Guest post: A view from Kampala, Uganda

This post is from Dr. Anne Dougherty, MD. She is almost in the middle of a six-week project at Mulago Hospital in Kampala where she is providing support and training to the OB/GYN staff. I will let her words speak for themselves.

Resigned helplessness – that is what the resident’s face said as she answered questions following her presentation.  The patient was a young woman who was transferred from an outside hospital for “confusion and severe anemia.”  On arrival at Mulago, the patient was tachycardic and tachypneic.  Her mental status was altered.  Her abdomen was distended and rigid.   She was bleeding per vagina.  A pregnancy test was performed and was positive.  My assumption at this point is that the patient has a ruptured ectopic pregnancy and is in danger of bleeding to death.  An IV was placed and normal saline was dripping into her vein.  No additional labs or studies were obtained.  This all happened at 1AM.  At 9AM – eight hours later, the resident stood before the department at morning meeting and related this story.  There was no more to the story than what I just told you.  For the last eight hours, the patient had lain in a bed on the ward where a single nurse watched over 40-50 patients with a single IV running crystalloid @ 125cc/hour.  The resident was asked, what did the ultrasound show?  Did you locate the pregnancy? What was causing the surgical abdomen?  Did you draw coagulation studies?  I was struck that in the telling of the story, the resident did not mention that these might be things that she considered.  When asked why such studies were not obtained, she simply stated that it was 1AM.   As if the main referral hospital in the country should close at a certain hour.  Well, as it turns out, it does or at least that is the perception that then becomes a reality.

A horrible inhumane experiment was performed with dogs in which they were placed in a cage with an electrified floor.  There was a high barrier in the cage over which the dogs could not jump.  The first few times the floor was electrified, the dogs tried desperately to get over the barrier, but as time went on, they would curl up in the corner until it was over.  The dogs continued to do this although the barrier was lowered such that the dog could jump over it.   This is not to say that humans are dogs, but it does demonstrate the effect of repeated negative events on the desire to keep trying, to keep striving.

I have seen repeatedly that when even a small challenge is presented here at Mulago, the answer is often, “it is impossible.”  And yet I know that it cannot be as I see some are able to overcome the challenges.  Today, while performing a series of exams on patients with suspected cervical cancer, I ran out of exam gloves.  I asked the “sister” (that is what the nurses are called) if she could get more gloves.  She said, we do not have any more and just stared at me.  She said the person who was supposed to go to the supply annex last night to restock did not turn up and so we were low on supplies.  Not being one to take no for an answer, I persisted.  Well, I said, where can we get them from now?  She said, give me a minute.  In a short time, the “sister” returned with a new box of gloves “borrowed” from another unit.

One of the things about cultural exchange is that you really have to leave yourself at home.  That is, you need to surrender your sense that “this is the way things have to be done.”  As long as you continue to compare here to there, it is easy to be irritated by the way things proceed within the foreign culture and ultimately become very frustrated.  And in that frustration you miss the cultural exchange.  In medicine that can sometimes be difficult.  When you have a patient in front of you who could be helped with a few basic diagnostic tests and swifter treatment, I feel another force at work that is complicated to separate from my own cultural context.  The feeling of responsibility I have to the patient while embedded in my cultural context feels like it stems from an inner part of my being and is so painful to let go even temporarily. And yet, that is really what you have to do here at Mulago or you will be crushed by the tragedy of it.

I am not sure that I understand entirely where the resigned helplessness comes from.  It is likely multifactorial.  Being subjected as a colonial territory plays a part.  Follow that with decades of struggle and war while surrounding countries began to get their independent “legs” under them.  Add in poverty, food scarcity, unemployment, resource shortages and a dejected passivity develops.  I am also quite sure that western world “charity” contributes.  Interestingly though, when you learn the stories behind some of these Ugandans and the life challenges that they have overcome, you are left with paradox.   Ne woman told a story of moving out of her stepfather’s house because he would beat her mother when she showed affection to the woman and her sister.  She moved in with a relative who took her on as household help (a common practice here), but the woman wanted to go to school.  So she moved onto the streets where she tried to earn some money during the day to support her sister and herself and then went to primary school as an adult. She taught herself English while living on the streets.  As a cleaner at Mulago Hospital, someone discovered that she spoke English and promoted her.  She worked her way to a stable job as an administrative assistant.  She continues to go to school and is now married, expecting a baby shortly.  Amazing.  And her story is only one of many.  So many Ugandans have witnessed horrendous violence either at home or at the hands of the government.   Most have been in a home without enough food to feed the whole family.  Many have inherited entire families of 6, 7, 8 children when parents pass away from HIV related illnesses.  They will work against all odds to send those children through school.  The strength and wherewithal to persevere through such trials is more than the average American in 2013 would tolerate I think. And yet that same woman might tell you there are no more gloves.   Such a strange paradox.

Anne K Dougherty MD
Attending Physician, Department of OB/GYN, Fletcher Allen Health Care
Assistant Professor, University of Vermont