Pediatric Cases

I have been amazed at the variety of the patients in “Ward Pediatrie”. I love visiting the ward: Children are happy to chase bubbles and mothers display a tenderness that could be missed in other aspects of the culture as they care diligently for their children. However, it is equally overwhelming. The smells are powerful just like the suffering that seems even more heart-breaking in young children. Most are hospitalized for severe diarrhea, pneumonia, or malaria. But we’ve had several rare challenging cases that seem to epitomize the unique formula of African medicine. This does not even include all of them…

Many infants receive Oral Rehydration Solution (ORS) through a naso-gastic tube. ORS is a life-saver for children who can rapidly become dehydrated from diarrhea. It relies on Na-K pump in the GI tract which naturally absorbs the body’s requirements. In a third world setting without labs to measure electrolytes, this is more helpful than IVs requiring calculating electrolytes. It is also a fraction of the cost of IVs. The nasogastric tube ensures that the children get all they need even if the mothers can’t get them to drink it.

When a child is admitted, part of the hospital chart reads: “Grattage” checked OUI or NON. Grattage is a local practice of scrapping or cutting the throat. This tradition is based on the medical practices for diphtheria. Diptheria causes a grayish coating on the throat. Before vaccinations were routine, the disease was common and treated by health workers who would scrape the coating off. I wonder if this tradition also applies the belief in some parts of Africa that cutting an area of pain will “bleed out” the pain.

Now it is a problem because many children come to the hospital after their parents have (out of the best intentions) scrapped or cut the throat which can lead to infection. This child above had pneumonia and had his throat scraped. He is treated with Chloramphenicol. It is not used in the US much because of an extremely rare condition of aplastic anemia (although unlikely, just one case could ruin a career in the states with legal suits). In Africa it is utilized because the chance of aplastic anemia is less than the chance of ototoxicity or renal damage (which in not monitored as carefully here) by the other options: Gentamycin and Ampicillin. Also, cost is always an issue. One drug, Chloramphenicol, is less costly than using the combination of Gent and Amp.

Clarice Musawimana is 7 years old, but her 4 year-old brother has outgrown her. Along with the growth retardation her mother said she has had a chronic cough since she was 1 y.o. Through all the exams I only heard her cough once. At first we were worried about her heart. An echo showed that it could possibly be enlarged, but the interpretation is very subjective. She had no murmurs, rubs, or gallops, just a physiologic split with inspiration. After a day trip to the nearest town we had an X ray that showed a normal heart size. The X ray showed somewhat prominent hilar markings, but otherwise normal. Her lung sounds were clear on auscultation. Eventually we ruled out lung pathology. We worried about HIV, but she tested negative. TB was part of the diagnosis because of the delay in growth and cough. Her PPD was negative, and her three sputum collections showed no Acid-Fast Bacilli.

We moved on to other possibilities of growth retardation. Malaria is always on the differential here, and recurrent bouts could possibly cause growth delay. But her blood smear showed no malaria. An abnormal presentation of Cystic Fibrosis? No other symptoms were present, and there is no cure anyways especially in Africa. We brainstormed hematological causes and malnutrition, but nothing matched the history and symptoms. She came in with a slightly distended abdomen, so we treated for worms; and, after a week in the hospital waiting for tests, she was released with the worm drug that costs pennies. We concluded that some families have small and large children. Maybe she’s the oldest yet smallest and worms delayed her even more.

I loved this case. It was a privilege to work with Dr. Theoneste and Dr. King on it. Her case was such a great example of African medicine: always operating under a wide differential while you wait and wait for tests. Many tests are extremely costly and distant, so you must decide what you will do with the findings. TB, HIV, malaria, malnutrition, and parasites are always in the back of your mind—to treat, to rule out, or to finally accept as a most likely diagnosis.

This was a particularly tragic case to me. Maurice Maniragaba was a 14 y.o. boy. His family noticed his eyes were yellow in February. In May his body became swollen. He had some convulsions and was hospitalized in another district for three days. He came to Shyira in a coma and liver failure. His head was swollen from hepatic encephalopathy. His belly was swollen from ascities. His blood glucose was 25 mg/dL and I could smell ammonia as he breathed.

Most likely, he had an acute hepatitis that made his eyes jaundiced in February. After his release from the hospital his parents used local herbal remedies that are less expensive than medical care. We assume that these local herbs were toxic to his already damaged liver. I drained some fluid from his belly for testing and Dr. Theoneste did a lumbar puncture to make sure the coma was not from another infectious source. I did not see the results because he died before the morning.

This child is 15. His thin frame makes it unbelievable though. A basic test for malnutrition is arm circumference: your fingers should not be able to touch. He is an orphan. He has no farm or land to live on. His parent’s plot may have been taken over in the conflict after their death. He has been hanging around the hospital more since people are helping to take care of him.

See one, do one

Dr. Kohl and his students: two pre-med visitors touring the hospital and moi

One of the experiences I value the most from Shyira has been working in the OR. Dr. Kohl worked in surgery in Niger for three years, and he graciously taught me in the bleached surgery room of this rural Rwandan hospital. I have been able to watch/assist/perform tubal ligations, hysterectomies, hernia repair, a lymph node removal for biopsy, a circumcision, amputations, a skin graft, and C-sections.

Last week I watched Dr. Kohl do a finger amputation of a lady with leprosy. She had lost feeling in her hand, injured it, and it had gotten badly infected. So, when a man presented this week needing a finger amputation Dr. Kohl let me practice what I had seen. This man had an injury several years prior. His index finger had not been kept in extension while healing, and the tendons healed so that his finger was curled. He did not use it much, and when it became infected from a second injury he came to the hospital. After a week he agreed to have the procedure.

Before and After

Case: Osteomyelitis

Today I saw an operation for a skin graft on an 8 y.o. boy, one of my favorite patients at Shyira. He has a playful attitude, a beaming smile, and a limp. His right shin is wide open and has been for years. He has chronic osteomyelitis—infection of the bone.

Osteomyelitis usually infects the bone through 1)bacteria traveling through the blood that finds a home on the bone or 2)through a deep injury (or surgery) that gives the bacteria access to traumatized bone.

In America osteomyelitis is not common. Injection drug users and patients with intravenous catheters are two small groups at risk for bacteria introduced into the blood. However, after working in Uganda and Rwanda, I no longer consider it astonishing to see patients with deep wounds that will not heal, with infections that have persisted for years or children limping because osteomyelitis has kept their infected bone from growing.

Staphylococcus aureus is a bacteria that normally grows on our skin. The Kings have both commented that the Staph in Africa seems unusually vicious. Combined with the differences in sanitation, it causes problems. Just this week I’ve seen a liter in total of pus drained from patients coming in with abscesses caused by Staph. Two patients had fingers amputated that were taken over by the bacteria. It is also the most common cause of osteomyelitis. When in the blood it settles most commonly in the long bones or vertebral bodies. If untreated it can cause an avascular necrosis of bone. In children this is especially disastrous because it causes a stunt in their growth. Another mechanism is through a wound providing direct contact to the bone. If a wound is deep enough the bacteria can settle in the bone, so treatment requires surgical debridement and IV antibiotics. However not all patients in Africa will come in for cleaning of their wounds.

The small boy had skin grafted from his thigh to cover the gaping wound on his shin. With this and antibiotics hopefully his leg will heal and he won’t have to continue his childhood using a cane.

At the orthopedic hospital in Uganda many patients with osteomyelitis wore these devices to allow bones to regrow to normal length.

A patient's death....

Last night I walked to the hospital. Students in their uniforms were crowded around the windows of the hospital wards taking advantage of any escaping light to study for their exams. I was going to visit a critical patient. She had come in on the weekend with labored breathing. On my first time to examine her she was in the tripod position trying to get breath. Drops of sweat were beading on her face and she moaned with each movement. Her lungs were filled with fluid that also swelled in her legs and stretched the skin tight. Because of the fluid she could not lie down to sleep. This woman was on my mind, and I had asked Dr. Louise if she could get more Lasix. Louise said that if her systolic blood pressure was over 95, that I could give more if I wanted. My cuff was too big for her shrunken arm. The last reading from the afternoon was 100/80, and I asked the night guard to give it.

This woman was my age. She was HIV+ and her husband had left. She had two children and worked on their farm. Last year her CD4 count was 266 but she was lost to follow up and never was treated with ARVs. She had been coughing for three months. She came to the hospital because breathing had become painful.

Because of her history and the high incidence with AIDS, Tuberculosis with an effusion was at the top of the differential even though her PPD was negative: in immuno-suppressed patients there are many false negatives because it requires an immune response to show a positive result. Shyira has no Xray, but an exam was sufficient to realize there was a problem. On exam her lungs sounded crackly all over with expiratory wheezes. The oxygen saturation of her blood was 84%. Her lungs were dull to percussion because of the fluid. When fluid was drained it contained 1400 wbc/mm3. TB treatments were begun. Augmentin was added in case the pneumonia was bacterial. Bactrim was added in case the pneumonia was PCP, also common in HIV patients. There was likely cardiac involvement. I could hear an S3 gallop on auscultation. She had been given Lasix to remove the excess fluid and a blood transfusion when she became very anemic.

When I entered the ward this morning I noticed her bed was empty. The nurse noticed my gaze and told me, "The madame has died in the night."

I wonder how, in a hospital room that holds twenty beds side by side, how the death of one affects the others in the dark night. Does the room grow anxious as she cries? Do the others wake to offer condolences to the family staying with her? Do they mourn? Offer help? Or do they remain asleep...just like the rest of us.

Over two million people died of AIDS in sub-Saharan Africa last year. That was 72% of AIDS deaths in the whole world. I wonder what will happen to these countries laden with this burden of HIV. Will others offer help, money, interest? Will we stay comfortably asleep?

More on AIDS

Almost two thirds (63%) of all persons infected with HIV are living in sub-Saharan Africa. An estimated 2.8 million adults and children became infected with HIV in 2006, more than in all other regions of the world combined. (WHO/UNAIDS, 2006)

HIV and Tuberculosis, two modern day public health epidemics, seem to go hand in hand. M. tuberculosis infects a third of the world's population. 95% of TB cases and 98% of TB deaths are in developing countries. In 2000, Sub-Saharan Africa had the highest TB incidence rate. Of the TB deaths in 2000, 12% were attributable to HIV. By the end of 2000 about 11.5 million HIV-infected people worldwide were co-infected with M. tuberculosis. 70% of those were in Sub-Saharan Africa. (WHO, 2004)

It is difficult to miss the impact of HIV at Shyira hospital. A voluntary counseling and testing center sees patients (they encourage couples to come together) and guides them through the emotional process. Social workers screen to identify patients who can be compliant with the medications. I enjoy sitting in with Louise as she sees outpatients who are HIV+. They are given special files to keep a comprehensive record of their health. If their CD4 count is below 350 they are started on antiretroviral (ARV) drugs. Regimens are adapted based on if they are pregnant or have had reactions to certain drugs. Screening for TB is done before starting ARVs. If positive for TB, they are treated for TB first since treating simultaneously can cause an immune reconstitution syndrome. Patients with a CD4 count of less than 200 are started on Bactrim. This is prophylaxis against PCP (pneumonia) and, a more common complication in Africa, Toxoplasmosis. In an outpatient setting, HIV+ patients are seen for treatment. Many dermatological problems are manifest with the patients as well as normal complaints of cough, STDs, fungal infections and diarrhea. Some of the problems, like neuropathy, are a result of the medications, and changes are made in the ARVs.

The work at Shyira reflects a larger work especially strong in the countries of Botswana, Kenya, Malawi, Namibia, South Africa, Uganda, Rwanda and Zambia. Provision of antiretroviral therapy has expanded dramatically in sub-Saharan Africa: more than one million people were receiving antiretroviral treatment by June 2006, a tenfold increase since December 2003. However, the sheer scale of need in this region means that a little less than one quarter of the estimated 4.6 million people in need of antiretroviral therapy in this region are receiving it. (WHO/UNAIDS, 2006)

In Shyira, they are making plans to start a special home to give care and counseling to HIV patients who require a longer stay. We’ve had several patients wasting from AIDS who have been in the hospital as long as I’ve been here, so it the need is great. They have decided not to refer to it as a hospice home because the number of patients dying a long death from AIDS is decreasing as Rwanda is implementing such fervent ARV treatment.

This patient was at the hospital longer than I was! After waiting on results we found her CD4 count was > 350, and she had TB. She has started treatments and her son here stays at her side as her helper.

The woman on the right had a low CD4 count of 76. Fungus infections are common with immunosuppression, and she had a fungal infection of her ear, breast, and thighs. ARVs were started.

Heart Cases at Shyira

This week Dr. Caleb King had to take three pediatric patients to Kigali because of their heart conditions. Apolline is 13. On exam I heard a loud, grade VI systolic murmur radiating to her axilla. I could feel a palpable thrill on her chest. Dr. King took her and two equally impressive cases for an echocardiogram in Kigali and hopes of getting them onto a list of 30 cases that a visiting team of cardiologist surgeons will perform next April. The echocardiogram showed that Apolline had mitral stenosis, mitral regurge, and aortic stenosis. Her heart was enlarged from working so hard to keep up with the demand. She was also in atrial fibrillation most likely because of the extra volume of blood in the atria. She was put on diuretics and an ACE inhibitor to relieve the heart. She was put on digoxin to control the rate and anticoagulants to prevent her atrial fibrillation from throwing a clot into her lungs, brain, or elsewhere in the circulation.

While discharging her I looked over the cardiologist’s notes. He recommended an INR weekly to check her blood’s coagulation since she was on coumadin. I asked Caleb if they did that test here. They do not. But, like a true inventive African doctor, instead of accepting the lack of technology, he headed off to the lab. We discussed what an INR actually measures, then put a drop of his blood onto a slide and timed it to see how long it took to clot. While trying to think how to get a proper control, his wife Louise said, “Why don’t you just use her blood now before treatment as a control?” So thus was born a practical way to check her coumadin levels.

The three children all need cardiac surgery to survive. We hope they make it on the list, survive until the surgeons come, or someone with wealth decides to sponsor their trip to a generous hospital in the states. We assume that the damage to the mitral valve was from an untreated case of Strep throat that has caused rheumatic fever. It seems to me that the hardest part of medicine in Africa is not what you do with your hands, but having your hands tied so frequently…realizing what your facility cannot do.

Violence

My first live birth to see!

A patient with conjunctival hemorrhage

In both Uganda and Rwanda I’ve seen patients suffering from physical beatings. Several have had blows to the head resulting in conjunctival hemorrhages that look horrible, but as long as the vision is intact, they are nothing to worry about. In Uganda a man had been beaten by thugs on the street who stole his phone and money. Here a boy had been beaten and was in the hospital wondering who would pay since it wasn’t his fault for needing care. A boy came in yesterday needing stitches from being stoned.

Today we saw a woman with a displaced fracture of the ulna from domestic abuse. Dr. Kohl said he sees women often who have suffered from abuse from their spouse. In most abuse cases medical reports are filled out for the police, but in spousal abuse the cultural question is, “Well, what did the woman do wrong to deserve it?” Women have a difficult life here. They take on the responsibility of the children, cooking, cleaning and sometimes even a side job. They are “disciplined” like a child by their husband. It is culturally acceptable for husbands to beat them for whatever they do that does not please them. Drunkenness is very common for men in this area. Beautiful banana trees fill the fertile mountains offering a bounty for the malnurished, but half are used to make banana beer. It only makes the violence worse.

I watch these African women with such respect. They walk into the birthing room while in labor and situate themselves on the exam table. Without any pain medications or cries they silently clench their fists and give life. While we suction the newborn and tie off the cord she stands and wipes the blood off her legs with her own skirt. Barefoot, she makes her way down to her bed to nurse the new child. Their strength is nonchalant: it is how they handle all the hardships and injustices. This quiet perseverance begs no one’s pity. It is life and they do what they must.

Welcome to Shyira Operating Room!!

I'm writing this on my third day at Shyira--also my first time to see a tubal ligation, C-section, and eclamptic seizure (not just to see them, but to assist with them in surgery). Because of the high population density of Rwanda the government is working to educate people on methods of birth control. Today three tubal ligations and one viscectomy were scheduled (and the one scheduled for a vasectomy did not show up: I know what gender is the wimp in this culture!). I watched the second surgery, and then the doctor asked me to assist the third. I figure that this business will seem commonplace sooner or later. But, for now, I am still in awe that I dipped my hand into a woman's belly, found her uterus and plopped it onto her belly. I am completely amazed that I held a woman's ovaries in my hands today. The doctor told me to get started on suturing her up, then left the OR. I got a little shaky when the patient moaned and I realized I was alone--suturing a human abdomen together and not just a pig's foot like I've practiced on.

After lunch I got to see my first C-section. The P1G0 21 yo woman had been given oxytocin to initiate contractions at 9 am. At 1pm, her cervix was still only 3 cm dialated. Because of her active phase arrest, Dr. Kohl did a low segment transverse C-section. I got to be his first assist and close the incisions. It was quite an experience: In his German accent Dr. Kohl explained everything. "Dis is ze sfubcutaneouz fatz," he pointed out as he dug his hands in and ripped it from the fascia. He looked at me and said, "Now youtz. Rrrrip. Watchz carefully: you dzo ze next one." There was blood everywhere, a blue baby screaming, bloody rags being pulled from her peritoneum, and latrine smells wafting in. She had to recieve a transfusion because of the blood loss. I was stunned. I loved it.

An ambulance brought in the next patient. She looked to be at term and was seizing. Her BP was 160/90. The fetal HB could not be found with a fetoscope (old school here) or a doppler. They gave her MgSO4 and brought her into the OR. Three assistants held her down and monitored her BP and O2 saturation. She was unconscious so she was just given a local anethestic and a classical incision was done. I carried the blue baby to her chitange. While Dr. Kohl and I did the matress stitches, I wondered what she would think when she regained consciousness.

International Medicine at Shyira Hospital

I am working at Shyira hospital in the rural mountains of the north. When I arrived, I met the German OB doctor whose wife had been my contact through e-mail. The first thing he said was, "Good. I hear you are fluent in French." The national language is French, and all the hospital charts are in French. The people speak Kinyarwanda. The doctor I am working with is German. The culture is uniquely Rwandan. The pharmacy formulary is British. C'est facile, non?

Now I am working on a staff of two Rwandan doctors, two Congolese, one German, and two Americans on the way. My days include rounds in the maternity ward, pelvic exams, rounds in the internal medicine ward, visiting the lab to see stool samples infected with parasites, ect. And I've added French lessons at night to help with my "fluency" from high school classes.

More on Shyira's website: www.shyira.org

Rwanda in BRIEF

Most African tribes are known by their unique traits. The Rwandans have been known for their distrustful nature for generations. In this 'land of a thousand hills' there is less of a community feel since farms and families are separated by the dramatically hilly landscapes. Rwanda was colonized by Belgium. They brought the French language, European culture, churches, and a status symbol separating the two main tribes of Rwanda. They favored the tall Tutsi tribe with the better jobs than the Hutu tribe. Eventually independence came and a Hutu was elected president. Years of racism culminated in hate propaganda; and when the president was assassinated, Hutus joined together using it as an excuse to begin killings against the formerly favored tribe. In 1994 Rwandan Hutus killed eight hundred thousand Tutsis in one hundred days.

Almost one million. Hard to comprehend? Annie Dillard puts it in perspective: Just imagine yourself, in all your uniqueness, individuality and passion, and multiply it by 800,000. Easy, huh?

Rwanda now struggles to overcome the genocide. Memorials are throughout the countryside: Churches with bullet-holes preserve the stories of mass killings that happened in places people gathered for safety. People throughout the misty hills suffer with nightmares. From where I sit and type I can see soldiers posted to march around this area and make their presence known to the Interhamwe that hides in the Congo and hopes to return.

Gachachas are haphazard courts in an attempt for justice from a time when neighbor killed neighbor. Yesterday one met outside of the Shyira primary school. It's one's word against another, and with the Rwandese's history of mistrust it breeds paranoia. One member of the church has gone missing. People say he's innocent, but people also say his brother is innocent and he has been imprisoned for 13 years because of someone's accusation. He is fearing the same.

There is hope for the Rwandans. Progress is also visible in this country. Despite the corruption of many East African countries, Rwanda's government is very active and not corrupt.
Many NGO's have a strong presence in the country. In Rwanda, one day a month is 'community day' for projects. There is no trash and no street food. In the capital city of Kigali flip flops, spitting, and bota bikes are outlawed. It almost doesn't feel like Africa seeing a goverment so involved. I can tell it will be a pleasure to live in this unique place.

Left over Case from Uganda: Peptic Ulcer Disease

Grace is an orphan from Burundi living as a refugee in Kampala. She attends the life care women's group and since she has no family, another Burudian couple treats her as their own.

We got a call that Grace was in the hospital. She had suffered from ulcers and GERD in the past. Ellen tried to keep her supplied with proton pump inhibitors, but for Africans it's not an easy concept to take medicine even when you don't feel bad, so it had been a while since she'd taken the medicine. She was low on money, so she wasn't eating. This exacerbated the ulcers, and she ended up in the hospital. When I visited they had done tests to rule out malaria, typhoid, and HIV--common causes in Africa for general malaise and vomiting. She was recieving a PPI, Cipro, and worm treatment. Her nail beds were extremely pale, so I asked about her getting iron. They said, "It's not so bad," as they pointed to her hemoglobin result of eight. She was in extreme pain, but it seemed to be somatic. Perietal signs were negative with no guarding or tenderness to palpation. Psoas and obturator signs were negative.

The ultrasound showed a normal liver, spleen, and bladder, but they had reported fibroids in the uterus. She seemed to be having an extreme exacerbation of her peptic ulcers most likely with blood loss that caused her anemia and fatigue. However, all that was reported to her was this foreign word: fibroids. We got to explain to her that they were very common in women (even more so in black women) and they were not the cause of her pain. She is 27 and still wants to have children so it was a relief to her that she would not have to have a hysterectomy to cure this epigastic pain she was experiencing. Now Ellen is seeing that she stays well supplied on PPIs and Iron.

I included this entry for several reasons. First, to show an example of lack of resources as a cause of health problems. We can educate about eating right, but some don't have the money to do so. Second, I want to have an example of how patient education is lacking. Because they did not explain fibroids, Grace was under the impression she needed a surgery to remove her uterus. She figured that fibroids were causing her pain. She was at the mercy of the doctors but without being educated herself to realize her fibroids are a benign finding. I feel that health education is a major goal to keep the people empowered over their own health. It was a good lesson that anywhere people deserve to know about their bodies, their test results, and prevention.

ode to Kampala

i'm leaving the city by bus for Rwanda and my next clinical rotation. It's very hard to leave. I "feel free" in this place thanks to the community that has welcomed me. These last few days I've carried my camera around everywhere trying to steal pieces of this place. Now, I'll write in an attempt to share the life of this place with you.

The streets of Kampala are so alive: they are the climax of a live symphony. third world style. Men pushing wheel barrows brimming with colorful fruit compete with diesel trucks for space, and rivers of motorcycles flow through any room that's left on the road. The bota-bota motorcycles carry women side-saddle, little children wearing bright school uniforms, and even wooden bed frames that tower several feet above the driver's head. Horns blare and merchants approach moving vehicles in the lively chaos.

In the morning I ride a bota to the top of Nairembe hill. I can taste dust in my mouth--the same dust that coats the old buildings along the street. They look like they have risen up from being buried alive. The lines of drying clothes give the dingy buildings the color that they have lacked since the colonialists painted them years ago. From the top of the hill I hear the call to prayer from the mosque as I look out at the hills arising from the city below. Seven of the mounds are the hills of the city and the rest are stacked clouds of the morning haze filling in the valleys. Two million lives arise to collide in the small spaces of the city. I was one of them.

The nights are warm and lively. Merchants light their crowded wooden dukas with oil lanterns and candles. Away from the city the loud sound of crickets takes over the honking. From Ellen's house I can hear the brassy sound of the neighbor's radio. It's playing Ugandan hits that repeat and repeat a simple reggae beat.

I enter the Better Living Resource Center just off the main road. On the couches on the porch I am greeted by whatever regulars are around for the day. This place is home to a multi-generational group that has been a powerful example of community. Students are scattered around utilizing the library or reading the newspaper. Rebekah, who most people refer to as their "auntie", cooks lunch everyday using fresh garlic and ginger root: I'm still not tired of her beans and rice even though I eat it five days out of the week. Moses and Able live in a small closet behind the center. They talk to me about music, culture, and help out with whatever we're doing for the day. Seth is a goofy artist who loves children. His art is up around the office, and he hangs around to take me to a near-by orphanage on my day off. He has dreams to open his own. There is a group of girls in their twenties who show up for choir practice and then take me out dancing with them. They are amazing girls, and I'm so proud of how hard they work. Teddy comes from the royal family of Tutsi in Rwanda. Before the kingship was abolished her father was carried around on men's backs. Fred is an evangelist at the church. He comes with his niece Rachel who is in his care because the African concept of responsibility to family reaches beyond the immediate family, and his sister has put him in charge of one of her children. Fred knows a great deal about the cultures and history of Uganda. He has taught me a lot. A women's refugee group has meetings at the center. I will sing with them before they come to the clinic on Saturday. I have gotten to know many of them from staying in their homes, buying their jewelery, and visiting them in the hospital. They have unbelievable survivor stories and I admire them.

I could go on....Issac, Able, Josesph, Maggie, Sheba... but this may be more detail than one cares to read about. The point is that this rotation has been a treasured experience in family medicine: All my patients have become like family. I know them and their stories. Most of them I have seen many times--in and out of clinic. We play football together, I see them at church on Sunday, I eat lunch with them, dance, we practice singing together, I love their children, I admire their perseverance. It has been a joy to work at this community center.

Culture

Last week at the craft market I had a long conversation with a vendor from Ethiopia. When I mentioned I liked Ethiopian food, she invited me to her home for dinner. Ellen and Fred accompanied me. I was amazed at their hospitality and their rich culture. As the Ethiopians recount, their Queen Sheba visited King Soloman and came back to her country pregnant. The royal line in Ethiopia claims its present lineage from the descendent of Soloman. The people have a distinctive look among Africans from their Semitic heritage.

Yorda and her sisters performed a traditional Ethiopian coffee ceremony in the specific coffee ceremony dress. It is a cornerstone of the culture. Coffee was discovered in Ethiopia, and in the ancient ceremony the green beans are roasted above coals and crushed with a wooden mortar and pestle. Incense was burning but the rich smell of the fresh beans was overwhelming it. They added water to a wooden urn and then poured it into small ceramic cups. They told us that when you have your friends over for a ceremony, you keep filling the urn with water until there are no more grinds left. They were enthusiastic hosts. On the way home Ellen and I were discussing what a privilege it had been, and she said, "Imagine leaving your home from war. You're in a foreign country and culture. I think they can relate to us more than the Ugandans who feel at home here. They must appreciate an eager audience to hear about the land they are missing."

For dinner we had njera and dorowat (my favorite!). The njera is made from a type of grain indigenous only to Ethiopia. It is a foamy bread that is used like a spoon to wrap up the spicy meat and sauce. After dinner they put on Ethiopian music videos and taught Ellen and I how to do their traditional dances. The music videos were hilarious: women badly lipsinking while cutting onions and making food with interspersed clips of dancing. We were given wraps that they use during the dances. The girls were amazing: they move their shoulders up and down, back and forth so fast while their head stays perfectly still.

One Sunday night we got to see a dancing troupe. They performed dances that are each unique to a Ugandan tribe. I am in awe of all these traditions and rich culture. I watch all their dances and costumes totally amazed, and can't help but feel that in comparison my own culture seems lame.

I feel like one of my best gifts here is to complement their culture and show interest, especially since so many colonists have treated Africans as inferior in the past. On my last day, some Ugandans presented me with a musical finger harp. They said they chose it because they saw how much I loved their music and how I loved to dance. What a complement.

Lost in Translation: Ft. Portal clinics

We just finished our clinics in the Western part of Uganda near Fort Portal. The village was nestled in between bright green tea fields by the Rwenzori mountains that form a barrier from the neighboring Congo.

In a small village, a mzungu (meaning white man, literally "running around fast") clinic is kind of like a circus coming to town. Fortunately, there were less life-threatening cases here. These complaints were my favorite:

"I'm having trouble yawning"
"My legs are jiggly" (which she demonstrated)
A man walks in, sits down, and says,"My legs are paralyzed."

In this area witchcraft is more prevalent. Many time, especially at night, when someone whistles at another person they are casting a curse on them. So it was not taken well when one of the Americans, trying to get the crowds' attention, whistled loudly with her teeth in her mouth. Hahah. It definately got everyone's attention.

Gross Diseases

One of our favorite diseases to talk about here (especially with visitors) is the Mango worm. Although it sounds like a joke, this worm burrows into clothes and sheets while they are drying outside. It then burrows into the skin and develops into an itching welt. It grows inside the skin to produce young. The innovative treatment sounds even more like a joke: it is to lay a piece of bacon across the welt. The worm burrows into the bacon fat and can be peeled out. Avoidance includes using a dryer or an iron on laundry to kill the eggs instead of air drying. On our rural clinics we've been staying at local places, and last night Dr. Hall realized what he thought was a mosquito bite was a Mango worm. We had to inject lidocaine because it was itching so bad it kept him from sleeping. I'm not sure if he'll get on the airplane with a piece of bacon wrapped around his elbow or just use some scotch tape. I was going to enter it into Typhon for documentation for school, but I can't find the ICD code for Mango worm or "Bacon placement".

Many of my patients over the last few days have "worms" as their complaint. They feel itchy and attribute it to worms. Others have a sore throat and attribute it to worms crawling up. Basically my patients over the last few days have attributed almost any symptom to worms. I try to get more information on treating their symptoms because often it's from another cause. But while I'm on the subject of tropical diseases I'll write some on Ascaris, the most common parasite here. Ascaris, hookworm, is a result of infected stools making their way to water or food and are ingested by humans. When they enter the blood stream they hatch and can cause general itching. The young worms travel to the lungs and can sometimes cause cough while the worms crawls up through the windpipe, slide down into the esophagus, and feast in the intestine.
Roundworms in the intestines can cause indegestion, discomfort, and weakness from the anemia from blood-loss. On rare, but memorable, occasion the worms can come out of the stools or crawl out through the mouth or nose. One 400mg tablet of Albendazole kills the worms. These were handed out to most patients.

Case: Chronic Renal Failure

I took note of a strange-looking little girl who entered the Resource Center while I was helping out with the dental clinics. Later we saw her in clinic. Her beautiful face looked large in comparison to her body that came just above my knee when she stood. Ellen introduced Ester as an 18-year-old. Across the table I noticed her small arms were shaped like the letter "s", bent and curved in all directions. Her legs were bowed and she could not support herself to walk. She was mentally alert and the Catholic Father that brought her told us she was top in her class. She is sponsored by a church off Tramway in Albuquerque where he will visit soon (small world!).

Esther was a stunning example of how kidney failure effects the whole body, and how much permenent damage can be prevented with proper treatment and dialysis. Her mother gave the history that she got sick in 2nd grade, "got puffy", and her bones became disfigured. Most likely, the infection in 2nd grade was followed by a glomerulonephritis, nephrotic syndrome, and now she has chronic renal failure. The kidney plays a role in making vitamin D to help absorb calcium. Without the kidneys she did not have bone growth, especially in the long bones. She also showed signs of anemia: pale conjunctiva and nail beds. Erythropoetin is a hormone made by the kidneys that signals growth of red blood cells; and, without the hormone her bone marrow does not produce enough red blood cells. In America, she would have been treated with vit D, erythropoetin and a kidney transplant. However, she has just recently come under the care of Ellen. With a consult from a nephrologist in the states, she gave Calcium and vit D supplements, Fe and folate supplements, and protein supplements. We sent her to a lab for an Ultrasound and a Voiding Cystourethrogram to determine the next steps.

Village clinics in Jinja

Thyroid goiter

I am writing this on the way back from our three days in the villages around Jinja doing medical clinics. I feel sympathetic to the poor New Orleans dikes that had to hold back the waves of Hurricane Katrina. The villagers flooded the clinics. It was a wonderful experience to see patients on my own, to learn to diagnose with only a history and physical, and to get better at intercultural interviewing. However, I was also overwhelmed, even to tears, at the pressure to treat correctly with a limited and confusing history, no lab, and in too much of a frenzy to get a complete consult from another doctor esp. since I'm still a student. For example, in my first hour a woman I saw complained of "fever in her stomach". With the help of a translator I found out it had been there for more than a week. The rest of the details are a blur to me now. I remember her shaking and moaning when I touched her stomach. Her BP was high, and when I wanted to auscultate her lungs, she could not breathe deep enough because of the pain. Was it PID? Pylonephritis? Ruptured ectopic pregnancy? Appendicitis? Diverticulitis? .....??? All I could do was a urine dip. I told her to get to a hospital in case it was serious. We made arrangements with the family. I felt safe giving this advice until I talked to Ellen. She said the hospitals sometimes don't even have medicine needed and the doctors are poorly trained. We sent her with a course of Cipro in case the hospital had nothing better. I felt sick myself, but the line was backed up, so I helplessly continued. I remembered my frustration when our ill students in Kenya would come back from the clinic with a shotty diagnosis and only painkillers. I was afraid to become the same, but with limited supplies, time, and technology I felt helpless. Helpless:again, a step closer to how one must feel in this village overlooked by the corrupt government and without the education to be empowered with knowledge.

On the busiest day, in the village plagued with malaria, the three doctors and I saw almost 400 patients. This is not a bragging right. It is a horrible way to do medicine, but my only condolence is that is more than they will usually get, which is next to nothing. We treated many children with malaria; we treated pneumonia, gave iron and folate to pregnant women, as much education as possible, H2 blockers for "ulcers" (GERD), painkillers to old men stiff from years of hard work, cream for yeast infections ect.

My translator was a 19 year old girl who is in university in Kenya at Baraton. This is 30 km from Mariann school! She knew of my school and all the Kenyan dishes I'd enjoyed. We got along really well and even more so after figuring out all we had in common. I got to do health education for her, and she was great at relating it to the patients.

As we were preparing to leave the final day, I saw a mother and her sick child. I think I gave the mother medicine for her allergic rhinitis. Her boy was less than a year old, tachypnenic, and looked like he was sleeping. She told me that he was suffering fever, blood in the stools and blood in the urine. I asked a few questions and felt over my head. I told her to wait as I asked the other doctors to take care of it. We ended up gathering some money and sending him to the hospital. The conjunctiva of his eye was white. Dr. Hall, who worked here for six years, explained to me later that this is a common presentation for dying children in the area. Children and pregnant women are already low on iron as their blood supplies are pressed to keep up the body. Meat is the main source of iron, and it is in low supply in the village. Also many take tea, which has phytates that bind iron in the intestine so it is not absorbed. Worms steal blood as they suck the intestines, and they are common in Africa. With one bout of malaria which bursts red blood cells a child is thrust into an anemic state. They increase their breathing to get the oxygen they need, but with so few red blood cells it is almost futile. Without enough oxygen to the brain they slip into a coma. Dr. Hall guessed our little patient had a hemoglobin of 3 or less. He needed a blood transfusion, and Dr. Hall guessed that he had a 50/50 chance of living based on his condition and the probability of the hospital having a blood supply. I asked him about the blood in the urine and stool. He assumed it was Disseminated Intravascular Coaggulation. The strain of malaria named Falciparum (95% of what's found here) causes the red blood cells to be bumpy and stick. This causes clotting, and the DIC could have resulted from that and spilled blood into the urine and stool.

The last we heard he'd been accepted at the hospital, recieved blood, and was beginning malaria treatments.

This is me trying to sound like an expert.... (without spellcheck)

A worker bends down under an open window. She comes up, hits her head, and exclaims, "The window hit me!". A worker pumping gasoline tries to pump to the roundest number. He is afraid to go over the amount handed to him, shrugs, and says, "It has refused". A villager is lacking a health clinic and good road. They say, "The money: it has refused us."

A Westerner would lable this "fatalism". We would put the blame on the person. "I hit my head", "I can't pump it more", "We can't get funding"....

In America we feel we control our fate. We're told we can accomplish whatever we put our mind to, and we believe it. We think the answer to the Africans' problems will begin when they take control.

Maybe I would agree until I remember the feeling of living in Kenya. My mindset was molded by having no control. We'd plan our trip into town for supplies, but we were at the mercy of taxi's. Would they pass, would they have room, would they get a flat tire? We realized that we had changed while in line in Nairobi. All the Westerners were complaining, questioning, and trying to get their documents quicker. We waited. Just a few months had taught us that in Africa, that's all you can do.

So I can understand how one becomes fatalistic. Without any way to get a job one has to rely on "sponsors" from rich countries to send $100 for children's school fees. Without a reliable government one just has to learn to be complacent with no roads or clean water. Without any means of getting a "second opinion" one has to be content with medical treatment that isn't even working. While in wealthy America, if we do everything in our power to be healthy and still get cancer: "it isn't FAIR". We search for blame, for a cure, for anything to feel in power.

Other countries have recognised the poverty of Africa. Many dollars are sent here to the governments. Corrupt governments officials take the money as their own, and the villages still wait because "the money has refused them". The gifts are beautiful sacrifices, but do they feed the feeling of dependency?

So what's the answer? I don't know. I don't think the answer is to make the whole world mzungus (white people). I believe some of the solution will involve empowerment.

I have been privaleged to hear from Dr. Mark Hall here on the medical mission. He worked for six years in Jinja, mostly doing basic health training in the villages. He recognized that building a hospital is sexy and Western, but is more like opening a candy shop in a land suffering from famine. For every life saved in a hospital, 100 people die in the villages from simple diseases. I've heard the stat that every 5 seconds a child dies in third world countries from treatable diseases. Dr. Hall recognized how many lives could be saved if the people could recognize dehydration and make Oral Rehydration Solution, if people could recognize malaria before a child is severely anemic and go for treatment, if people could understand nutrition--and all of this in a culturally appropriate and understandable way--hundreds could be saved. Prevention is about as glamourous. Neither are unknown grass-roots project with no website OR huge numbers to boast. The safari ants over here are not very glamorous either, but they drive entire households from buildings.

Case: Long Term Effects of Polio

A 27 yo Congolese refugee and member of the church often comes to the clinic to translate for us. He uses braces and crutches to walk and wears a shoe fitted for the difference in his legs'

lengths. Today he came for himself. We were not overwhelmed with patients, so Ellen suggested I take a full history.

This man got polio at the age of six. Since then he relied on braces and corsets to get around. I had to admit that I did not know much about the pathology of polio--only that it was a routine vaccination now.

He suffers from effects of post-polio. It is really a shame to see a man in such pain from a disease that is preventable. Polio effects the upper motor neurons, and now he still has fasiculations (muscle twitching) and abnormal joints because of a mismatch in his extensors and flexor muscles with one being tightened (much like in cerebral palsy) he has joint pain. Ellen keeps him supplied with painkillers that help and we sent him for muscle relaxants.

My latest African Slumber Party

On one of my first days at the clinic I met a Rwandan refugee woman who showed me around the area. I believe that staying in someones home is the best way to really get to know a place, so I told her I wanted to come stay with her. In Africa, hospitality is great honor: families consider guests a gift from God. So, I didn't feel like I was imposing.

So last night I stayed with her and her children Dear, Lucky, Winner, and Joy. She had just been "chased" from her last house because she could not pay. I was with them on their first night in their new place. I honestly don't know how she survives. It is so hard to find work in Kampala that she is unemployed just looking for odd jobs to support her family. She is completely reliant on others' generosity for school fees for her kids and places to stay.

While we were waiting for her daughter to go get some charcoal for a fire I asked her about her home. She is Tutsi and married a Hutu man before the genocide. She could not stand the hate in Rwanda, and so after her husband disappeared she brought her family to Kampala. I love talking to her because she is able to see past the hate that many cling to after such a war. She told me that when her children ask about the war, she only tells them political reasons. She said that she will not place blame on any tribe and cause them to hold hate in their heart. She told me that we should love everyone--that tribe doesn't matter, but she explained that although she tries to love everyone she cannot trust everyone. Because her children are "mixed" (Hutu and Tutsi) she explained that many people hate them. Because she is Tutsi but married a Hutu she felt, and still feels, hate from both tribes. As she told me more about her experience in Rwanda and people who have helped her here, she continued to remind me that these are secret things. She does not even want other members of the church to know because she cannot trust them. She feels they still have resentment to her heritage.

It is such a privilege to meet people like Pascasie. Rwanda is certainly not the only place with tribal hate and prejudices. Around the world people identify with what they are familiar with and hate what they do not know, even building a hierarchy based on tribe and color. However, this beautiful lady from such a violent background realizes that hate and blame is not the answer. She chooses to love, and is raising her children to do the same.

She braided my hair for me. It took 12 hours, so we got good bonding time. I was able to pay her a good price, and I think when I leave I may try to use some of the donation money to give her another month's rent. Thanks again for the donations. Some have asked about leaving some: just see my first post.

Donation

Thanks to all who contributed funds!! While in Sang'alo, about $400 was left to Arap Chumba: this was our "Kenyan father". He was a neighbor and management of the school. He has 11 children and works as a sustinence farmer. Three of his girls were in 8th grade when we taught at the school. He had sold some of his land and even some of his cows to pay for them to continue their education, but he does not have enough to pay for two of them. When he found out he was getting help he was so happy. Joseph Kitur, another member of the managment, told me that Chumba has been not even been sleeping lately because he does not know what else to do to get money for school fees. His daughter Clara was one of our favorite students. Last year she was third in a class of 176 students. This family is very deserving of any help!

Another $400 was donated to the school's orphan fund that enables 12 students a year to attend who are missing parents. The funds were running short, so this was a great start.

If you'd like to donate more, there are always needs. Please contact me at thisiserika@gmail.com and I can let you know ways to wire the money there.

Thanks again! Kongoi missing! Asanti sana!

Back to Sang'alo

In 2005 I got to teach at Mariann Primary School in a small village: Sang'alo, Kenya. While Ellen took a trip to visit the churches in Gulu, Uganda, she set me loose to go back and visit and see any patients there. Going back brought so many wonderful memories to mind. I got in around 8 pm. As I walked to a classroom, I heard an expectant gasp from inside where they saw my headlamp. I opened the door, and there was the 2nd grade class that I used to teach P.E. They all jumped up screaming, "Erika"! They ran over to encircle me and we just jumped up and down and up and down before I could think to formally greet them.

Living in this village was not an act of sacrifice or being a saint: it was a privaledge. The Nandi people are truly the most hospitable people on the planet. They took us in as their own. They are unpretentious, hard-working, farming country-folk who display the most heart-felt hospitality I've ever experienced. I consider myself fortunate to have part of my life invested here, and plan to visit again and again. During this visit I really did not have a free moment: as soon as I visited one family, another family invited me over for the next meal.


The students are so hard-working. School is a privilege that the families sacrifice to pay for as well as their only way out of poverty. These are girls from the class I taught English, CRE, Science, and nutrition to. I had made up songs about nutrition, AIDS, and a drama about the prodigal son. They preformed them for me!!!


For about $10 I got a bulk supply of Albendazole, a de-worming tablet. Studies have shown that students in Africa who take this pill have significantly more growth and better school performance than students who don't. I got to play Doctor and de-worm the whole school. After explaining to the classes what it was they all started cheering, especially the part when I mentioned better test scores. Even the teachers were excited: many telling me they had never been de-wormed before.

This is Standard 8. They will sit for the exams this year that will determine if they can go on in their schooling. I'm so proud of them: They are so bright!!! I got to teach them some "medical lessons". They asked questions like, "If I mostly eat Ugali and Sukuma (greens) why is my blood the color red when I cut myself?" They asked about Diabetes and Heart Attacks and could keep up with all my explanations.

Night in the Museum

Our afternoon clinic patients did not show up, so I went to the Uganda Museum with Fred, a “cultural expert” from the church. It was very interesting to learn about all the tribes and the changes that have come so rapidly since the first British explorers in the 1850’s. I could have spent days in there.

The picture is of a knife used to do a C-section in 1879. Eleven days after the surgery the patient had completely recovered.

Orthopedic Hospital

Today we went to the Cheshire Orthopedic Hospital. It was a great experience. The hospital treats children from all over the country with congenital malformations including club foot, cleft lip, cleft palate. They also do physical therapy for these patients and also patients with cerebral palsy. Many children were happily running around with crutches and devices on their legs that are helping their bones heal (usually from osteomyelitis rotting away part of the bones) to a normal length. Ellen sees patients there once a month to give pediatric advice and treat any other problems. It is a great facility: normally a malformation in Africa means that you will be doomed to be a beggar the rest of your life. Many beggars on the street have malformed limbs, cannot get around easily, and are dismissed by their families as a curse. So, it is amazing that this place can offer healing to many malformations that are totally treatable. The stay is usually a long one since the patients receive physical therapy, and families come stay with them. There is a farm and garden that the families can work on to help “pay their stay” and keep all the guests fed.

After a quick tour of the workshop for making casts and walkers and braces we greeted the children. Then we saw some very interesting cases. The first child was 7 months old and had hydrocephalus. A doctor noticed his large head circumference a few weeks after his birth and he was sent to the country’s hospital. However the hospital was backed up and he did not receive treatment for months. Finally a shunt was installed to drain his CSF from being clogged in the brain to his stomach area. When we saw the boy he was comatose and would not follow our fingers with his eyes. He also had a hydrocele (a descended bag of fluid into the scrotum). So I preformed my first real testicular exam on a comatose infant--not a bad way to start! It is a tragedy that brain damage has occurred because the hospital was not able to treat him in time.

The second child really shocked me: the 2 month old baby boy was less than 4 pounds!!! The mother unwrapped this tiny creature that only had one finger on each hand and whose arms were kept retracted because of radial malformation. He was very pale, and Ellen ordered a CBC because she suspected pancytopenia. It is most likely that the mother had syphilis, toxoplasmosis, or rubella early in the pregnancy that effected his growth. The hands are formed by the 8^th week, so her infection was probably before she really knew she was pregnant. We ordered a VDRL on the mother. Syphilis is very common here.

We also saw a boy with cranisynathosis. He had an “egg shaped” head because his skull bones had fused and his brain could not grow with his body. He obviously had brain damage because he was mostly unresponsive. The mother had abandoned the boy, and now the grandmother was taking care of him. This is common in Africa: when a child has disabilities it is considered a curse and a drain on the family’s resources. The local “euthanasia” includes locking the child in a home and leaving until he dies, abandoning him in the street, or anywhere else. Grandparents are put in the role of the family provider if they have the heart to take care of these children. Many grandparents have to adopt the role of taking care of all the children when the parents die of AIDS. There is a neurology hospital in Mbale (where Mrs. Chechanowitz will work), but they would not take on the case. The child was already five months, and even with the surgery he had irreversible brain damage.

The time there was very touching. Despite the sad conditions of some of our cases, it was encouraging to see all the children getting treatment. If not for this hospital children all over the country would lack the attention to overcome their conditions.

A typical day

(Ellen's home)

Ellen lives on a hill several miles from the middle of the city. It is a nice home with running water and electricity half the time--a lot nicer than we were used to in Kenya. Traffic in Kampala is crazy, so it takes a while to get to the “Better Living Resource Center” which was set up by the church in Kampala. Behind the grounds is a crate that’s been converted into a clinic. Medical records consist of a notecard with a name, estimated date of birth, the date they are seen and what they are treated for. Documentation is obviously not as big of a deal. Ellen makes the diagnosis mostly by taking a thorough history and basic exams. Her drug cabinet is mostly antibiotics, pain killers, asthma medicine, antifungals, anti-malaria meds, antacids and vitamins and ect. Our special tests include urine dips, using a fetoscope for pregnant women, and, well, that's about it. We have to refer out for malaria blood smears, X-rays, ect. Drugs are given out without payment to those she sees. It seems that many are lost in the shuffle. Even though the hospitals are apparently free, patients are often pushed for a bribe (because the government doctors don't get paid by the government and have to get money from bribes) or get lost in the shuffle. One patient from the village had osteomyelitis for 15 years. He had a gaping wound and come to Kampala for treatment. Ellen has referred him to the hospital repeatedly because it now requires amputation; however, we’re not sure why he hasn’t gone yet.

Most patients are members of the church. There is a large refugee population. I thought it was interesting that she also had a stock of antidepressants. Many refugees have been through so much trauma that they suffer Post-traumatic Stress Syndrome. Ellen gets them involved in the church’s bible study groups, and amytriptilene has a sedative side effect so it helps them get some sleep.

Patients are seen daily, with Ellen’s only day off on Monday. A lot of time is also spent ordering medicines and taking care of church business—and answering all my questions! I come home and do a lot of reading. Ellen has a small library of books on infectious diseases that I pour through. My favorite one is the book on African dermatology. I fall asleep looking at pictures of nasty skin lesions. I miss visiting homes, so at least once a week I try to stay the night with someone from the church. This past Monday I had a really good time staying with some girls who live in a nice slum near the clinic. They took me to a "Gospel Club" where we got to do some dancing. They were great and I can't imagine coming here without experiences like those.

Tomorrow we'll visit an Orthopedic hospital, one of the odd jobs for Ellen. Then, in about a week, two doctors and some others from Texas are coming for a medical mission in the Jinja and Ft. Portal areas. Patients will walk miles to be seen and spend the whole day waiting. We will see as many patients a day as possible. Today was spent getting medicines, going over the formulary, and getting acquainted with the African names of antibiotics.

This weekend Ellen is going with a team to do a survey of the north for a church plant, so I’ll take off to visit my old school in Kenya and do lectures and give out medicines there. I was able to purchase a stockpile to take them for only 20 USD. Visiting my old students and home will the highlight of my stay here.

African medicine

I thought this was a good example of how medicine works different here:

Yesterday we saw a 40 yo Somali man. He had urinary urgency. We tested his urine which only showed a very high specific gravity, which is normal for Africans who have chronic dehydration. We encouraged him to drink more water, but clean water costs money, so simply education does not solve the problem. With the differential, we figured the most likely cause was Benign Prostatic Hypertrophy. In America you would consider prostate CA in your differential, but it would be no use to test for it here because even if he did have it, nowhere in the country would treat him for that, even in here in the capitol city, and at 40 he is considered to have lived a full life. We did not do a rectal exam. Even though this wpuld have been good medicine, a Somali man would not culturally accept two women sticking their fingers up his butt.

We did not have an alpha-blocker to treat his condition, but we did have an old Tricyclic Antidepressant that has a side effect of urinary retention. So we gave him this and if it works, he can come back for more.