the public service, most physicians try to spend as much time as possible at their private clinics. This leaves a group of semi-trained residents to guard the trenches of medical care without supervision, equipment, or support.

As happens every week, one of the consultants complains about the lack of clinical work from his fellow surgeons. As happens every week, the chairman notes his concerns, agrees with him, points out that little can be done at present, and expresses hope that something will be done eventually – Three weeks later, one of my neighbours, a middle-aged woman who was once this same consultant’s patient, will describe to me a case of semi-benign neglect suffered at his hands. She was briefly paralysed and is now forced to wear a brace for the rest of her life. The irony surprises me only a little. The system is difficult.

The meeting continues. Amna and I try not to fall asleep.

"What is the situation for Operating Theatre 7?" asks the chairman.

"Mr. Chairman, as you know, Theatre 7 was meant to open on Monday," responds one of the consultants. "Unfortunately, this has not yet happened."

"Though the original problem has been fixed. Results from samples in the theatre show that it is still not clean of anaerobic germs. We have asked that it be properly cleaned again and new samples taken."

Another doctor feels the need to clarify. "Mr. Chairman, the problem arises because there is a trash heap smelling of feces outside the theatre. It has been dumped there by The AIDS Support Organisation next door. Also Mr. Chairman, stray dogs have taken to perfuming the theatre’s outer walls."

It would be funny if the results weren’t so tragic.

The various wards declare their numbers of patients seen, discharged, admitted, and transferred. With the central operating theatre closed for nearly a month, the number of patients awaiting treatment is growing constantly. Every week the bottleneck is supposed to be cleared. It never is. It will be almost another month before the situation is rectified.

Reports come in from the nursing units in the different wards. "Sister, how fares your section?" the chairman asks the nurse in charge of the central ward, 2CO. "Not good," comes the reply, "We are severely understaffed."

"Sister, how many staff do you need?"

"We need at the very least eight to be able to care for those with spinal injuries and others requiring constant care."

The chairman addresses her with the Luganda word for healer: "How many staff do you have Musao?"

"Mister chairman, we have eight but two are on leave and may never return and two have spinal cord injuries."

In a room full of spinal specialists, some snicker at her casual diagnosis.

"What do you mean spinal injuries?" comes the forcefully benign reply.

"Mr. Chairman, one has a slipped disc, the other has weakness and can not bend her back without excruciating pain."

The snickering dies.

"Musao, are there any other difficulties?"

The question is a little incredulous. What other difficulties could there be?

"Yes. One of the remaining four is pregnant."

There is nervous laughter in patches throughout the room. The chairman pauses. He knows the difficulties. He wishes they would disappear. Beyond comforting words, he is powerless to help. "So, in fact, you have three nurses to perform the work of eight?" he asks.

"Yes, Mr. Chairman." The nurse takes a deep breath. She is steeling herself for the inevitable lack of support. After a short pause, she continues. "Mr. Chairman, we have all been working double and triple shifts for several weeks. I fear we shall be unable to continue."

The understatement in her next words lands with all the subtle dark humour of a mortar round striking a balloon factory:

"Mr. Chairman, we are very tired."

More words. More promises to raise the matter with the administration. Cold comfort without the power to effect change.

It would gain more sympathy if it hadn’t become routine.

Rounds on the Orthopaedics Wards

Three weeks before this meeting I assisted on my first surgery. It was almost accidental. The attending physician had me inadvertently providing the extra pair of hands needed to allow him to go somewhere more profitable. On the way to the operating theatre, I stopped with Dr. Otiano, one of the residents, to collect blood from the hospital blood bank. "Have a look in that fridge there," he said, pointing to the far wall. "All of the blood supply for the entire hospital is in there."

"You mean this fridge?" I asked, "That can’t be right, there’s only one unit."

"No. That’s probably right," he replied with a smile of stoic dejection, "There’s always a shortage."

To add insult to injury, the unit was AB positive, a type of blood useful to less than four percent of the population. "Sometimes some of the departments hoard their own," he continued, "You go ahead to the theatre. I’ll try to find more."

Unfortunately, this is a recurring story at Mulago, Uganda’s largest, proudest, most well-equipped hospital. Hundreds of well-trained physicians, nurses, and support staff, people in whose treatment I would be confident in any Canadian hospital, left to work without beds, tools, drugs, finances, support, or in some cases, even gauze.

On a recent visit to the Pediatric Infectious Disease (PID) clinic, Amna and I found a similar story. Children waited in crowded rooms for nutritional support, lab work, clinicians, and counselors. Bright cheerful paintings of animals played on the walls. A teacher gave English lessons to a group waiting seated on the floor. Thanks to the AIDS pandemic in Sub-Saharan Africa, PID is synonymous with HIV. Every child there was HIV positive. Every single one.

We were visiting through Canadian Feed the Children (CFTC), our medical class’ official charity. Money made available from charitable groups has allowed this clinic to increase its capacity several times over in recent years. It is still not nearly enough.

Infected children need more than drugs to survive. They need adequate food and resources to keep them healthy while the drugs take effect. How do you provide food for infected children when there is not enough for their siblings? How do you counsel teenagers, patients who have lived with HIV since birth, about their budding sexuality? What do you do for families too poor and too far from a clinic to receive treatment?

As we walked past the lesson, our nurse guide made an announcement. I caught the Luganda word for "We thank you," before a scattered applause began. What had we done to deserve such a reaction? "She’s just informed them that you are Canadians who have helped by making donations to support this clinic," Christina, CFTC’s Country Director, told us. Too stunned to reply, we watched the lesson continue.

"We are moving forward in Uganda," the teacher intoned.

"We are moving forward in Uganda," the children repeated.

"God, I hope so," I thought to myself as pat of me wanted to laugh and the rest to cry.

Sadly, HIV is not the only burden overwhelming Uganda’s limited health resources. Earlier this month, I manned an educational booth with Jacqui, the chief physician in Mulago’s Casualty – British for Emergency – department. We tried to teach children the basics of first aid, the ABCs: Airway, Breathing, and Circulation. In Canada, the goal is to teach people how to stabilize friends and family until they can be rushed to hospital. Here these lessons seem sadly impotent.

Jacqui

In Canada, if someone stops breathing, one helps with mouth to mouth resuscitation. Here, with a bleeding victim, mouth to mouth is an invitation to infection. Our booth had pictures of masks used for protection from infection. They are both unaffordable and unavailable in Uganda. Other first aid lessons seemed equally inept. To avoid spinal injuries, if someone hurts their neck or back, Canadian children are taught not to move them until help arrives. Sadly, with no public ambulance system, in Uganda help will never arrive. Moving the injured is a necessary evil.

Jacqui is a vibrant woman, cheerful, quick, and no-nonsense, someone with whom I would be honoured to work one day. Soon after we met, she asked me in frustrated disgust, "Do you know how many quadriplegics we could save if we just had proper spinal boards available?"

I empathised. Throughout June and July, as mangos, avocados, and a local olive-like fruit called Jambuya were all in season, broken necks from falls out of trees had become so common that the orthopaedics residents had begun referring to them as "Mango Syndrome."

For Jacqui, the lack of understanding, funding, and support has become almost unbearable. "It’s a silent epidemic," she told me, referring to injuries. They are the third leading cause of death amongst the young in developing countries. We see them as the inevitable result of poverty. They are anything but inevitable. Were they the result of some virus or bacteria, we would be hearing as much of injuries as we do of HIV, TB, and Malaria. As is, very rarely does anyone stop to consider how many everyday mishaps, quickly treated and discharged at home, become life-altering for the poor.

Case in point, Osteomyelitis. It is a disease almost unheard of in Canada. In Uganda’s hospitals, it is seen every day. A cut becomes infected. Through neglect and poor conditions, the infection spreads to the bone. There is some pain and swelling. This fades. Most patients don’t seek medical care. Transport costs to hospital are too expensive. The infection consumes the bone, leaving it so brittle it snaps. Broken shards spread in the wound. Some of them regrow, combining into a weak, misshapen, useless core. Left long enough, the only available treatment is amputation.

It’s something I’ve seen first-hand. My first surgery was on a thirteen year old girl. Arriving calmly in the operating theatre, she seemed nervous but not scared. As Dr. Otiano arrived with the blood for which he had been searching, we both made our way to the sinks to prepare.

When we returned, the girl was anaesthetized and draped. The young woman I had seen was gone. In her place, an anonymous arm poked out from under green sheets. "So," I asked, remembering with confidence the girl’s nervous but reassured appearance, "what’s our plan of attack?"

"Oh," Dr. Otiano replied, "A simple amputation from just above the elbow."

First Surgery

During the surgery, we made small talk while arteries, nerves, and muscles were severed. I reminded myself about clinical detachment. The arm was anonymous. The girl was not. When I could, I placed my free hand over the green draping, feeling the spot where her stomach rose and fell, reminding myself that a person lay beneath. When the procedure was done, the arm was discarded into a shining steel bucket.

We paused for a break. Sitting down outside, Dr. Otiano completed his paperwork. Soon, we were scrubbing for our next surgery, a young boy.

"What’s this one?" I asked with forced casualness. Observing the movements of my hands under the water, I felt a sense of gratitude and shame I had never felt before.

"Amputation. Lower-right limb. Just below the knee," came the reply.