Guest Report: Uganda

Southwestern Uganda. Image courtesy of the University of Texas.

Megan McIntosh Frenzen writes:

We are exhausted at the end of every very long workday and, in many ways, it feels like we’ve already been here for a month.  If you’re interested in hearing what’s up in Uganda, read on. It’s lengthy, so get comfortable. Or, if you prefer, just read the first and last sentence of each paragraph – after all, that is how I survived grad school…

We left last Wednesday morning and arrived at the Entebbe airport in Uganda late on Thursday night. We collected our things and spent the night at a modest and fairly strange little guesthouse in town. It was incredibly fun to watch the World Cup match with Africans that night, they’re quite proud to be hosting the event. Thankfully, the jetlag was still on our side as we’re 7 hours ahead over here. On Friday morning we tied our luggage to the roof of a Land Cruiser and embarked on quite possibly the most ridiculous drive I’ve ever been on.

The first five or six hours weren’t that bad, people, cows and goats everywhere, but the roads were more or less paved. That was the easy part. We stopped in a town called Mbarara for lunch – it was almost edible. We continued on for another seven or eight hours on roads that more closely resembled goat paths. As the sun began to set, we found ourselves bouncing along through Queen Elizabeth National Park in western Uganda. Zebras grazed by the roadside, several annoying and confrontational baboons came looking for bananas as we passed (they happen to be my second to least favorite animal on the planet, second only to the tennis ball-sized spider I found in my hair the other morning), elephants wandered into the middle of the road with their huge eyes reflecting the headlight beams and it turns out that the buffalo here don’t have very good eyesight.

At some point after nightfall I noticed a lengthy stretch of forest fire burning on a hillside in the distance. I asked our driver if it was controlled burning, he glanced at me and said, “Oh, that. That’s just the Congo. Did you know that we have 612 species of birds here, in Uganda?” I was grateful it was dark so that he couldn’t see the stunned look on my face. 

Eventually, we arrived at Bwindi Community Hospital. Seth [Frenzen] was busy unloading gear and I was hard at work in one of my semi-neurotic unpacking/organizing fits when I discovered what will always be one of my least-favorite parts of Uganda, my aforementioned absolute least favorite animal: those stupid giant spiders. After hunting for an adequate execution device and with some small amount of guilt, I killed that first one quickly and quietly. At the time, I was frankly proud of not shrieking like a girl. Now I just growl. And then I murder them, entirely guilt-free. It’s war. After convincing myself that that first unwanted guest must’ve been an anomaly, we ate something that was referred to as dinner and headed to bed.

Our platform tent is nestled in the jungle, a five-minute walk from the hospital. It’s a commute like no other. It beats navigating Sewage Street (Cambodia-style) by a mile. At night and in the early morning it’s colder than you might expect. I’m piled under a couple of blankets and some serious mosquito netting every evening after the World Cup matches are over. Our tent has a main area just large enough for twin beds, mosquito nets and our gear. There is a solar light that works about 20% of the time. Mostly, it’s just dark. If you exit the rear of the tent, there is a small open area and then symmetrical enclosures on each side of the rear of the structure. The right side is our “shower.” It’s actually just a shower head with a large cistern above it. A charming Ugandan named Joseph comes at 6:30 every morning to pour about 4 minutes of hot water into it.

The left enclosure is our “toilet,” which is a padded plastic seat above a bucket. There is another bucket in that tiny dark cell – it contains a trowel and dirt – for “flushing” the bucket, for lack of a better term. One of the Josephs who work at the camp makes breakfast every morning–some pineapple, a banana, some toast, scrambled eggs. The coffee isn’t half bad–then it’s off to work.

Thankfully, the staff at the hospital is so happy to have us that they worked straight through the weekend (and late every single day so far) in order that we can get as much done as possible. The first morning at the hospital was rough. In fact, the entire first day was horrific. If we were not literally stuck in the middle-of-nowhere-Africa, I would’ve seriously considered pulling the plug on this little adventure.

This place makes Haiti look well supplied. No anesthesia machine, no cautery (that’s the equipment you need to get stuff to stop bleeding during surgery). There really is nothing here, just three partially empty shelves of supplies in the operating room: some suture, a few gloves, some gauze, a few sterile instruments and blades. It’s unbelievable. They do, however, have an X-ray and the very first patient we went to see that day was a 20-year-old boy named Shaban. He had fallen three months ago and gone to see a “bone setter,” much like the Haitian or Khmer “witch doctors.” It’s impossible to tell from his X-ray if he had ever had a fracture or not, the mass on his lower leg now obscures so much of the bone that there’s no way of knowing. No fever, no indication of infection, but I’d prefer to be hopeful. Seth tends to take the more realistic approach and I scheduled him for a biopsy that afternoon.

Following our visit with Shaban, we headed to clinic. Given the lack of instruments and supplies, it was not exactly a surprise, but I learned two nights ago that we are, in fact, performing the first orthopedic surgeries that this hospital has ever seen. This place serves a population of more than 300,000 people in far southwestern Uganda, nestled in the mountains between the DRC and Rwanda, where they have no other healthcare options apart from bone setters and other witch doctors. It’s hard to explain to the Ugandan physicians (without tears in your eyes) how our town in Vermont has more than 20 orthopedic surgeons when this entire country (of more than 30 million people) has a total of ten. The closest hospital with orthopedic facilities is a six-hour drive on some of the aforementioned crappy roads. In Bwindi, trauma = death.

Part of me is starting to wonder just how much time I’ll be spending here, if this might be a more regular stop on the tour, a summer home, if you will (where you crap in a bucket and annihilate giant spiders). Perhaps, just maybe, getting a functional trauma facility up and running here might be part of my special purpose. I’d like to think it is higher on the list than being a 5 handicap golfer, but maybe it’s tied?

I’m so exhausted every day but feel like I learn something amazing every other minute. I am trying to keep a journal, at least covering topics I need to research. Before HIV/AIDS, communities used to mourn deaths with 7 days of not working – 3 days for children. After AIDS, death rates rose so quickly that communities couldn’t do it, they couldn’t mourn their dead. Rural Ugandans self-selected into smaller groups, called Burial Groups, bound mostly by geographic proximity with very little socioeconomic commonality.  This is the cool part: the hospital here is trying to become self-sustaining and they are working to implement a community health insurance plan–$6 per person a year and a $0.50 co-pay for a visit. They are approaching individual Burial Groups, who are electing to participate en masse–elders make decisions and social pressure dictates that the rest of the group follows suit.

I have to say, I consider this phenomenon to be the most interesting unintended consequence of the AIDS epidemic ever. Burial Groups are an effective way to provide health insurance and fairly distribute the cost of care. Funny, rural Ugandans can figure this out, but we in the U.S. cannot?

Back to “real life.” Clinic was…busy. The staff here collected 54 of the most bizarre cases they could find. We made it through about 20 and started surgery that first afternoon. As I had mentioned, it was a rough start. The Ugandans are amazing, they make the best effort and have the best intentions, but apparently also have little understanding of the concept of a “sterile field,” or why something like that might be important when you’re cutting someone open. There is an OR staff, but no real scrub nurses or other surgeons around, which means I’m honing my techniques at the table. That first day, we excised a mass, took off an extra toe and took a biopsy from Shaban’s leg. I waited patiently for a purulent steam of something to pour from the incision. I found myself almost praying (gasp… praying isn’t exactly my bag) for an infection. No such luck. All softened bony crap. Not a drop of pus in sight.

I don’t really see tumors in my line of work, so it’s hard to judge, but Seth sure believed that it was the fastest growing malignant tumor he had ever seen: it’s presumably only been growing for 3 months and it’s the size of a grapefruit. The biopsy has to go to Kampala. It’s a 14-hour drive (back on those crappy roads again), there is a night bus, but we are still waiting for someone to be able to take the specimen to the lab there. It will probably not happen for days. An above the knee amputation is most likely the only option to save Shaban’s life (although there is no Gigli saw here to even consider performing an amputation of that nature). Most of the people here cannot afford prostheses, even if they can find somewhere to be fit for them, so when they find out they need life-saving amputations, they go home to their huts and don’t come back until two months later when they’re coughing non-stop and their chest x-rays look like a joke. It seems like they do a reasonable job with pain management here, but it’s still an unfair way to die.

People die all the time. In fact, people die in lousy ways all the time. I’m still not sure why Shaban upset me so much. I have a sneaking suspicion that it has a lot to do with my students. I look at him and I see their faces. I see Burlington and RJs and What Ales You and the waterfront. I see college campuses with perfect buildings and skinny jeans and popped collars and hangovers. I think about his future and I think about theirs. I think about anxious parents, waiting for their kids to come home for the summer. I think about what my kids deserve out of life, what potential they have and then I look into the saddest, darkest eyes I’ve ever seen. Shaban is here alone, lying on a lousy piece of foam on a cot a foot off the floor in a room with 5 other “beds.” Nobody is waiting for him and all he is waiting for is to find out roughly how quickly he’ll die. I can’t get past him.

Some other surgical news is not good. We cut off a foot mass yesterday. The guy wanted to be able to wear shoes, but had these huge masses on the dorsal sides of his feet (that’s the top). The arteries in your feet (things that should bleed a lot) are all on the plantar side (that’s the bottom), but the masses on top wound up having arterial blood supply, meaning there were lots of things pumping out lots of blood. It was awful. No cautery, no real tourniquet (we’ve been using a blood pressure cuff, but just got a tire tube today – not kidding), so there was no actual way to stop the bleeding other than to try to tie off every little bleeding hose. Imagine trying to tie off 10 of them, flying blind because the lights suck and there is no way to stop the bleeding fast enough to see what you’re doing. It was awful. Patience and applying pressure… we eventually got there, but I was afraid we would be the first people on earth to exsanguinate someone (that’s bleed them to death) from more-or-less a toe surgery.

There is some surgical news that is awesome. An 18-year-old woman who is now desperately looking forward to market on Thursday because she will buy shoes for the first time ever – we removed her extra toes yesterday. A 22-year-old woman who had a syndactyly (that’s webbed fingers) of her middle and ring finger on her left hand – she told us that she’d finally go to the church with her husband because she can now wear a wedding ring. A 1-year-old with corrected bilateral clubfeet.  In other exciting news, I removed my first two polydactylies (extra digits) today. An 11-year-old boy with bilateral hand and feet – that’s right, 11 years with extra pinky fingers and toes – he too was very excited to wear shoes for the first time. Seth took one side, I took the other. I removed and sutured and…well, not to blow too much smoke here, but I dare say my side looked just as good as Seth’s!

Apparently, it was on the local “radio station” that there were American doctors at the community hospital doing “bone” surgery, so we’ve become quite popular. Strange, strange stuff in clinic: we saw some more elephantiasis (the first case either of us had seen was in Haiti). It smelled bad there and it smells bad here. The Ugandan physicians are amazing. They do so much with so little. They told us that they like to draw blood to look for the worm that causes elephantiasis, but that they wait until nighttime because apparently the worms are relaxed when the patient has been sleeping, and they are more active and easier to “catch” in a sample.  The family hasn’t saved enough for the lab fee yet, but hopefully, we’ll get to see the worms before we go. I’ll feed them to those damn spiders.

And speaking of worms: my hard work has finally paid off. I have been hoping for a good case of worms in countless countries with real potential and I think I may have my first case ever. It’s like a badge of aid work honor. Fear not, deworming is just as easy for people as for your dogs, but I was hoping to lose a few pounds first, so I’m not in a huge hurry.

After work, we eat mostly odd food around 7 p.m. (thank you, Joseph) and then wander up the “road” to a place aptly named the Good Shed. It is a shed and it’s good. They have two 12” TVs in two separate rooms. The main room is about 12×20, the smaller one 10×10. It’s literally just a brick shack, but they play the World Cup games on TV and every night at 9:30 we head there. Many hospital staff frequent the place (there isn’t much to do around here) and they make us feel so welcome. Watching Ghana beat the US in that shack is something that I will never forget. Of course, Seth just had to root for the US – so, not only was he one of two white people, certainly the only redhead, but also the only ass not rooting for Africa’s remaining team! Now that the US is out, he’s changed his tune and we’re looking forward to Ghana’s next match. Watch the game, and think of us sitting in the Good Shed, very white, very far away and very overwhelmed.

Until then – lots of love from your favorite Mzungu (that’s Ugandan for really white person),

Meg

Meg McIntosh Frenzen, MBA, PhD

Megan McIntosh Frenzen is an MBA and a PhD in Marketing. She specializes in Consumer Behavior with minor areas of study in Social Psychology and Statistics, but her primary interest is in health related behaviors. In December, Megan is attending London School of Economics to start an MSC in Health Policy. Seth Frenzen is an orthopedic surgeon who specializes in hand and upper extremity surgery – he is a partner at Associates in Orthopedic Surgery in South Burlington. He completed his residency at UVM and fellowship at the University of Utah. During 2006 they took a trip to a hospital Cambodia during the worst hemorrhagic dengue fever season ever recorded. When she heard about the earthquake in Haiti, Megan said “well, how do you NOT do something when you know you can? So we went.” After an impromptu meeting with a founding board member of TOUCH Uganda, Kris Owens, Megan and Seth made their way to Uganda.