Prologue

Having returning safely, the first thing I noticed was how clear the air is here. Everything looked so..sharp. I'm still blowing charred debris out of my nose. The mission is over but I have a few final random thoughts on the trip. In no particular order.

 

Medicine:

The medical system is driven by the university, not a hospital department. This means that pay and promotion is based on academic status, not on one’s specific medical training. So a PhD will command a far greater salary than someone is more surgical training and experience. For this reason, pursuit of degrees take priority over fellowships and training. This cant be good for surgical skill development.

When Ugandans finish medical school, they intern for a year for which they are paid a small salary. However, should they decide to enter a residency program, such as plastic surgery, they are essentially doing a masters and do not get paid anything. NOTHING. In fact they have to pay tuition during their residency, though it is only three years, instead of five in Canada. This means either only those with money can pursue medicine or those without have to somehow fit another job into their life. Given how BC has almost tripled tuition and gutted the student loan system, I guess Uganda is the ideal goal for here at home, but at least residents still get paid, sort of. It is nice to have something to aim for I guess.

One of our secondary goals was local education. Unfortunately with pay so low, even for fully trained surgeons, it was rare to see them in the OR with us, their obligations split between the hospital and private endeavours. At $500 a month (rent costing about $200 for a modest place in the city) salary, it is hard to blame doctors for seeking other sources of income but it is clear that unless these staff are paid enough to make the hospital their only priority, patient care will never be improved.

Antibiotic resistance is always a big concern. Standard protocol is to use cheaper, less powerful antibiotics in healthy patients and step up to more powerful (and expensive) medications if no improvement occurs. As culture results come back from the lab, the choice can be modified to the best option. This keeps our big guns from getting prematurely used and developing resistance among those who are very sick. Unfortunately in Mulago, the first line is often a largest gun in the arsenal of options, namely Imipenum. This is sadly driven by aggressive marketing both inside and outside the hospital in the form of posters, presentations and lobbying. Even the nursing aprons sport the product’s label. Their slogan is “The first choice is the best choice”. Even worse, the microbiology department that processes the wound cultures, stack the report with a bias towards these antibiotics, again a product of aggressive pharmaceutical campaigning and outright bribery. In Canada, pharmaceutical companies have lost a lot of clout in their ability to lobby doctors. We no longer get free weekend ski trips at Whistler or free Hawaii “conferences”. I can see where they have shifted their attention and it will only lead to misery for patients as these vital antibiotics become resistance and useless.

Social:

North Americans are loud. I never realized this until spending time in Uganda. Ugandans speak in soft, steady tones, with a low pitched. I felt deaf half the time when talking, squinting my eyes and hold my hand up to my ear. It had nothing to do with accent; Ugandans speak excellent English for the most part, from doctors to street sweepers.

Christianity is the dominant religion in Uganda with a smaller minority of Islam (about 10%) but many other faiths exist, with relative freedom. Religious violence is an issue but not rampant in Uganda. Indigenous religion is fairly limited but many Ugandans loosely subscribe to practises such as making scarifies to ancestors.

Social issues have not progressed significantly; Homosexuality is considered a sickness even among some of the more educated and is a difficult topic to broach. Abortion is illegal, except in extreme circumstances where the life of the mother is threatened. Public perception is that any woman getting an abortion was unfaithful adding social stigma to criminalization. As is often the case in countries that ban abortion, the underground market for illegal abortions is huge as are the complications which end up in the hospital. It is not uncommon for these women to be charged while admitted in hospital if it is revealed they had under gone the procedure, revealing a less than rigorous patient confidentiality culture within the medical system.

Public sector has borne the brunt of Uganda’s financial woes (remind you of anywhere?). As mentioned previously, nurses have been unpaid for weeks while teachers had just recently gotten caught up on a portion of their back pay while I was in the country. This is a very common and seems like a national system of cheque kiting. The government holds pay from one group and dumps some money on another. This creates a situation where no one wants to protest, because previous attempts to strike typically result in that particular group getting punished with longer pay freezes. So everyone keeps their mouth shut and weathers the dry spells with the hope that they will get a reprieve at a given interval. God, I hope our government doesn’t figure this one out.

Diet:

While meat is a regular part of the Ugandan diet, its role is much less prominent. Consisting of maybe 10% of the total meal, most of the calories come from high carb sources including Irish potatoes, Yams, and a white grit like dish made from a variety of starches. Despite this heavy carb diet, the bane of the North American, you won’t find many overweight people here. This supports a dietary theory that it is less about what you eat, but eating what you genetically and geographically evolved with.

Candy and sweets in general are not a common snack in Uganda. For this reason kids went pretty nuts when it was available but I felt kind of guilty given they are likely better off without it. One surprise hit with the locals was Nutella, which I suggested as a logical combination with their local chapatti, similar to crepe and Nutella. To the Ugandans this seems like sacrilege at first until they try it. Needless to say, I had everyone eating this at the hospital break room and a jar of the stuff never lasted long. Too bad a jar is about 30,000 shillings (over 10 dollars). I’m going to miss those chapattis. 

Commerce:

There are metal workers in this country that can recreate almost any item you want providing it doesn’t have complex electronic components. This includes many firearms, so the number of fake weapons in circulation is very high. You can buy a Ugandan knock off AK47 for as low as 12 dollars American. I was very tempting to test out one, but it isn’t appropriate for a medical professional to associate with firearms in my opinion.

Despite dozens of vendors selling rolls of it by the road side to drivers caught in traffic jams, here is no toilet paper anywhere to be found in this country. There are a lot of smears on the bathroom walls though.

Shopping is much like other developing nations. Bartering is considered a given though my enthusiasm for beating locals down on their prices was limited. I have no issue with hammering vendors in Mexico into the ground so I guess that makes me a hypocrite. A careful eye is needed if you are looking for authentic Ugandan, “locally made” products, as most items in the country come from the same place everything else comes from: China. One item I was continually impressed by was batik painting, which uses wax and dyed canvas. I managed to pick one up for about ten dollars and it is beautiful.

Grocery stores carry many of the items one would find in North America but at higher prices compared to the average income (but still relatively cheap by a westerners perspective). Security checks are everywhere, even these supermarkets and getting pat down for weapons is common.

Final words:

Some have asked if I’ll be continuing my blog based on my experiences in medicine at home. My gut is to say no, mostly because it is a significant chunk of work and I’ll probably get fired if I start speaking frankly about my patients. I do appreciate the comments and emails. Thanks to everyone for reading and tolerating the typos including those readers in Russia, Australia and Germany (the blog website tracks country of visitor in addition to other stats), I have zero idea who the heck you are but welcome all the same. This isn’t the last overseas mission I plan on; in fact it is just the beginning, so maybe I’ll be back with another blog at some time in the future.

I’ll be in touch…later.