During my residency, I participated in the Yale/Johnson & Johnson Physician Scholars in International Health Program, through which I spent six weeks rotating through Mulago Hospital in Uganda — and what I saw has forever shaped my perspective as a clinician.
Situated within the capital of Kampala, Mulago Hospital was founded in 1913 by a medical missionary, Sir Albert Cook to treat venereal diseases and sleeping sickness. Today, the hospital is a 1,500-bed facility that attends to 120,000 inpatients and 480,000 outpatients annually.
On my first day there, I saw more than 60 of the 70 patients on the neurology ward. Some were in beds, others between two beds, and even under the beds. The patients — all awaiting or actively receiving care —had cryptococcal meningitis, tuberculous meningitis, cerebral malaria, CNS toxoplasmosis, new onset seizures, neuropathy secondary to leprosy, cerebellitis, and ischemic stroke.
On round, patient presentations would occur at each bedside, starting with the chief complaint and a history of present illness that included occupation, village of residence, and clan affiliation.
Unless proven otherwise, cerebral malaria seemed to be the most common diagnosis — covering patients with new onset seizures associated with headache and double vision in someone with ISS (Immune Suppression syndrome) —the name given to HIV/AIDS — as well as those with lethargy and a blood smear positive for Plasmodium vivax.
After each presentation, much time was spent asking patients if they had enough money for medication and investigations. Nearly 85 percent of health care expenses throughout Africa are paid “out-of-pocket” since few people have private insurance and there is little or no social insurance on the continent.
Every patient coming to Mulago Hospital receives a free complete blood count, erythrocyte sedimentation rate, ISS testing, and a chest x-ray. There is also no charge for such procedures as a lumbar puncture. Some patients had enough money to afford other laboratory tests or even a brain CT scan (costs $100 US) or an EEG ($7 US). Patients who can't afford the service would either petition the hospital to pay a lower amount for further testing or would be discharged. The plan for the day would be shared with the patient, but also with their attendants.
The average nursing ratio on the neurology ward ranged from one nurse to every 20–25 patients. Because of this, attendants or women who accompanied the patient from their home village provide most care — dispensing medication, bathing and grooming their clansmen, and oftentimes returning to their village to raise money for proposed studies.
Once a plan was agreed upon, an intern would then draw blood or start an intravenous line while an attendant took a prescription to the pharmacy to be filled. Since nearly half of patients admitted carried a tentative diagnosis of meningitis, lumbar punctures are frequently performed on the ward. When one is needed, another intern will take the patient into a “procedure room,” where a nurse assists with the lumbar puncture. Patients are sterilized prior to the procedure. Localized analgesia is seldom available, whereas systemic analgesia is variably given. Lumbar puncture needles were not available while I was there; instead, large bore intravenous needles are used to collect CSF. Lumbar punctures are always performed prior to head CT, even on the multitudes of patients with ISS.
Attendants are often available to lend support to patients during the procedure. As you can imagine, the procedure is seldom well tolerated. When attendants report back to the families and friends of patients, this is often relayed to them. In the community, there is a belief that if you go to Mulago Hospital with a seizure, you will receive a lumbar puncture and die. Many patients do die several days after receiving a lumbar puncture, more so from the natural history of their primary neurologic problem, like cryptococcal meningitis, rather than from iatrogenic complications. Nonetheless, the fear of dying after a lumbar puncture often delays the patient from seeking medical attention sooner.
Rounds may last for several hours, partly because of the volume of patients and lack of sufficient ancillary staff. The country has very little in terms of neurologic specialty care. There is one neurologist for every three million people in Africa; Uganda fares slightly better with six neurologists for its 27 million inhabitants. Mulago Hospital has one neurologist on staff, with most neurologic care done by internists interested in neurology.
Mulago Hospital also houses one of the nation's two CT machines and one of the four EEG machines, which was under repair during my time there. Few nurses and fewer neurologic drugs are available. At times, people can afford these medications; most of the time, they cannot. The availability of medication within the hospital is a moot point for some, since upwards of 75 percent of the population lives in rural areas with little or no access to transportation.
The distribution of very limited resources by few physicians and nurses to patients capable of journeying to Mulago Hospital is challenging. Becoming more aware of the circumstance in which they practice medicine better enabled me to find how I could best help them. By teaching their physicians more about the diagnosis and management of neurological illness, I enhanced their ability to care for their current and future patients.
My experience in Uganda was enlightening. I had an opportunity to see and make diagnoses I have only read about while learning about the hurdles of another health care system. For those who are able to participate in an international neurology experience, your time and effort will be worthwhile; not only will you improve your own fund of knowledge and clinical acumen, you will help a country in need of your expertise. •