Iganga Hospital is a 200-bed district general hospital run, and largely funded by the government. It has male, female, paediatric and maternity wards, an outpatients department, pharmacy, laboratory, x-ray, ultrasound and an operating theatre. The gate opened straight out onto the main road and once inside there was always a great crowd shifting around the white buildings. Clusters of outpatients, families preparing food and mothers strapped to their infants would sit in the shade of the avocado trees.
If there was a rota, or system of job allocation, we never found it. However our day-to-day-role in the hospital was quickly established. We did a brief spell in the humdrum of outpatients with the cheerful Senior Clinical Officer. This acquainted us with the disease burden, the tests and the limited array of treatments available. However, the outpatient conveyor belt was reasonably well staffed and it became quickly apparent that we would be most useful on the wards.
A pay dispute with the ministry of health had shifted the attention of many doctors toward their private clinics. Appearances were limited to sporadic, fly-by reviews for the sickest patients and a weekly ward round. Specialist teams from the bigger hospitals would occasionally appear, friendly and unannounced. Despite finding written evidence in the notes from mysterious evening visits, it was three days before we met another doctor.
Running the wards were ward sisters dressed in nightingale-era uniforms, commanding a milling shoal of nursing students. White-coated Clinical Officers were appointed to each ward. The ‘C.O.’ is a great African compromise. They train for only three years with a more practical slant and gain their experience on the job. They admit, diagnose, prescribe and make decisions in lieu of the doctors input. They cost a fraction of a doctor’s salary. We found them to be excellent for treating the common, uncomplicated conditions such as malaria. The problem was that they didn’t have enough doctor contact for feedback on the decisions they had made. This usually meant that anyone without a clear diagnosis would tend to get all the bases covered with a combination of antibiotics, high-dose steroids, anti-malarials and various other contradicting combinations. In a job that relied on practical experience, nobody was taking the time to provide feedback or explain the clinical reasoning for management. In short, whilst their moments of good practice were repeated, so were the mistakes.
Both with some experience of Hospitals in Africa, Rich and I were prepared for a fewer clinical options, a less systematic approach and general inertia. We were also very mindful of our brief intrusion into hospital and how minimal our impact would probably be. We had to pick our battles. A daily, systematic ward round seemed like a good place to start. Initial management was usually as optimal as the resources would allow. However even post-surgical patients could then sit and get better or worse without being regularly reviewed.
The male and female wards were long squat buildings with corrugated iron roofs, crowded with patients in closely packed iron beds, usually surrounded by their families sitting and sleeping on mats (who were cleared out for drugs/ ward rounds). There were no cubicles or curtains, although there was one set of screens. Despite this, there was always a calm, easy atmosphere. Every morning we would arrive to a welcome of protracted handshakes and somewhat undeserved congratulations. Everyone was doing what they could. The patients would lie stoically as they improved or deteriorated with treatment and nature took its course.
If there had not been a senior visit that day, Rich and I would divide up the ward into two rounds. The clinical officers would often join us but if they were too busy, there were usually five or six attentive nursing students each, competitively keen to learn, translate and run errands. Our ward rounds would often include quite a lot of bedside teaching. When the senior doctor did their weekly ward round, we would follow in the throng, presenting the patients we had become familiar with. These were always lengthy, slightly jovial affairs with lots of academic discussions in English and difficult questions fired at the petrified nursing students.
By mid-morning, the sun beat down on the thin roof and the humidity was asphyxiating. At 2pm, we would walk the short distance home and quickly change into shorts. Here, the worries of the day would be overshadowed (quite literally) by an enormous and extravagant lunch. Mountains of rice, matoke (mashed Plantain) or poshe (mashed millet) piled with rich beef of ground-nut stews. We were spoiled. By this time, the afternoon heat would have built to a sweltering climax in anticipation of the evening storm. We usually needed a siesta before heading back in.
Rich and I both pride ourselves on our ability to befriend the ward sisters, which I maintain is the single most important skill a young doctor can possess. However it was the Clinical Officers whose toes we were treading on. They were essential to our integration on the ward; they knew the patients and were able to turn requests into actions. Every morning it was them who would take us to review the patients they were worried about. We were careful to maintain a dynamic of working together as equals and remain magnanimous. It was important to explain the changes we suggested and agree on them together. It wasn’t always easy. One particular patient caused a tense but cordial debate between me and the clinical officer who was determined for me to drain the fluid out of a certain patient’s abdomen with a tap. I thought that this was dangerous and largely unnecessary but despite the protracted courtesies, neither of us would change our stance. The patient left of their own accord before the matter was settled.
Although the ward rounds were largely harmonious, turning the plan in the patient’s notes into action was a greater challenge. There was no formal ward list, no jobs list and a very casual system of delegation. Any tests had to be pushed-for relentlessly or done oneself. Furthermore any progress could hit a brick wall if the equipment or drugs were not available that day. Needles and gloves for example, were at a premium and guarded by the ward sister. Cost to patient was another common show-stopper. Save for critical emergencies, all equipment, medication and tests had to be paid for by the patient’s family who often would struggle with the bill. The ‘disappearing patient’ became an expected phenomenon. The tense, swollen belly of a patient with ‘nephrotic syndrome’, a fever who’s origin remained hidden from all tests or an HIV positive man stable but in a coma; we would ponder, discuss, research and plan, only to find another patient in their bed the next morning. It was hard to get a straight answer as to where they had gone. Whilst some had been taken to a bigger hospital, died or recovered, it is likely that many simply returned home when their families to fight their illness without our help.
We were doctors by day and mechanics by night. In our spare time we were had a lot of work to undo the ravages the journey had inflicted on our car. The first half of Africa, especially the endless rocks and corrugations of the Lake Turkana road, had shredded our tyres, and left our suspension a sorry state. We were also dripping from several points. We replaced a lesion of bushes, gaskets oils seals and wheel bearings, serviced the engine and installed new tubeless all-terrain tyres. The age of the puncture was over. Every morning, we would furiously scour our fingers to remove the oil, dirt and grease ready for the wards.
The case-load differed wildly from the UK. The prevalent infectious diseases which we became familiar with were once in a lifetime diagnoses back at home. Brucellosis, bilharzia, and typhoid were endemic, as were tuberculosis, syphilis and HIV in their countless manifestations. Sleeping sickness, virtually eradicated a decade ago had made a steady comeback owing to the fact that the expensive anti-microbial needed to treat it, became unprofitable to manufacture as the demand waned. At any one time, malaria took up a third of the beds. In fact, most unwell patients, no matter what their underlying diagnosis, probably had malaria compounding the problem.
Trauma cases were also very common and had the power to spring all staff into action. The majority came from the country’s primary road, which ran outside the hospital. Children were often the victims and whilst the hospital could manage simple fractures, we were limited beyond that. Once stable, we would try and refer these patients to Jinja, the nearest city, four hours away. This was usually a problem as the family were expected to pay for the ambulance. We had two paediatric head injuries in the space of a week. One had fallen from a mango tree, sustaining a deep depression skull fracture. He was conscious but with a weak leg, corresponding to the area of brain injury. The second was unconscious and seizuring, having been hit by a truck. Their right pupil was blown out; a bad sign. We controlled the seizures and the patient’s level of consciousness improved. We also managed to persuade the x- ray department to take a ‘trauma series’ free of charge (a set of x-rays surveying neck, ribs; pelvis etc). With both cases there was a long delay whilst the family dashed around borrowing money for an ambulance. Although the ambulance had been donated by the UK government, there were no funds available for diesel or a driver. Patients would sometimes decide to take crowded public transport instead.
The patients were, on average a much younger demographic then the U, if they could get good early management it was amazing how they could bounce back into good health. However they would only come in when they were really unwell. Severe malaria was often a positive example. Children especially would come in profoundly unwell. Fluids, Anti-malarials, antibiotics and not to forget glucose (malaria causes hypoglycaemia) and they could be sitting up and eating in a 24 hours. HIV patients were of course an exception to this; the end-stage of the disease being a slow loss of ground to recurrent infections.
As our time there lengthened, we learned how to play the game. Even in the hyper-systemised NHS, every hospital has its knacks, shortcuts and magic words; its go-to people, favours and trusted professional relationships. Iganga wasno different. A good example was with a man who was brought in unconscious, although breathing slowly and seemingly stable. The only other history we were able to illicit, was is his positive HIV status. We did what we could, but he needed referring. We had learned that research projects often funded patient treatment, so we made an urgent referral to the Cryptococcal Meningitis Research Programme in Kampala. He was accepted the following day as a possible diagnosis. Unfortunately we don’t know what happened after that.
Of course we didn’t spend all our time at work. Also in the hospital, we met Kat, a medical student from Boston who would often join us for a ward round and escape with us for coffee. In the Sol café, a bar popular with NGO workers and Peace Core volunteers we also met Keeley and Morgan, who were working on projects nearby. Together we began to plan a few trips away to see a bit of Uganda.
I was finishing a ward round with Rich and Kat one morning when I received a text message. It was from a Rwandan number I didn’t recognise. It read: