On Pediatric Surgery.
In November of 2016, I embarked on a clinical elective in Uganda with the dual motive to experience a developing nation’s health-care system and to conduct an economic research project on the first pediatric operating room (OR) in the country. The OR was constructed in Naguru Hospital, a public referral hospital in the capital city of Kampala, furnished by the ARCHIE Foundation, a Scottish non-governmental organization (NGO) with the mission statement to build pediatric surgical capacity by supplying heavy-duty operating equipment in the resource limited areas in Sub-Saharan Africa.(1) Uganda was a excellent place to pilot this endeavor, with 48% of the population under the age of 15, and only 4 pediatric surgeons serving over 20 million children. (2,3) Upon completion of the construction project, ARCHIE became interested in the returns of their investment to inform future similar projects, so I was given the task to address their question through a cost-effectiveness analysis study.
As an international medical student in America, traveling has always been the best way to broaden my worldview. My visit to Uganda was no different, and I not only had extraordinary clinical exposure in the public hospitals, but also became familiar with the larger sociopolitical climate that inevitably impacted the health-care system in unexpected ways. Within the first two days of living at my host university, I witnessed student strikes and their aftermath. The students were protesting about the lack of lecturers, who in turn were also on strike for being chronically underpaid. On campus, I walked passed armored cars and policemen armed with rifles and tear gas, stepping over charred pavement and broken branches. On the third day of my trip, Uganda’s president Museveni placed an abrupt executive order to shut down the university indefinitely to halt the civil unrest, and the bustling university became a deserted ghost-town for the remainder of my stay.
However, the president’s quick decision did not account for the responsibilities of the medical residents (or senior medical officers) who were enrolled in the university’s graduate program but also worked the public hospital where I was stationed. In effect, the university closure barred these residents from working, and the resulting short-staffing was astounding. The remaining hospital staff buckled under the constantly shifting workload with little questions asked, and even fewer answered. On some days, the surgeons would implore striking anesthesiologists to return to the hospital and ‘volunteer’ their hours in order to operate on emergency patients with intussuceptions or ileal perforations. On others, there would be one or two physicians primed to see a clinic of over 70 patients in one morning. To be sure, staff strikes were a common event in Uganda and seldom raised any eyebrows, but as an incoming observer I was both amazed and impressed by the physician and nursing staff’s tireless pace to serve their patients regardless of limited pay or resources. I cannot begin to imagine how a teaching hospital in America would function without the capable hands of the resident workforce.
On Pocket Money.
Another type of shortage became apparent as I began collecting cost data for my OR study from the patient’s perspective. Part of my project involved a survey of the out-of-pocket costs incurred by patient’s family, and I also obtained costs for medications and medical supplies that are utilized in the OR. In Mulago hospital, the bulk of the hospital medications and disposable supplies (e.g. syringes, catheters) are sourced from the National Supply Store, a nationwide stockpile funded by the Ministry of Health that restocks the public hospitals quarterly. Theoretically, this public hospital system should render every patient stay free of charge. However, supplies tend to dwindle at the end of each quarter, and since I happened to be there through December, drugs that were essential in post-operative care such as rectal acetaminophen, metronidazole, even 50% dextrose, ran out of stock. With the help of the ward’s nursing team, we asked the patients’ families about the money they had spent since their arrival to the hospital, and it turned out that a medical visit that was supposedly free on paper required them to make substantial purchases prescribed medications at nearby private pharmacies.
Furthermore, the families also had to pay for any imaging and laboratory tests more elaborate than the run-of-the-mill blood count or electrolyte panel, as the hospital was not equipped to run these diagnostics. Transportation also imposed a substantial financial burden and barrier for the patients’ families seeking access to health care, as some of the families came from far away provinces. Not to mention the heavy reliance on vehicles such as boda-bodas, the motorcycle taxis which provide the fastest but most fatal way to travel. I shudder to remember a father who carried his newborn son while clinging onto the boda-driver as they snaked precariously through the heavy city traffic in order to get to the hospital.
On top of all the in-house costs, patients’ families usually remained in the hospital for an extended period due to numerous delays in curative surgical treatment. The care-givers thus accrue significant productivity loss, as mothers and relatives missed many days of work as they tend to their children on cramped cots, sleeping on the floor under these tiny beds with only thin straw mats between their bodies and the cement floor. In fact, some families had to borrow or sell possessions, whether it be a goat or a carpet, in order to amass the finances they would need to cover their health-care expenses. In short, there is no such thing as a free lunch, and these families were actively drained of their personal resources as they waited passively for their turn at an operation, which sometimes did not occur for weeks due to hospital shortages. Allowing the patient families speak about their financial burdens gave them a voice to air their economic challenges. This surprisingly uncommon patient perspective is both refreshing and sobering, as health care in Uganda is usually delivered in a physician centered approach, where the patient is usually not invited to contribute to the medical decision making, or asked about their opinion. This was evident as the nurses who were conducting the patient cost surveys were as taken aback as I was by some of the patient responses.
On the People.
Working alongside the local pediatric surgeons largely inspired my desire for a surgical career, as I had the opportunity to scrub into many cases and witness the miraculous work of fixing all forms of congenital anomalies. I also had the privilege to witness the installation and the opening of the second pediatric OR in Uganda in the neighboring city of Mbarara, again funded by ARCHIE. I traveled 4 hours west on bumpy dusty roads to visit the Mbarara regional referral hospital with my research team, and upon entering the new OR space was greeted by the fruits of labor the ARCHIE team had put together. The walls were plastered with geometric rainbows of giraffe, bird, and butterfly silhouettes, and the rooms were lined with brand new beds. the OR was the most impressive feat, with a state-of-the-art OR table, a spacey UFO of a light hanging (with seamless battery installed, of course, to overcome electricity cut offs), and cupboards stocked full with surgical consumables, ET tubes, IV cannulas and all sorts of other surgical goodies.
That Monday, Mbarara OR for was officially open for business for the first time. The morning air was charged was sparks of excitement, as Dr. Ozgediz, my research mentor, rolled his hockey bag, chock full of sutures and surgical gowns, and other supplies down the orange dirt road towards the hospital. There were 4 rooms set up, and the list started with 14 patients, with a sprinkling of PSARPs (posterior sagittal anorectoplasty), pullthroughs, nephrectomies, and a good dose of hernias. By midday, the list has grown to 3 pages with many add-ons. I flitted through the many ORs, amazed by the number of index cases. Most astounding to me was the seamless collaboration between the local and visiting surgeons tackling the cases for the day, and it demonstrated local providers’ open and accommodating attitude towards foreigners who have committed time and developed relationships with their colleagues.
“Osiibi Otya?” The phrase is a greeting for good afternoon and good evening, but directly translates to “how was your day?” In Luganda, the mother tongue of most Ugandans in Kampala, the first interaction skips the formalities and inquiries about the recipient’s wellbeing and is often accompanied with an earnest handshake and a bright smile. Ugandans, I discovered, are real talkers. They can be conversing about anything for the longest time, and it somehow is never stilted, perhaps because of the way they draw out emphasis in their words. I have met so many friendly faces, shook so many hands, hugged so many warm bodies that I have not felt lonely at all since being here, even though I am traveling alone for the most part. I am also always surprised by the ease of conversation I have with strangers, despite our cultural differences, and how quickly friendships form.
Survey-taking in the hospital was never a dull moment, as mothers of neighboring beds would chime in, and families from distant districts would laugh along and banter about (what I thought would be personal topics of) salary amount, or who was getting discharged first. Instead of shriveling up into worry-warts by focusing on the illness of their child, these families have the levity to laugh with each other and in chorus. It was simply a joy to be around these people, even when they watch their most beloved suffer. I loved nurse Scola’s shrieks of laughter and her scrunched-up her nose as I taught her how to use the IPad, and she always followed her Apple technology revelations with an emphatic slow-motion high-five. I loved nurse Sister Ann’s eye widening as she builds up to the climax of her jokes before cracking herself up with barks of hearty laughter. There is something that exudes embracing warmth from these people, which draws me in like a moth to the light. I feel like I am drinking the elixir of life as I immerse myself in the bright spirit of these people, and it is this energy that has driven me to pursue a career in academic global surgery.
- The ARCHIE Foundation: http://www.archiefoundationhome.org.uk/
- Bickler SW, Rode H. Surgical services for children in developing countries. Bull World Health Organ 2002; 80(10): 829-35.
- United Nations Department of Economic and Social Affairs: Population Division: http://countrymeters.info/en/Uganda