Student Blog

 Yssra Soliman, MSII: 

Dr. Superwoman and Superman  

July 19, 2015  

Dr. Superwoman  

  As soon as I walked into the cath lab, I knew this unit was going to be different. Everything was organized, clean, modern like any of the finest hospitals around the world. The nurses and the physicians seemed to work together like a well-oiled rig. The spirit of camaraderie was almost overwhelming. The environment was nearly stress free and all of the patients in the waiting area seemed comfortable, confident that they were in good hands. It reminded me so much of the hepatology unit. The nurse let me into the meeting room to wait for the head of the department, Dr HH. I had heard so much about her during my time in the rheumatic clinic. She seemed very well respected and loved by both patients and physicians. At the same time, the physicians knew that she was very strict when it came to caring for patients. She tolerated very little in terms of error. They told me that she had single-handedly changed the pediatric cardiology department when she became the head of the department. University hospitals receive very little funding from the government here. Thus, they strongly rely on private donations. Each resident at the hospital has a sum of donations that he or she can use to help any patient who they believe truly cannot make ends meet on their own. For example, the funds can be used to purchase formula for a baby or a medication if it is not available in the free pharmacy at the hospital. Dr. HH had done much more than just secure a few private donations. She had secured massive amounts of funding and grants for her department and changed over much of the equipment including ultrasound machines, cath lab equipment, and computer systems. While I was waiting for Dr. HH, I imagined her as an older, more formal physician. I was far from right. Dr. HH was a middle-aged physician who quickly took my hand and gave me a huge hug. “I’ve been expecting you all week” she said grinning from ear to ear. She was perfectly put together in pink scrubs yet exuded so much confidence and grace. It was incredible to see a female cardiologist leading the most prestigious pediatric cardiology unit in the country. Everyone seemed thrilled to have her arrive, we could now get to work. We had several cases lined up for the day including several congenital heart defects including patent ductus arteriousus (PDAs) and a few diagnostic procedures. Dr. HH took the time to examine each patient herself with sonography before procedures. Then, she went over all of their records in full detail and sat down and explained the case to each parent. In the OR, everything was held to the most professional of standards. Dr. HH made sure we were all 100% correctly scrubbed in and that the environment was kept sterile. She constantly reiterated the importance of infection control, something that is often overlooked here. Even more, she constantly checked my understanding as well as the residents. She would say “okay kids, does that make sense.” She effortlessly combined the roles of a physician, caretaker, mentor, and colleague into one. All with a smile on her face. In her pink scrubs, Dr. HH is truly superwoman to her staff, residents and patients.

Superman 

 Today was the last day of work before the Eid holiday. Thursdays are pacemaker day in the pediatric cardiology department and the procedures are done by Dr. W. Our patient was a one year old, 5 kilogram female with multiple congenital heart problems and our goal was to insert an endocardial pacemaker which would control her heart rate instead of her sinoatrial node. The procedure had a rather bumpy start. There was trouble blindly inserting the leads via the subclavian to be threaded to the right atrium. Dr. W and his resident then tried to insert via the femoral. At that point, they found that the patient had an interrupted IVC that was not included in the report from a procedure previously done at another institution. They hoped that this detail was just overlooked by the other cardiologists and that otherwise the procedure had been done successfully. We resorted to the subclavian again and the resident was successful this time. After that, the procedure went flawlessly and our young patient was able to leave with a brand new pacemaker inserted. Dr. W is the only pediatric cardiologist in the country who can perform this procedure solo. In fact, he brought this procedure to the country and currently has three trainees. The neighboring university hospital can only insert these pacemakers in children over 20 kilograms. Dr. W explained to me that in the United States our patient would have most likely received an epicardial pacemaker. Epicardial pacemakers last one to two years while an endocardial pacemaker can last five years. In the United States, the epicardial type is preferred because they worry about blocked veins that can result with the endocardial pacemakers. However, when Dr. W first started doing the procedure in Egypt, patents were dying. This is because if one has to come back to the university hospital every year or two, it is nearly impossible to get an appointment. Dr. W simply does not have enough time to handle this huge patient flow on his own. Thus, he resorted to inserting endocardial pacemakers for the sake of helping as many patients as possible. In fact, since he started, he has only had one blocked vein complication during an endocardial pacemaker procedure. He explained to me that even in that situation, the patient was already very sick and the pacemaker was a final try to save his life. I was intrigued by Dr. W and started asking him about his education and training. Dr. W told me that after finishing medical school he became frustrated by the lack of resources. He wanted to be the best physician possible and to improve the health of his community. He started looking to the United States and Europe for further training. After taking the US boards more than once, he couldn’t match into an American residency. He simply did not have enough experience at that time. Disappointed but still determined he looked to Europe. Dr. W became board certified in pediatrics and a member of the Royal College of Physicians. After his huge success, Dr. W was offered a fellowship in electrophysiology back in the States. He told me that he felt it was a dream come true. But at that point, he had realized that what was needed in Egypt was not what he would gain with the fellowship. He traveled to France and Turkey to learn how to insert pacemakers. He said “At that point in my life, I felt that this is what children needed the most here. They would die otherwise.” And indeed, Dr. W became an expert in his field and has single-handedly improved the lives of so many children in the country. On his own, he inserts more pacemakers annually than almost any other physician around the world. At the same time. Dr. W is a university professor who spends much of his time teaching medical students, grading exams, and assigning grades as required by the university. Even more, he has his own general pediatrics clinic in order to have a reasonable income. Dr. W could have taken that fellowship and left for a more comfortable life in the United States. Dr. W could have stayed in Europe. Dr. W could have chosen any residency in Egypt. But he did not do any of that. He looked around his community and tried to see what was needed most. He always kept the patients in the back of his mind and became the best physician possible for them. Today, Dr. W is saving the lives of more children than superman himself.

What to Eat?  

July 25, 2015  

  

I had never heard of a malnutrition clinic until starting my internship and I was very excited to see what types of patients and cases we would receive. The clinic runs five days a week from 9 AM to noon but more realistically until all the patients had been seen. Our patients were either referred to us by another service such as general pediatrics or the parents felt that their child was too short, too thin, etc. With my assigned physician, we saw nearly 70 patients which the doctor said was still less than the normal flow. Here is a snapshot of a typical case that we would see: The patient is an 18 month old boy who is underweight for his age. He is still being breast fed and eats only chips and some rice The mother cannot stop breast feeding him because he refuses most solid foods. The doctor prescribed calcium and iron supplements as well medication (neodigestine) to promote proper digestion. He asked the mother to come back after 3 months. ———

The patient is a 9 month old male who weighs seven kilos. When he was 1 month old, his mother reports that he weighed five kilos. She is understandably worried that her son is quite underweight. She says that he will only eat a little yogurt and rice most days. He does not crawl yet and cannot stand on his own. The doctor recommended that he eat lots of cheese, yogurt, fruits, vegetables, and protein. Interestingly, he told the mother to stay away from “water of rice.” It is custom in some families to feed children the water left over from boiled rice. White rice and bread are staple foods here and most patients believe that they are the source of a healthy diet. Thus, they believe that the rice water is good for their growing children. In fact, this starchy water can cause the children to feel overly full and refuse other sources of food. Furthermore, the physician recommended 15 minutes in the sun every day between the hours of 8 and 10 AM to increase levels of active vitamin D. Finally he prescribed iron and calcium supplements to be given two hours apart. He told the family to come back in a few weeks for a follow-up. I also found it interesting that several parents brought their children in because their hair was not thick enough. In Middle Eastern society, long, thick, silky hair is a significant determinant of beauty. However, I did not realize that it could be a major concern for such a young age group. In fact, several patients had traveled to the hospital from far out areas to complain that their family believed their daughter’s hair was too thin. One young girl even had some spots on her skin that were troubling to us but less troubling to her mother. The physician referred the young girl to dermatology because he suspected that the girl could have scabies. But the thin hair was more troublesome to the mother. I think this situation showed how deeply cultural norms can interact with medicine.

 OBGYN 

 August 1, 2015 

 During the last two weeks of my internship, I decided to rotate through adult medicine services. This meant that I would be at the main hospital campus about two blocks down from the pediatric hospital. My first assignment was OBGYN. This summer I realized that I really liked procedures and I wanted to be in a specialty that was part medical and part surgical. Although the medical aspect of OBGYN was fascinating, I think it was the social aspect of the field that was even more intriguing to me. On my first day I was assigned to a gynecology clinic. I was working under a resident, Dr. A. I thought it was really interesting that the majority of the doctors I had seen in the unit were male. Egypt is a predominantly conservative society where many are observant Muslims or Coptic Christians. In our area, there was Dr. A and Dr. F, a female physician. A few of the patients who came in said that they only wanted to see a female doctor. But the nurses would say, we don’t have enough doctors today, there is only Dr. A and Dr. F. But Dr. A’s personality and patient interaction caused every patient to see past the fact that he was male. We saw an enormous volume of patients that day and not a single patient refused being seen by Dr. A. He spoke with a huge smile on his face, was calm and extremely respectful of every patient. This sounds much easier than it is. We saw patients in a tiny, stuffy clinic office crowded with dozens of patients and staff with a huge line of patients waiting outside the door. The first question the doctor would ask is “Are you an ‘anissa’ or ‘madame’?” One is an anissa if they are unmarried and a madame if they are married. With this question comes the assumption that you have not had sex if you are not married. Coming from a western society, I felt that this assumption was not a safe one to make. Pre-marital sex is religiously forbidden and socially unacceptable. Even more, it would be very difficult for the patient to admit such a private matter to a physician with tons of house officers and medical students crowding next to them and with patients and nurses within earshot. Also, on one’s personal ID, it lists their marital status and religious identity. I asked one of the house officers attending the clinic about what would happen if a physician realized that their unmarried patient was sexually active. The house officer replied that the physician would try his or her best to cover it up because the family would most likely cause huge problems in the hospital or could even harm the daughter. If the patient was accompanied by a parent, the doctor might have the parent wait outside the room while they discussed matters privately. It was even more interesting to me that during the week I spent in OBGYN, the word ‘sex’ was never used with patients. Instead, the Arabic word for relationship was used instead. Culture and religion are truly intertwined with medicine here. Although today was the gynecology clinic, we had a few patients coming in for infertility issues and I saw them with Dr. A. One patient was 22 years old and had been married for three years and never pregnant. To test for fertility problems, she had done hormonal tests and her husband had done exams to test for sperm quality. Her tests came out normal. However, the husband was found to have low sperm count (12 million with 15-30 million being normal) and abnormal sperm forms. The next step for the couple would be to try in vitro fertilization (IVF).   The patient told us that her husband won’t believe that “the problem is him and not her.” In fact, he had his sister come to the clinic with his wife to double check herself. The husband told his wife that he had taken his lab results to a pharmacist and the pharmacist said that he was more than fine. The physician told the patient that although the pharmacist has the degree of a doctor, he is not a qualified physician nor should he have made such a call. He said to the wife “when you’re married, there’s two people. It doesn’t matter who has a “problem” because in the end you are a team. Infertility is like any other illness and it is nothing to be ashamed of. We’re going to try everything to help you have a baby.” These words seemed to lift a little bit of weight off the patient’s shoulders who had been carrying around the burden of guilt and shame for several years. Throughout the week, I attended clinic, rounded on patients and was in the casualties OR. I saw some incredibly interesting cases from a 20 cm ovarian cyst to fibroid tumors to Gartner duct cysts, etc. I also found the high rate of intrauterine device (IUD) usage to be interesting. I volunteered at my school’s free clinic during first year and we were given information packets on IUDs to discuss with our patients. It didn’t seem to be something that the majority used or knew a lot about. I asked the resident why it’s such a common method of contraception here. He told me that the reason is mostly two fold. The first reason is that patients don’t have enough education nor understanding of oral contraceptives. They find that most of their patients are non-compliant with birth control. It is difficult for their patients to take their pills at the proper time every day. The second reason is that there is a misconception that birth control will make women gain significant weight. However, the doctor explained, most only gain two to three kilograms over five years on average, which they might gain on their own even without the birth control. Later that week, Dr. A’s ward was assigned to casualties. Basically, there are 6 OBGYN wards and each day one of them runs the OBGYN emergency room. They rotate which ward is assigned on Friday’s, the official weekend day. In the ER, we see patients who come in for natural vaginal births, c-sections and of course emergency cases. Our day was going really well until a shocked patient was frantically wheeled into the c-section OR. A house officer was taking her blood pressure downstairs when he realized she was in extreme shock. The patient had an unavoidable abortion earlier at 24 weeks. The patient was scheduled for a manual placenta separation but she had gone into shock before that. She had a history of three pregnancies that were unfortunately not carried to term. When she came up to the OR, anesthesiology immediately tried hanging colloid IV solution. The patient need O positive blood but, again, there was none available at the hospital. Still, we couldn't get her blood pressure to read and the anesthesiologists had the house officer and I try to hold the patient down as they hung more fluids. We were anticipating the patient arresting at any second. I asked the OBGYN standing next to us if we could try giving her adrenaline (epinephrine). She said “yes, that’s going to be the next step.” A few minutes later, the patient arrested. The anesthesiologist handed me the IV fluids and instructed me to alter the dials on and off to control the flow while they pushed epinephrine and administered CPR. At that point, we thought we had lost the patient but after half an hour she miraculously came back. We couldn’t have been happier in those moments. The OBGYN team was going to go ahead and manually separate the rest of the placenta now. However, they had the patient’s husband and son go to the local blood banks to find O positive blood just in case.. When we finally got to closing the bikini line incision, the resident asked me if I had ever done sutures before. I told him that I had practiced on a cadaver in anatomy and a little bit in plastics that week. He told me to watch closely as he closed and that I would be the judge of his suturing. Indeed, his sutures were those that the finest plastic surgeon would be proud of. I was allowed the final touch, tying off Dr. A’s incredible sutures. Right as we were taking our gloves off, a resident burst through the OR and called Dr. A into the neighboring OR. The patient we had seen earlier had gone into disseminated intravascular coagulation (DIC) and irreversible shock. The patient had bled out a lot in the time we were in the OR and her blood looked almost like watermelon juice. Dr. A tried to stop the bleeding but we all knew that it was too late. The feeling of defeat, frustration and pure sadness filled the OR. There was nothing else we could do for her now. Just a little over an hour ago, she had come back with a miracle but the miracle was too short lived. I had been at the hospital for over 16 hours at that point and it was time to go home. The house officers and I went to change, our shoulders slumped with defeat. As I was leaving, I recognized one of the house officers running from the other side of the hospital with bags of blood in his hand. He had finally found our patient O positive blood, but he didn’t know it was too late. If only we had that blood an hour ago, if only. But, I suppose this is the reality in most medical fields. Some days you win, some days you don’t. Maybe the trick is to be grateful for our wins and to make sure we learn from our losses. But it’s easier said than done because some days even a miracle isn’t enough.

Plastics  

August 6, 2015  

The second adult medicine specialty that I rotated through was plastic surgery. One of the house officers that I had met during pediatrics was now on their service and was having a great experience. I would be lying if I said I didn’t have my own biases concerning plastics. But I’m really glad that I ignored that and chose to rotate throughout this specialty. It was truly one of the most memorable experiences of the summer. On my first day, I saw an eight hour long hairy nevus procedure and was allowed to scrub in. The patient was 21 years old and going to be married in the next year. She had lots of hair from her lower backside to her upper thighs. Understandably, she did not feel comfortable with the hair and decided to have it removed. At first, I didn’t understand why “hair removal” required such an extensive procedure. However, it turns out the hairy nevus is actually pre-malignant and needs to be completely removed. The surgeons had previously inserted four extenders (2 large and 2 small) under each side of the patient’s skin. The extenders were under her backside, where the skin was normal. The extenders are like plastic bags full of water. The idea is that we can extend the normal skin, remove the pre-malignant skin and use the normal skin as a sort of flap to cover. The process sounds much easier than it was. Each side of the patient’s body took over four hours. When we starting suturing the new skin, I realized there was so much of the hairy nevus left. In fact, we had only replaced inches of the old skin. The doctor explained to me that this surgery needed to be repeated several times before the hairy nevus could be totally removed. That means several more rounds of plastic bags extending the skin and several more grueling eight hour surgeries. After the senior surgeons finished, the residents were left to close. Until then, I had been retracting, holding flaps of skin down, etc. However, Dr. K let me help him as he closed on his side. First, we placed two drains on each side of the patient, near the groin area. The doctor let me tie off the knots that would hold these drains in place. Then, the sutures we used to close the external skin were called “vertical mattress sutures”. Dr. K explained that you take the needle “far far and then near near.” Dr. K asked me if I wanted to do some of the sutures. I told him that I had practiced on my anatomy cadaver and that my anatomy cadaver might be less upset with my sutures than this patient. Dr. K laughed and said “okay, fine, we’ll teach on some of extra flaps of skin.” Honestly, it was just as exciting for me to snip off the extra pieces of prolene. After Dr. K was nearly done, he asked the senior resident to check his progress. She looked over and said “K, they’re awful.” I held my breath. I was waiting for Dr. K to be offended, irritated after all the work he had done. We had spent nearly 45 minutes now on these sutures. But, I could see a genuine smile under that mask. Dr. K said “No problem doctor.” We snipped out all the sutures and started over. I was amazed. For Dr. K, a plastic surgeon, to be so good natured about this criticism says volumes about his character. Plastic surgeons are thought to be meticulous, perfectionists, proud of their work, etc. But Dr. K could have been nothing but humble for him to accept this criticism so naturally and easily. Also throughout the week, I realized that Dr. K cared much less about himself and much more about how happy he could make his patients when the anesthesia wore off. If I can accept criticism like Dr. K, with complete grace, ease and humility, I think I will be a much better physician and person. And just like that, all my previous conceptions about plastics were shattered in a single day. On another day, I attended a hand surgery. The patient had injured her pinky finger and as a result a tendon was torn. Today, we were going to take another tendon from the forearm and insert it into the flexor side of the patient’s finger. The surgeons chose palmaris longus. Palmaris longus is a tendon that is absent in about 15% of people. In the United States, hand surgery is a very specialized and prestigious field. One must first complete a residency in plastics, orthopedics or general surgery before completing a fellowship in hand surgery. In Egypt, there aren’t established fellowships. Hand surgeries are done by plastic surgeons. During the surgery, the surgeons were having difficulty picking out palmaris from the other tendons in the forearm. One even asked if we had a certain tendon on the palmar side of our hand, flexor digit minimi. I was shocked that they had opened the patient’s hand and forearm so confidently without being confident of the anatomy. I offered to look it up on my phone. I quickly googled the flexor tendons of the hand and forearm. The surgeons confirmed that they had found the right tendon. They snipped palmaris longus and wove it interosseously through the distal phalange of the pinky finger. The rest of the surgery went flawlessly. But still, I was amazed at the event from earlier. But my surprise was two parts. On one hand I was shocked that they had opened up a patient without having a solid plan or knowing the anatomy completely. But I was amazed that they were so experienced that they could figure it out as they went along. To an extent, I guess this is how it has to be when a surgeon is responsible for so much. In plastics, they do hand surgeries, cosmetic, reconstructive, burns, grafts, removal of malignancies, etc. It is much harder to be an expert in one thing here. Also, I think this is a quality all surgeons will have to an extent no matter where they train. It is hard to know 100% what you are working with until you open up the patient. I think one of the reasons I loved plastics so much was because I was able to see completely different surgeries all in one day. It was never boring here. As I was talking to a house officer, we realized that as patients, we would rather have specialized surgeons. Nonetheless, these plastics surgeons are incredible, intelligent, the brightest of their class. It takes truly unique skills and confidence to be able to trouble shoot and problem solve so well in the OR. Throughout the week, I saw the widest range of surgeries. I saw everything from a squamous cell carcinoma removal to rhinoplasties to abdominoplasty/liposuction to burn and grafts. I thought it was really interesting that cosmetic surgery was being done at this public university hospital. I decided to ask Dr. K about it. He said that indeed these cosmetic surgeries were still completely free for patients. The only thing a patient would pay for would be implants in a breast augmentation. Also, if there were any medications or tools that were missing in the hospital and needed for the surgery, the patient would have to buy that as well. Again, I was really surprised. I told Dr. K “We have such little resources here as it is. Do you think it is right that we are using them for cosmetic purposes?” Dr. K said “Doctor, everyone knows that nose jobs are more important than open heart surgeries.” I laughed and asked if he was joking. But no, Dr. K was completely serious. He believed that the positive psychological effect that a nose job could have was even more significant than its cardiothoracic counterpart. Over the week, I had cultivated a good relationship with Dr. K so I felt comfortable prodding him with more questions. I asked him what types of procedures were his favorite. He replied that it was easily cosmetic surgeries. Dr. K said “Do I have to operate on a dying patient to be a good and important doctor? I don’t think so. Nothing makes me happier than seeing my patients truly happy. After their surgery, when they look in the mirror and I see true happiness and confidence in their eyes, that’s when I feel that I have made the biggest difference.” It was a new perspective for me, but I understood where he was coming from. It was also incredible that this department gives even the poorest patients the chance to look the way they want to look. I ended my shift feeling differently about nose jobs. They say that one of the factors you should consider when choosing a residency is the type of people you are going to be working with. Will your personality jive with theirs? I think if I was an Egyptian medical student, my heart would have been set on plastics. Their easy going, warm personalities were everything that I didn’t associate with surgery. The OR isn’t a cold, stressful environment here. We end our days being pushed around on a gurney by the scrub nurse while taking selfies to document the memories. Plastics  was an incredible experience for me. If I can have as much humility as Dr. K, the quick mind of Dr. A and the warm personality of Dr. S, I will be a better physician regardless of the field. Plastics changed my perspective on surgery and the OR. It taught me to have an open mind as I go forward.

The Good and the Bad  

 August 5, 2015 

 Medicine is a hard field to go into anywhere, but I think it might be even a little harder here. So, I asked a few physicians about the good and the bad.

Dr. E

Q: What is the hardest part of being an Egyptian doctor?

A: Doctors are paid very little here. Ten years ago, when I was a resident, I was paid 240 pounds a month (today 1USD is equal to about 7.8 EGP). That is less than a sanitation worker makes. Also, the medical system is very disorganized. There are no review boards and as a result no consequences. Finally, I feel that there is very little support for physicians here.

 Q: What is there best thing about being an Egyptian doctor?

A: There is a spirit here that you can’t find anywhere else. We are a very family oriented society and that translates into every part of our lives. We see family in our patients, colleagues and staff. Also, doctors do enjoy a certain amount of prestige here.

Q: Why did you choose medicine?

A: In any other field, you work with what man has made. But in medicine, you work with what God has made. There is no higher privilege.

 Dr. H

Q: What is the hardest part of being a physician?

 A: There is stress in dealing with the lives of others. Many times complications are unavoidable and it is frustrating when you lose a patient or can no longer help them.

Q: What is the best part of being a physician?

A: When you feel that you’ve actually done a service to someone else. When you know that you have truly helped someone. When you see these children get better.

 Final Reflections 

  August 10, 2015   

I am back in NY and writing this post from my apartment. I put off writing this post a little bit because I wanted to process as many of my thoughts from this summer as possible. Since I’ve been back, people have been asking me about my summer. This summer has been the most incredible experience for me in so many ways. I am Egyptian-American and grew up spending many summers in Egypt. I got my tonsils removed in Egypt at a young age and needed stitches after a game of tag went awry. So, I have had exposure to healthcare in the country. But of course, it was nothing like being at a public university hospital. I think I need to explain a few things. During my grandparent’s time, this university hospital was not just one of the most prestigious in the region, but in the world. Older physicians at the hospital told me stories of how physicians from all over Europe sought to train in this hospital. Egypt was renowned for producing some of the most brilliant physicians in the world such as Dr. Magdy Yacoub, a famed cardiothoracic surgeon (seriously, look him up). But with political turmoil and a steep decline in the economy, the quality of healthcare went down as well. Today, there is a lot of corruption in the country. The funds that the university hospitals and medical schools receive from the government are completely out of proportion to the huge volume of patients that they treat. This is not to say that every hospital in Egypt is like this. During Ramadan, nearly half of the commercials on TV were to raise money for a cancer or heart disease hospital in Egypt. If you were to set foot into one of these cancer hospitals in Egypt, you would be amazed at how beautiful, clean and modern it is. Some of these hospitals make American hospitals look average by comparison. Even more, many of these hospitals do offer free, comprehensive healthcare. But the problem is twofold as I have been told. First, university hospitals don’t have the funds to pay for such advertising as do the private hospitals. Second, cancer and the heart are “attractive” to the general population. On the other hand, hepatitis C, parasitic infections and diabetes are not. Instead, the university hospitals run on many small private donations. On several occasions, one of the nurses would pass out 100EGP to each mother in the waiting room per the wishes of a donor. Also, each resident carries an amount of donations in their pocket to help out any patient who cannot afford to buy a medication from an outside pharmacy or cannot afford the bus home. No act of kindness is small and I think that they make this place truly special. However, I still hope that soon these public hospitals will receive more aid from the government because millions of people rely on them. On many days, I would go home and rant about something that had happened. But the next day, I would wake up and do it all over again. There was something that kept me going back even on my off days. There was something that would make me work a full day, come home to eat dinner and then work a night shift. I think that behind all the missed diagnoses and blood shortages, there really is something good here. This hospital is the only sure source of healthcare for millions of people in Egypt. Most patients have been referred here by the hospital in their city or village. “Go to X hospital, they’ll know how to take care of you.” Also, interns and residents make pennies and visiting residents even pay the institution for three years instead of being paid a salary. Yet, I have seen these doctors pour their own money into helping their patients. I have seen interns fundraising for their patients on their personal Facebook pages. I have seen physicians going to the pharmacy and buying medications for their patients. I have seen senior physicians going back to the wards to spend time with a patient’s family after working 15 hours non-stop. These doctors have shown me advocacy, compassion and healing in its rawest form.

About the doctors  

I rotated through many, many services this summer. I have interacted with dozens of physicians from house officer to chairmen of the hospital. Yet, I have never felt so welcomed before. After every, “Hi, My name is __, I am an MS2 at ___” came the warmest welcomes I have ever felt. The doctors went out of their way to teach and show me everything possible. In the malnutrition clinic, the physician allowed me to ask the questions and suggest the treatment needed to the patients. In tropical medicine, I was asked to come up with an extensive list of foods that contain gluten and then educate patients on a proper diet for Celiac’s disease. But, I also spent hours getting to know these physicians on a personal level. They have shown me the greatest hospitality as we broke our fast together many nights during Ramadan. I was able to get to know several physicians on a personal level and be inspired by their accomplishments and goals. I will miss the hours we spent in the blood bank telling jokes while the blood was being processed. When the ER was overwhelming, working with the house officers made it a little more sane and I became good friends with many of them. Overall, the physicians here have been the most incredible mentors, colleagues and friends to me. There really is a spirit here that I have never felt before. One’s family and social life are truly valued. A physician told me that you see family in the people you interact with here, and he was right. These doctors really did become a family to me this summer. I think one of the greatest privileges of being a physician is being part of an incredible medical community. This summer I realized that my medical community doesn’t stop in the states. My medical community goes as far as Egypt.

About Patients  

This summer I saw so many rare medical cases that I may never even see again such as Crigler-Najjar syndrome, Epidermolysis bullosa and Alagille syndrome. I feel forever indebted to these patients who allowed me examine them. I feel even more indebted to these patients who told me about their journeys, about their disease, how it has impacted them and how it has changed their lives. I saw thousands of patients this summer but I remember many of their names and faces vividly. I think each patient I saw changed me a little bit. They planted another seed of motivation in me. I know that my second year of medical school is going to be a tough year. But I hope that whenever I doubt myself, I can remember my patients. I want to be the best advocate, healer and role model for these patients and my patients in the future. Unfortunately, this summer I experienced what it means to lose a patient. In fact, we lost three. I remember I couldn’t move the first time a resident said “that’s it, we can’t do anymore.” I remember the screams of a mother as she picked up her deceased son under her scarf so that she can get to her village before sundown and bury her child. I remember the look of defeat on everyone’s face when we couldn’t save our OBGYN patient. I think many of us go into medicine thinking of all the lives we are going to save. But rarely do we think about all the lives we can’t save. When something is important to me, I find it really hard to give up on it. The words “there’s nothing more we can do” were hard for me to accept. As a future physician, I think this something that I will have to work on. I learned that when those words were uttered, it was time to focus on the family because there is more we can do for them. I learned that it is important to learn to cope with grief and loss. You can’t help your patients if you’re not doing so well yourself. And as the summer went on, I think I got a little better at it.

About Myself  

I learned a lot of things about myself this summer. Honestly, I was bit reluctant to write this blog. I knew that I would see a lot of good and not so good things at the hospital. I feared that I would come off as too judgmental or letting certain events blind me from all the good that happens in the hospital. It is also hard for me to criticize the place that my parent’s grew up in. I have a sense of loyalty and love for this place. But I think that being committed to this blog forced me to be as neutral as possible. It also provided me with a venue to think critically and process my experiences.  Before starting this internship, I was unsure of the medical field I wished to pursue but I was very interested in pediatrics. This summer, I did CPR on a patient who had arrested, gave my first injection, learned how to hang blood, palpated an enormous amount of livers, did an ultrasound, learned the vertical mattress stitch, assisted in surgery, spent days watching endoscopies and much more. For the first time, I realized that I enjoyed procedures. I was happy doing things with my hands even if it was just hanging a bag of blood. At the same time, I enjoy taking patient histories and deciphering labs. Furthermore, as I rotated through many specialties, I realized that there is nothing that I actually disliked. I realized that I like medicine in its many different forms. On my days off, I would find myself going to the hospital because I enjoyed being around my patients and working with the medical team. What I love the most about medicine is that we are given the privilege of making someone’s life even a little bit better. This is going to be true no matter what field I choose to go into. As a second year who still isn’t completely set on a specialty, this is very comforting to me.

 I cannot say thank you enough to my mentors, colleagues and patients at the hospital and back home in the States who helped me put this experience together. This summer has opened my eyes to many things while continuously reaffirming my love for medicine. I hope that I have the opportunity to volunteer at this hospital as a future physician and to mentor another medical student the way I have been so generously mentored. The lives of my patients and the inspiration of my doctors are all the motivation I need to become the best physician I can be. This summer has been life-changing and I feel truly lucky to have experienced it. Thank you to everyone who made it possible.

 The anesthesiologist and I went back to the surgery as the nephrologists began the perfusion process. Initially, it seemed as if the kidney had triple arteries. But during perfusion, it turned out that there were two renal arteries and a vein. Although this was still a medical anomaly, the senior surgeon reassured everyone that he had been forced to anastomose five renal arteries before and this shouldn’t be any more difficult. He was right and the rest of the surgery went very well. Even with all the complications that had arisen, the entire medical team was ecstatic that the surgery was overall successful. We all hoped that our patients would be better off after the surgery than before. I was able to see the patients to post-op and spend some time with the donor’s mother before heading out for the day. She couldn’t be happier that she was going to be able to spend more time with her daughter at home and less time in the hospital. I left for the day and came back the next morning to check on both the father and daughter. Except for some pain, the daughter was doing very well. There was usually someone from the nephrology staff checking on her, bringing her toys or even reading her stories. Two floors up, the father’s blood pressure had dropped to 80/40. Fortunately, they were able to bring it back up but the episode left him feeling nauseous and dizzy. The nephrology attending told me that they would keep  monitoring him but they predicted that he was going to be fine in a couple of days. In a little over a week, the donor and recipient should be discharged. I am so happy and privileged to have been able to witness this part of their journey. Even with all the bumps in the road, I believe that this family will be much happier and healthier than they were just a few  weeks ago.

 

 

 

June 21st, 2014 from Cairo, Egypt. 

Today was my first official day of the internship. Between the crazy Ramadan schedule and jet lag, I think I snuck in about two hours of sleep. But still, I woke up feeing excited and just a little bit nervous. I had been told repeatedly that I would “see things here that I’d never see in the US.”  

I started my day off at 9:30AM. The physicians were all extremely welcoming and excited to have an American medical student. They were also a bit confused on why I would leave the US to come learn in Egypt. My first  assignment was outpatient clinics. Physicians of all specialities are required to cover a certain number of outpatient clinics. The shifts seem to last around 2-3 hours.There are three physicians and three nurses in one room or their offices as they are called. Each physician is given a desk or a bare bed to sit their patient on. Patients from this city and much further governates come to this hospital as it offers free pediatric care. Many times they’ve been referred by doctors in their villages to this well-known university hospital. The young patients and their families are often from the most humble and vulnerable populations due to lack of resources, education, healthcare literacy, etc.  

I knew that physicians here practiced an art called “spot diagnosis”. In about two to three minutes, the patient can diagnose, refer or write a script for a patient. The patient and parent walks in, the physician asks what brought them. Often, the parent has some type of scans and lab tests that was done at another facility.  The doctor quickly skims over the scans and test results. Then, they ask the parent a few questions about the symptoms. Just after that, the patient is sent on his or her way with a script or referral scratched on the back of a piece of paper.  

Back at Einstein, I had completed my intro to clinical medicine course in an ER. I had spent months learning how to get a chief complaint, history of present illness, family history, social history, etc. We spent weeks just practicing how to construct solid HPI. I had interviewed several standardized patients,watched the flaws in my technique on video and discussed how to improve with my preceptor. Building rapport with the patient was key to a successful patient interview. My preceptor reminded us endlessly about the importance of the physical exam. Even more, we had completed several write ups after interviewing our patients and received critical feedback. Suddenly, there was no room in this outpatient clinic for the clinical skills that I had tried so hard to develop during MS1. 

Yet, I must admit that I am impressed by how swiftly the physicians think. Many times, the physician will not ask about things like the patient’s age or family history. This is unsettling and worrisome for me especially when a genetic disease is being considered or medication prescribed. But, I am still impressed at how confident they are in their diagnosis.  

Here are some of the cases that I saw on day 1:  

Pt. A is 2.5 years old. She clenches her hands, sits on here stomach and cries as if “she is giving birth” according to the mother. Her stomach becomes hard as a stone. Pt. A has had these episodes for 9-11 months and it seems to happen more at night. The doctor says this is a psychological event and refers her to their service.  

Pt. B is 1.5 years old. He became feverish “a few days ago”. The fever passed; however, since then he cannot walk on his own. He will only stand on his own and void if placed in a tub of water. The mother and sister are understandably worried. The patient starts crying loudly in the clinic. I pulled out a few stickers from my white coat and that seemed to distract him a bit. The physician asked me to place him on the ground and see if he could support himself. He could only stand if we held his hands. When his sister held his hands and moved a little further away, he waddled over to her and climbed into her arms. The physician was ready to refer him but the adjacent physician asked what was going on. When we explained to her the case, she came over and put the young boy onto her patient bed. The two physicians checked his reflexes and decided that the issue could be neurological or autoimmune. They decided to send him to the ER. Later during a night shift, I saw the patient in the wards under observation for 24 hours. I spent a bit of time with him and his family that night before the Fajr (dawn) prayers. I wished there was more I can do than just play with stickers and offer words of support. 

After the outpatient clinic, I went to the pediatric ER. A feverish one year old boy was carried in by his mom. Before even touching him, I could feel the heat radiating off his skin. The physician asked his mother to go to the pharmacy and buy 1) a thermometer 2) anything to bring his temperature down before coming back to the ER. I knew that here patients buy their own medications, carry around their own blood bags, carry samples, etc. But, I was really confused on why patients were sent to buy their own thermometers in an ER. The physician explained that it was due to sanitation reasons since they can’t use the same thermometer for several patients. I asked why they didn’t use the plastic covers we often use in American healthcare settings. The doctor replied “that type of technology hasn’t reached us yet.”  

I probably saw over fifty patients on my first day alone. These cases offer just a snapshot of a typical day at one of the most prestigious medical universities in the region. Throughout the day, I couldn’t help but feel lucky to be both a patient and medical student in the US. I know that the American healthcare system is far from perfect and even broken in some areas. I am often frustrated by healthcare disparities, language barriers, lack of universal access to healthcare, etc. But I always took our latex gloves, sanitizer dispensers and covered hospital beds for granted. In the US, patient privacy is an unnegotiable right guaranteed to all our patients. Here, several patients can be examined right next to each other on a desk with numerous white coated interns, residents, and attendings peering curiously over. Lab results are loudly called across the ER.  

I walked out of my first day on the job feeling exhausted, frustrated, blessed but still somehow strangely positive. One thing really stuck to me. A patient came up to the ER desk and said “this is the cleanest hospital that I have ever been in, everyone is praying for you doctors.” She sent chills down my spine as I imagined her journey.  

I am waiting to see where the next few weeks take me.  

  June 30, 2015 from Egypt 

 A Week of Hepatology, Gastroenterology and Tropical Medicine 

I spent my second week at the hospital rotating through these services. Although I still find myself frustrated at the lack of resources or proper training, there is a bit of a silver lining. These services are run by extremely dedicated physicians who do whatever they can to make ends meet for their patients. Here are some scenarios from this week:

1) Pt YA is a 28 month old patient. He presented to the hepatology clinic with abdomen distention, pallor, jaundice and doll-like facies. His mother claims that he has been “sick since he was born”. For the past six months he loses consciousness and has episodes of cold sweats, the classic description of fasting hypoglycemic spells. His history is also positive for previous convulsions, hemoptysis and melena in the past six months. The physician explained to me that his untreated hypoglycemia has caused a permanent epileptic focus. Pt YA is now on anti-convulsant treatments for the syncope attacks. The physician also concluded the pt had delayed motor development. The next step was to order a CT scan to rule out associated myopathy. Furthermore, the patient had positive palmar erythema, a sign of liver failure. We palpated his abdomen and found the liver to be RT 8cm, MCL 7cm and LT 10CM. In other words, his liver was enlarged We ordered a myriad of lab tests to check his CBC, liver profile, lactate, glucose, uric acid, etc. Unfortunately, not all of these lab tests are available at the pediatric hospital and the family will have to go to different outside labs to finish the exams. An ultrasound revealed the liver to be enlarged and bright without focal lesions. The size of his spleen was on the upper limit of normal for his age group. This patient most likely has a glycogen storage disease. The patient and his mother were sent to complete the labs and come  back to the clinic later in the week.

 2) Pt SM is a five year old bilharizia patient. Bilharizia or schistosomes is a chronic, endemic disease in this region. In fact, the disease is often associated with the late Abdel Halim Hafez, a legendary singer in the Middle East who passed away due to liver complications of his disease. Bilharzia is caused by parasitic worms spread via contaminated water. This patient had been diagnosed only four months ago. His CT showed a urinary bladder with diffuses nodular dense thickening and intravescial soft tissue masses, hallmark findings of the disease. This family is from a remote village where clean water is a luxury afforded by few. It is frustrating that many of our patients become ill because of things we often take granted in the West such as pollution, llack of clean water, and poor sanitation.

 3) Pt AM presented to the hepatology clinic with diagnosed Criggler-Najjar disease, a disease Ithought I would only ever see in class. Patients with this disease have a deficiency of conjugation enzymes and have very high levels of unconjugated bilirubin. The only available treatment is intensive phototherapy. However, when the child grows up, it becomes difficult to do sessions of phototherapy lasting 12-14 hours a day. Thus, the child will become a candidate for liver transplant. The patient’s father was set to be a liver donor for his son. However, the situation became complicated when the father was found to have a bifurcated portal vein. Furthermore, the patient’s mother has an incompatible blood type and cannot be a donor. The rules of the hospital are that only the parents or first degree relatives are eligible to be donors for their children. This puts many patients in difficult situations especially if the health of the parents is also poor. The plan for this family is to reevaluate the father to see if there is anyway that the transplant surgery can take place. Otherwise, they will have to seek out close relatives ass possible donors.

4) Pt DC presented with tyrosinemia with hepatorenal manifestations. These patients cannot convert amino acid tyrosine into dopamine. Instead, tyrosine is degraded to toxic metabolites that can build up and cause damage to the kidney and liver. In fact, it can put the patient at risk for hepatocellular carcinoma. In developed countries, the treatment is a drug that causes tyrosine degradation to a non-toxic metabolite. Unfortunately, this drug is not available here and costs 20,000 EGP a month if imported from other countries. This is more than most of our patient’s families make in a year. Thus, our patient is a candidate for liver transplant, the only t!reatment option available.

5) Pt RA is a five year old female with Alagille syndrome and growth hormone deficiency. Alagille is an autosomal dominant genetic disorder with systemic manifestations often affecting the liver. This beautiful young girl had the facies typical of Alagille, deep receded eyes, a straight nose, prominent chin and broad forehead. This was the first time I had heard of the disease but it wasn’t the pathophysiology that made this case stick out. The mother explained that her daughter’s father was one of the wealthiest in their village. However, the father had spoken to several physicians who had said that the girl’s prognosis was poor and would not make it to her teens. The father told the mother that “it is not worth throwing our money in the ground” about his daughter’s treatment. Immediately, the physician called over Dr. H, the head of the department. They sat down with the mother and explained that we can never say for sure what will happen to the patient. Dr. H said “if I leave this hospital right now, I can get into a fatal car accident but this does not mean I should stop living.” Dr. H and the physician told the mother that it was her responsibility to make sure that her daughter received all the care she needed and that they would help her. They followed their promise and set up an appointment with the best cardiologist and endocrinologist at the hospital for pt RA. They also found all the medications that she needed and confirmed another appointment for her at their clinic.

 July 10, 2015 from Egypt 

Medicine, Education and Buttons 

The circle of poverty is more like a whirlpool for our patients. Last week a physician said to me “look at how the patient’s overalls have been sewed together without a button, this is because even a button is too expensive for some of our patients.” The circle gets wider when one’s education and health gets sucked into it. For this generation of children, a good education might be the only way to climb out of the circle of poverty. But what are they to do when their health sstops them from attending school?

  “Yellowness” 

A 9 year old female patient came to our hepatology clinic with her father. In her history, she explained that 9 months ago, she had become rather jaundiced. Labs done in her far-out town showed elevated liver enzymes. However, doctors were not able to conclude what the underlying pathology was. A recent liver biopsy showed patterns of chronic hepatitis with moderate fibrosis. The physician at the clinic ordered a full liver panel, CBC and ultrasound a among other things investigate what could be making the patient ill. When she presented in to our clinic, the sclera of her eyes was clear and did not appear jaundiced. However, this “yellowness” is what had caused her to be dismissed from school in September and has not been allowed to return since. The patient should have completed the fourth grade this year. There are no rules here that require children to stay in school until they are 18. In the states, if a child skips school to go to the mall, a local police officer may very well drive him to school and his parents could receive a hefty fine. When I volunteered at a childrens’ hospital, a teachers aide would deliver the student’s homework to the hospital and tutors would hhelp the children stay caught up on their course work. None of these social services exist here.    I became very frustrated and upset for our patient. The physician explained that there is a common misconception that anyone with jaundice is contagious. This is ironic especially in a country with endemic rates of Hepatitis A virus. HAV is transmitted via the fecal-oral route, mostly via unwashed produce and contaminated water. Poor sanitation and personal hygiene here probably contribute to the high prevalence. However, any of us here are at risk for contracting HAV at anytime, we all drink water and eat fruits and vegetables. Also, the physician explained that the period of contagious activity is only about 10-15 days, not an entire school year. Before leaving the states, I was vaccinated against HAV. Unfortunately, this vaccine is still nnot required even with the huge health burden that it causes to residents of this country.  Our patient will most likely not be allowed back to school until we figure out her disease and can give the school a signed note saying that she is no way contagious. But what if the principal of the school is still fearful of the “yellowness”? She may still not be taken back to school. What if the lengthy trip from her town to our city becomes too much for her parents? She may still not be taken back to school.

 “Alpha One” 

I met patients M and H during my first nephrology clinic. They are both brothers ages 9 and 5. The older brother, patent M, had been dealing with Nephronophthisis for years. His disease went undiagnosed for a long time. At a young age, he suffered multiple recurrent fractures and had fragile bones. It took several different doctors to finally diagnose him with Nephronophthisis, a primarily renal disease not orthopedic as was once thought. This is a genetic disease where there is progressive destruction of both kidneys. The disease is marked by polyuria and polydypsia. Patient M dealt with both of these things as well as incontinence. He could no longer walk at all and was quickly approaching end stage renal disease. He was going to become a candidate for liver transplant. All of these details were discussed in the stuffy office with both boys listening. The younger brother, patient H, had not yet shown full clinical signs of the disease. However, the doctors were monitoring him as they expected him to follow his brothers course. 

However, all of this is besides what brought the family into the clinic today. They were here because they needed alpha-1-hydroxylase that they simply could not afford. A strip of the medication costs 40 EGP, simply not sustainable for the family. Both boys were deficient in this enzyme and that put them at risk for more fractures. This enzyme is what produces active Vitamin D in the body. Their mother was divorced and has several personal health problems to the point where bringing her sons to the hospital was a feat. The older son cannot walk on his own and was carried around by their neighbor, a 15 year old boy. All children in this country receive health insurance as long as they are in school. However, the mother’s health problems prevented her from being able to take her children to school everyday. Thus, they do not qualify for health insurance. The only other option is to have three physicians sign off on a document that states that indeed these children should be covered by the national health insurance due to outstanding conditions. The physician finished the paper work for the mother and her sons immediately. The head of the department of nephrology even gave them enough Alpha-one drops to last until the government processed their paperwork. I am thrilled that they were able to finish their paperwork immediately. But what good does insurance do if the mother cannot bring her children to the hospital most of the time? Even more, the mother claims that they do not have any family to help them. Who will donate their kidneys to these children when the time comes? The mother cannot because of her own health problems. I don’t think they can afford the hefty price tag that comes with private hospitals that allow transplant donors to be non- relatives. What good does insurance do if the children will not be able to get an education? These alpha-one drops seemed like a small victory at the time but I found myself entertaining more cynical thoughts throughout the day. I found myself frustrated at the complete lack of social services in the country. There aren’t enough Alpha-one drops in the world to fix this whirlpool, no tsunami, of poverty.

 

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August 8th, 2014. Cynthia from Kisoro, Uganda 

I can’t believe that we are on our way home! Or maybe we are leaving home, I guess it depends on how you look at it. After two months in Kisoro, it definitely felt like home to me. But the end of our time went very well. Since I last wrote it has been two weeks, but the last several days were all report-writing and preparing our final presentation. The last work days were pretty good though.

On Thursday, July 24^th, we had our great Thursday shadowing day at the chronic care clinic. I got to work with Nate, which was really wonderful since he was going to be leaving on the coming Saturday. Most of the patients were pretty straightforward, but it was really nice to see the way he worked with patients. Even when the medicine itself isn’t too complicated and I don’t have too much to learn from the case itself, watching good doctors care for patients is always educational. We had one very interesting patient though, a man who was in acute alcohol withdrawal and had severe abdominal swelling. I felt so badly for him, he was just shaking all over. Examining his abdominal swelling was a great review of the abdominal physical exam that we had learned last year. Since he had so much swelling, which is called ascites when it is due to fluid, Nate was able to figure out how much fluid was in his abdomen by listening to the different sounds he heard while percussing (a physical exam technique that is a specific method of tapping) on his stomach. By using this technique with the patient in different positions, we were able to find a kind of fill line where we knew that we was full of fluid. After CCC we went to beans place as always, and it was delicious as always. Then market day! It was our last time down to the big market, which was kind of sad, but it was fun. We completed most of the shopping we had to do for the rest of the trip that afternoon.

On Friday we had a nutrition screening day, which was kind of fun because it was back to our old routine that we had started with in the beginning of the trip. That went well, and we saw over 100 kids, which is always great. Very few who were malnourished, so that was even better. After screening we went to the café and worked on some of our reports until the evening. Since Friday was Nate’s last night, we went out for a great big fancy dinner at the hotel nearby, called Traveler’s Rest. It was one of the most spectacular meals I have ever had, and it was wonderful to be with our whole crew one more time before Nate returned home. All of the other students, the residents, and Nori are just amazing people, and every conversation I have had with them all summer has taught me something.

On Saturday I had my last day out with Jerome. It was a good day, but it was short and kind of chilly because it was misty and cloudy. But time with Jerome is always time well-spent, and I’m glad I got to have that last day with him. When I got home from that, which was early, I just went to Coffee Pot again to work more on reports. We took a bit of a break in the middle of the afternoon because Nori came by there to work too, and we had another lovely and highly educational conversation with him. We worked most of the day, until the evening when we had movie night with everyone. It was my first Planet Earth experience, and it was pretty amazing. Definitely going to have to see the rest of the series once I get home.

Sunday was a bit of a lost day, I wasn’t feeling very well so I just rested a lot. On Monday I had nutrition screening again, and it was an exciting day because my awesome translator, Julius, got his college acceptance notification! The screening day was like usual, and Hannah’s day doing nutrition follow up was good too. In the evening we went for a hike of Hospital Hill as we often do, and that was a really beautiful one. It was extremely clear weather and close to sunset, so the views were even better than usual. Definitely one of the moments when I was wondering how it would ever be possible for me to leave Kisoro.

On Tuesday, my scheduled activities got canceled because of conflicts with the VHW. So I decided to try and take advantage of the opportunity and go to the hospital to see some more of what it’s like to work there. I spent most of the day shadowing Adam, an awesome nurse practitioner who has been to Kisoro multiple times, and learned more than I would have thought possible for just one day. We saw a patient with HIV, a patient who had a stroke, a young woman who probably had a bleed somewhere in her intestines, and a woman with severe diarrhea. It was a huge range, and really interesting to see how a good history and physical exam can be used to learn so much even without as much technology as we have in the US. In the early afternoon we took a break and went to beans place, of course, and then I met up with Hannah because she was back from her day in the community. We had a planning meeting with Valence, who helps lead our focus groups, to plan our final focus group session. We decided that marriage would be a good kind of all-encompassing topic to use for the last day because it would let us touch on several of the other topics we had covered. We came up with some great discussion questions, and we wrote and translated a survey that we could use to get some feedback from the group members about their experience in the focus groups. Then we went to hike Hospital Hill again, but this time with Emma, Adam, Sean, one of the translators, Angel, and one of the residents who had just arrived for the month of August, Mai. That was the best hike of the whole trip. It was an even more beautiful day than the day before, and having so many people with us was wonderful. We had a great time, and I am glad I got to be there when so many people were seeing those things for the first time. Unfortunately, while we were eating dinner after getting home, I got a phone call that my focus group would not be meeting the following day. I was so disappointed because that was going to be my last opportunity to go to Nyagihenge and work with the group, but there was nothing I could do about it. I had a great focus group experience overall, but there were definitely a lot of frustrations involved. Losing the last session was really sad. I hope that some of our original goals for the group were accomplished, and that some of the men and women started to think and talk about things more openly with their partners. I think that next time students have focus groups it will have to be a little bit more organized so that attendance is more consistent and we are able to really work with the same people to make progress over time.

Since I didn’t go out to the focus group on Wednesday, I worked on writing my reports instead. In the afternoon after Hannah got home we made preparations for Wanda’s birthday! We baked oatmeal chocolate chip cookies on the stove, which I had no idea was even possible. We also made brownies and decorated the yard so that it would look awesome when she got home. The celebrations were all wonderful, and many of our Ugandan friends came. We had great food and a bonfire, where we played charades. It was all magical and wonderful, generally an awesome night.

Thursday was a CCC day again, and I got to shadow one of the residents who just arrived for August, Jon. He was really wonderful to work with also, of course, and it was a nice day. We didn’t have any crazy patients, but I still learned a lot as I have every time. After our usual beans, we just got down to work again. By the end of the summer 8 reports were expected of us, so we spent a lot of time writing in the last week.

Friday we had our last day of nutrition follow-up surveys. That was just hard to believe, we spent so much time working on this project and to have the data collection come to an end was really crazy. But the day went well, and we were able to see all of the children that the VHWs knew about from the nutrition program. The two VHWs we were working with were particularly wonderful, so it was a really nice day. We really haven’t taken enough pictures of our work or with the VHWs, but we remembered to take a picture with them before we left. That was nice, and they were really excited about it. But I always hate having to say goodbye to people. Everyone in Kisoro is so wonderful, and they all are genuinely sad to see us leave, saying goodbye is just brutal. Thankfully I know that it won’t be goodbye forever though. After all the amazing experiences and how much I have learned this summer, I know I’ll be back again 4^th year. But these two years are going to be a long wait to get back to all of the great partners and friends we have worked with and lived with.

The afternoon and evening were again filled with writing.

Saturday was supposed to be our last day in the community. But just as I had bad luck earlier in the week, when we got out to the village where we had planned to do one more nutrition screening day, we found that the VHW had just given birth and hadn’t been able to organize a screening. So we just had to turn around and head home, which was kind of sad. Friday was a great last day, but it would have been nice to be prepared to let go of our work at that time. The community in Kisoro has come to mean a lot to me, and not having the kind of complete ending that I wanted was hard. I wasn’t ready for Friday to have been the last day, I just wasn’t in the mindset. But one day more or less doesn’t take away anything from the amazing summer I had. I hope that our work had one tiny fraction of the impact on the community that the community had on me.

Saturday through Tuesday were spent writing reports and preparing a presentation for the administrators at KDH. All of that went well, and as much as sitting and staring at computer screens all day and night was not nearly as fun as working in the villages, it felt good to see all of our work come together and to be able to share what we had done with others. We were able to see that what we had been doing was going to be useful, and that all of our work and our findings will contribute to the future of great programs in Kisoro. We wrote a reports about each oft the following projects, and also presented all of our findings and suggestions for improvements to the team at KDH: follow-up with Jerome, nutrition screening, VHW interviews, focus groups, targeted surveys in the community about chronic disease, family planning, and home vs hospital delivery, and the nutrition follow-up project. If you’re at all interested in any of the projects we did, I would be happy to share the report about that topic with you. It was a lot of work to make these projects happen and a lot of work to create meaningful reports, but it was work that we know we can be proud of. And we know that it is going to be used right away to have real impacts on people’s lives.

On Wednesday we mostly spent the day packing and preparing to leave. In the afternoon we gave our presentation to a much larger group than we had expected to see. To our relief, it went well and everyone was really happy with the work that we had done. The end of the presentation was sad though, because it meant that our work in Kisoro had officially come to a close. Saying goodbye to everyone was difficult, but at least we know that it’s not goodbye forever. We will be back soon. In the evening on Wednesday we had an awesome taco night with everyone and some of our Ugandan friends, and we roasted marshmallows around a bonfire. Helping Ugandans make their first s’mores was definitely an awesome moment.

I stayed up way too late because I didn’t want the night to end, knowing that when I woke up I would have to leave. I can’t believe I ever considered doing something else for the summer. There is no better place I could have been and no better way I could have been spending my time. I have learned about many medical topics, about community health, about medicine in the developing world, about the wonderful culture of the people in Kisoro, but more than anything I have learned a lot about myself and what I want my future to look like. I am not the same person who left New York 9 weeks ago, and my plans for my career in medicine in this world are definitely not the same either. I may not know any more certainly what field I will enter, but I know that the world is a lot bigger than I ever imagined and that there are a lot more places worth going to and working in than I have ever considered. I don’t know where the future will take me, but I know that leaving Kisoro this summer is not the end of anything. This is just the beginning.

 

As we wait for the last leg of our journey home to begin here in Brussels airport, I can’t help but feel a little apprehensive about returning to a world that is now so different than the normal I have grown accustomed to over these weeks. But I know that I am coming back to amazing people who will make the transition significantly easier just by the virtue of their presence in my life. Thank you all for reading my ramblings all summer, and thank you for all of your help and support throughout this adventure and all those previously. I wouldn’t have been able to do this without you. Here’s to whatever comes next!

July 24, 2014. Hannah in Kisoro, Uganda 

                                              

Today I conducted nutrition follow-up surveys in one of the villages.  My coworker/translator and I rode a motorcycle to the village (he drove, I sat on the back and tried not to fall off), with our giant height-measuring board tied to the back. Immediately into the ride, the bike got a flat tire, but fortunately we only had to push the bike a little ways to the nearest repair shop (he pushed, I carried the helmets).  Only a little delayed, we finished the ride to the village, which was a bumpy one, and partly across a huge and very rocky field of grass. We had to swerve a lot to avoid all the volcanic rocks and cows. Many cows. Some goats, too. When we got there, I was relieved to find that the VHW (village health worker) had mobilized a good number of women and children for us to interview. We first took weight, height and MUAC on all the children, some being more difficult than others. We have to lay them down flat on a board to get their height, which is easier said than done when the child is screaming and squirming around. Weight is especially hard to get when the child is screaming and moving up and down, because the needle on the scale bounces up and down along with the child when the child won’t stay still. You have to catch their weight on the split second between screams when the child isn’t moving.  We managed to measure all the children eventually, and moved on to interviewing mothers.  In the meantime, the tire went flat for a second time and had to be repaired again. 

On our survey we ask how many children they have, many today had 8 or 9. I usually ask if they’re planning on having any more, and today most said no, but out of the 12 women, only 1 was using family planning. Many were interested in it, or thinking about it, so I hope that they will follow up on our conversations and visit the women’s clinic soon, or at least discuss their options with their VHW.  I’m now realizing more and more how important family planning is for the health of young children, not just mothers. If a mother has a child who is still breastfeeding and gets pregnant again, she is likely to stop 

breastfeeding, which puts that child at risk for malnutrition.      Many of the mothers we interviewed stopped breastfeeding their children before 2 years because they were pregnant again, some of them thinking that when they’re pregnant, the breast milk is making the children sick. I tried to emphasize the importance of breastfeeding to two years, I hope the message got through.  

One mother today had an 8-year-old child with epilepsy who had never been seen by a doctor.  We’re going to try to get her evaluated soon when the chronic disease team visits her village. In another interview with a grandmother, she revealed that she had gone to visit her daughter and found her grandson malnourished, so had taken him into her own care.  This reminds me of an amazing nurse that I met here who had a young patient with diabetes and negligent parents, and took the child into her own care as well.  Now the child is doing much better.  I am again and again amazed at how kind people are in Kisoro, even small acts of kindness really add up and mean something.

Yesterday I interviewed a mother who had a young daughter, let’s call her Molly (not her real name), who was severely stunted, and had already been in the nutrition program for 3 years but hadn’t grown properly. They told me how they had gone to another hospital far away and were told that Molly had a “hole in her heart”.  The hospital told Molly’s family that they would call to follow up. Molly’s family went home, they never called. That was more than two years ago.  I want to find out if she’s a candidate for surgery and then go from there. They don’t have the capacity for that kind of surgery here; I’m told people can go to Kenya or even India for heart surgeries.  I’m also told a surgery like that may cost around $500. The price of an Iphone. Puts things in perspective.

 

July 23, 2014. Cynthia in Kisoro, Uganda  

I can’t believe that my time here is almost up. Only two more weeks, and only 1.5 weeks left going out to the community. This summer has absolutely flown by. I feel like each day has gotten busier and busier, but I am extremely grateful for the kind of experience I have had here and for the knowledge that I have spent my time well. Since I wrote last Wednesday, things here have been good. Wednesday afternoon after our focus groups we spent a lot of time working on data entry and analysis. Things with that are going pretty well, but Hannah and I are not very experienced with using Excel so we are a little stumped with what to do now that we have finally entered all of our data. I think we are making progress on things though.

 

   

Here are two photos: one from our Wednesday focus group and one from nutrition follow-up survey days. 

            Thursday we got to shadow in the Chronic Care Clinic, and it was really awesome. Working with the residents is wonderful. They know so much and are great teachers. I worked with Sean on Thursday, and he taught me a lot about different kinds of heart failure, depression, and complications of diabetes, among other things. We reviewed a lot about physical exam technique, and I got to practice that a lot. I also appreciate how wonderful patients are about working with students here. Not that they aren’t great at home too, but I always appreciate when patients let us take the extra time to learn with them. We also got to see two special cases that Nori pulled us all out for. The first one was a patient with rheumatic heart disease, which is sadly very common here. There are a huge number of young people who have completely failing valves, and can’t afford the flight to India that they would need to get the necessary surgery. The woman we saw last week had two very particular and distinct heart murmurs that Nori wanted us all to hear and learn about. It was a really unique opportunity, and definitely a lot more helpful than listening to the recorded heart sounds that we get at school. I found the teaching case especially interesting because it had to do with something that we had actually learned about in class! There was a man with pellagra, a vitamin B deficiency that presents with a specific skin rash. Elena had diagnosed it herself, which was super awesome, and it was cool to see something in real life that we had seen in books.

After CCC we had the customary lunch at beans place, and then set off to accomplish a lot of errands, Thursday being market day. It was all a great success, and we returned home feeling very accomplished. We did a little bit more work before starting to work on dinner, which was a fantastic group taco night! We all ate together outside and turned off the lights so we could see the stars better. It was an utterly beautiful night, and we could even see the Milky Way. It definitely ranks highly on my list of greatest days ever. A day full of learning, tacos, great people, jazz music, and stargazing is just about as good as it gets.

Friday was a big adventure. I went out with Jerome for patient follow-up and to check on the TB registries at health centers to make sure that all Kisoro Hospital patients are getting their TB treatment on schedule. It was all going well and seemed like a pretty average day, apart from a marvelous sighting of a huge group of Ugandan cranes, which are seriously beautiful and not common enough here. Then around 12:30 or 1 Jerome got a phone call from Sean at the hospital. He told us that a patient had escaped from the hospital, and that he was suspected of having multi-drug-resistant tuberculosis (MDR TB). A patient like that walking around town is not a minor concern, but can be a public health disaster. Since TB is airborne and highly contagious, we even keep TB patients in an isolated room at the hospital. A patient with TB that is not responsive to the normal drug regimen is particularly disturbing, and spread of such a disease could have a huge cost. Given these concerns, Jerome and I stopped the rest of our work and set out to find the missing patient. We found out what village he lived in, and made the long, bumpy drive out there. When we got nearby, we started asking people if they knew the man and if he was around. Fortunately, we found some of his grandchildren fairly early in our search. They told us that he had come home late the night before and was at home resting.

They led us to the family home, and sure enough we found the patient lying on a mattress in the yard. There were many family members around: his children and grandchildren in a big crowd. We came and sat down and started to talk to him about what had happened and why he left the hospital when he was so sick. He told us that he left because no one was paying attention to him or taking care of him at KDH. I was surprised to hear this, since I know the people caring for him and know that they do not ignore their patients. We asked him to explain further, and he told us a story that made both Jerome and me utterly furious. He said that the previous week he had been told he needed a chest x-ray, so he went to the imaging center to have it done. When he got there, the imaging technician told him that she wouldn’t do it for him now, and to come back on Tuesday. When he returned on Tuesday, she again told him that she wouldn’t do it. He got upset and told her she had given him an appointment for Tuesday, so when would she do the x-ray. She told him, “When I feel like it, I’ll come and find you and tell you.”  He waited another day or so, but when she still didn’t come to do the x-ray he got very frustrated and decided to leave the hospital. I kind of understood why he would want to leave, especially because the progress of his care was halted until that x-ray could be done. Literally nothing was happening, and he was being told almost directly that he wasn’t cared about.

Jerome and I were both extremely upset by this story, because this is just one more in a series of issues caused by the same x-ray technician. The entire week she had been causing major trouble, and had decided simply not to work at all for several days. That was a pretty big problem at KDH, because there is a lot less technology than in the states, and one of the few diagnostic tools that we have here is the ability to do some basic imaging. This woman is the only tech, and if she decides not to work, there is no imaging. The toll of her laziness and selfishness (which is well-known by all the hospital staff) was mounting rapidly, and the fact that a community was exposed to potential MDR TB now because of her was the last straw for me and Jerome. I am surprised that our anger wasn’t visible as a great cloud in the air around us. I cannot comprehend a person who knows that people’s lives depend on her job regularly refusing to do that job. Why such a person would ever enter a healthcare field is beyond my comprehension. I cannot understand how she can live like that, knowingly denying people potentially life-saving care for no other reason than because she doesn’t feel like it. Such behavior is nearly equal to murder in my mind. It is highly unfortunate that the system here is setup such that hospital employees get government salaries regardless of how much work they do, and there really isn’t a way to keep them accountable. If someone decided not to come to work for a week in the US, that person would be fired immediately. But this woman has not been and will not be fired, despite her recurrent neglect of her job and the patients depending on her work.

Jerome and I spent a good amount of time trying to make our patient understand that the x-ray technician is not representative of everyone working at KDH. His doctors really care about helping to make him better, and wasn’t the fact that we had come to find him proof that people were really concerned about him? We also talked to him about the risk to his family if he stayed home. With so many small children running around and being particularly susceptible to disease, it was really not safe for them if he were to remain there. After some time, he agreed that he would come back to the hospital. He said that the problem would be transport, because he was not well enough to ride on our motorcycle back with us. This presented a problem for us, because there is no real system in place for this sort of occurrence. After a quick discussion, Jerome and I decided that we would go back to the hospital, and I volunteered to cover whatever costs there would be in finding a car to transport him. I felt that this was way too important to ignore, and I couldn’t think of any cost that would be too great to protect people from such a deadly disease.   

Jerome got us back to KDH as fast possible, and we got right down to business finding a car to get back to our patient. Sean was thrilled that we had found him, and we were able to get one of the cars from the established transport program, even though our patient wasn’t enrolled in it. Jerome had taken a phone number of one of the patient’s family members, so we called to let them know we were on the way back and where to meet us. After the 1-hour drive up there, we found that they were not at the meeting place. We went back to the house and found everyone gone – except for our patient hiding under his blankets. We kept talking to him until he consented to acknowledge us, but it was pretty clear what had happened. The family had all gone away and conspired so that no one was there so we couldn’t take him. We started to try to persuade him again, but he was very adamant about not wanting to go. He kept saying that they weren’t taking care of him and he was going to die there. Eventually, family members returned and we tried to help them understand the seriousness of the patient’s condition and the reasons why he needed to return to the hospital. We hadn’t wanted to pull out this argument, but the reality is that TB cases are registered with the government, and defaulting on treatment is taken very seriously. In the case of MDR TB, our patient would be arrested and dragged to the hospital within a couple of days at the most. When we told him this, he said, “Then let the police come and take me.” Our explanations had persuaded the family though, and with their help he eventually, grudgingly, consented to go with us. That was fortunate, because I was going to camp out right there in that yard until he agreed to go. There was no way after all the hours we had already put into this and the level of risk that he posed to his family and community that I was going to leave without him. He told us that he would only go on the condition that if no one was taking care of him the next day, he was going to leave again. With the help of his son and grandson we got him to the car, gave him a mask to protect the rest of us, and all piled in for the trip back to the hospital. We got him there, helped with his new interview, and made sure he was settled before finally going home. I got dinner for him, his son, and his grandson, and after 5.5 hours, called the quest complete.

Saturday was a much quieter day, just nutrition follow-up surveys again. They went well, and in the afternoon Hannah and I went for a nice hike up Crater Hill. That was a really cool hike, because the top of the hill has a giant crater with a forest in the middle. Really beautiful, and a nice quick hike. That evening we just worked on data, made dinner, and watched the Lord of the Rings. Definitely can’t complain about any of that. Sunday was also nice, since we had the day off we went to a nice breakfast at the nearby hotel. Then I went to mass for my first church experience it. To say that it was awesome is an understatement. It was really nice because there is a mass in English every week, and the Catholic Church is a two-minute walk from our house. It was really nice to be at mass again, and I was totally blown away by the musicality of the service. The singing and dancing was incredible, and was consistent throughout. It was similar to what I’m used to at home, but different (and I think better) in many ways. Of course the music was incredible, and I always find that to be one of the easiest ways to connect spiritually with others and God. But I think what I most appreciated was the sense of community, and the depth of people’s faith here. I do not mean to say that the faith of people in the US or other places in the world is not as legitimate or that it is insincere, but I think that to believe so firmly in something when there is so much more hardship means something more. To see families that have lost multiple children to disease or malnutrition or horrible accidents still believe unwaveringly that God is good and watching over them is extremely impressive. When people have so much less than most people have in the US, and they don’t complain or sit jealously watching their neighbors who have more, but rather thank God for all that has been provided for them, it is striking. I have heard the parable that was in the reading this week uncountable times before, but when I heard a story about farming while sitting with people who actually toil in fields for a living and experienced their understanding of it, it changed. The lesson this week was about patience. It was about the kind of love and patience that God shows to us, and that we should be showing to each other. I think that it was a good and necessary message for me to be reminded of, particularly as I have been getting angry with neglectful parents and hospital workers. We are all flawed, and none of us should be so swiftly passing judgment on others. This is certainly more difficult some times than others, but I felt as though there was a reason I was hearing it when I did, and I decided to pray in that moment for the neglectful parents and the x-ray technician instead of spending so much time being angry towards them. I think that whatever your beliefs, if you have the opportunity to go to church in Uganda some day, it is worth your time. Whether you have a faith, and be it big or small, seeing the intense spirituality of these people can’t help but move you.    

After church we went for a hike to the lake, but since the weather was bad we didn’t stay long. We just did more work when we got home until later in the evening, when we made a cake to celebrate Nate’s birthday. He had gone to hike one of the volcanoes, and since we don’t have an oven, we made a cake by stacking crepes and putting different fillings between each one. When the hikers got home we surprised Nate and sang happy birthday and celebrated a bit. It was a nice night, and I was pretty proud of the crepe-cake in the end, it was awesome.

Monday was a kind of disappointing day because there had been miscommunication and the villages we were supposed to screen for malnutrition weren’t ready for us. So we ended up going back home and working with data instead. In the afternoon we went to the market and got all the necessary ingredients to make an awesome chili. Then we went to a spectacular dinner party! Dr. Michael, the medical director of the hospital, and his wife, Jackie, had us over to their home for dinner. It was the most spectacular meal I’ve had in ages. I ate enough for three large men, and it was worth the strain it put on my waistband. It was really amazing, and so much fun to spend the evening with all the students, residents, and a truly wonderful family. There was a huge thunderstorm that knocked the power out, but that didn’t bother anyone. It was a spectacular evening.

Tuesday I went out with Jerome again, but no crises to solve, so a pretty standard day. Hannah and I made our awesome chili in the evening and watched Aladdin while we peeled all the potatoes and carrots and sorted the beans. Today we had focus groups in the morning, and wrapped up our discussion of domestic violence. These two sessions have been really eye-opening for me. Much of what the women shared was disturbing to me, and there was a lot that I didn’t expect. Abuse is always upsetting to discuss, but I didn’t anticipate the differences in experience here and in the US. Many women here believe that a man who doesn’t beat his wife doesn’t love her. Many also believe that if he has paid the bride price that her parents asked, it is more ok to beat her than if he hasn’t. Half of the time when they refered to their husbands, the women used the word “master” instead of “husband.” They always refer to their homes as their husband’s home, as if they don’t have any ownership in it. All of these things were horrifying to me. In contrast to the US where abuse is most often secret and hidden, here it is very much in the open and accepted. Although there are laws against it, there is very little enforcement of them. I was very glad to see that the women in our group seemed to grow through the discussion and recognize more of their own worth and value. I really like how the lead facilitator, Joseph, pointed out to them that their homes would completely fall apart without them. He asked them about al the things their husbands depend on them for, and after they listed all the things (a substantial list), he asked them who is really the master? If the man can’t sustain his own home, can he really be the master of it? If the women didn’t do all that they did, would the man live well? He made them see their own power, and it was wonderful to watch. It was unfortunate that the men did not attend these sessions, because I think that both groups talking together would have made more progress. But I do believe that the women left today knowing more and feeling more empowered than they had before.

I am already starting to get really sad about leaving, I have learned so much and gotten to know so many incredible people. Leaving will be very hard. I am so used to the way things are here, I’m not sure how the adjustment back to NY is going to go. I have definitely picked up some of the speech patterns here, so I know that I’m going to sound funny at the very least. I’m sure I’ll also accidentally say words in Rufimbira a lot. I think the most difficult thing will be the difference in pace and friendliness. Not greeting everyone I meet on the street and everyone rushing around in their own little bubbles is going to seem very strange after being here. The people here are so unlike people at home, it’s almost impossible to explain. When we go to a village looking for a patient, for example, we can just stop anyone we see and ask them for help. People often drop whatever they’re doing and will lead us to the patient’s house. They don’t act like it’s an inconvenience or like we are bothering them or anything. People always have time to help each other, and a visit from family or friend or stranger is always welcome and treated the same. Nothing like being in NY where people always seem to be annoyed if you speak to them. It isn’t like these people aren’t busy and don’t have things to do, because they really really do. They work exceptionally hard in most cases. But they have a very different value system, and I have found it really inspiring and humbling to see the way that people treat each other here. One of my favorite things that people say here is whenever you arrive at a place, whether the people know you there or not, they always greet you with “you are welcome.” And though it is the customary thing to say, it is also very clear that people mean it. As a foreigner, I have appreciated that immensely, but I think that as human beings in general, being truly welcomed wherever we are is one of the best feelings we can have. I am going to miss that sense of acceptance and belonging very much. And of course the scenery, that’s going to be rough. I’m going to have a hard time looking at concrete again after so much time surrounded by lakes and mountains and going hiking anytime I feel like it.

July 11, 2014 

Liz in Kisoro, Uganda

 
We are rounding out week 5 in Kisoro District and it’s almost time for me to head home… unbelievable! This summer was exactly what I needed between MSI and MSII to remind me why I entered medicine. The hospital staff and the partners we work with here are very dedicated, passionate, and genuine. It’s really been a pleasure to be a part of such a committed team.
 
Most of our work here is monitoring and evaluation of current nutrition, chronic disease, family planning, and village health worker programs. As fresh MSIIs, we have little to contribute in a clinical setting. However, while in the villages talking to parents, we are often asked clinical questions. Our foreign appearance and accent somehow seem indicative of medical credential…
 
We tend to be overly apologetic about our lack of knowledge and qualification, are cautious of giving false hope, and are fearful of doing harm through overstepping rank or through guarded silence. Yet villagers still want our advice, our opinion, anything we can offer that might help. Though not often externally emotive, they want the best for their families and are open to new ideas.
 
This week we began the nutrition follow-up project. Through the Village Health Worker network, the Nutrition Program screens children by measuring their MUAC (mid-upper arm circumference) and weight. Those children who are underweight for their age or have a MUAC less than 12.5 cm are entered into the program. These kids receive nutrition supplements like Plumpy Nut ® or Unimix, depending on what is available.
 
We reviewed the database of previously malnourished children who graduated from the nutrition program. Then, we sorted the kids by village and made a plan to find the children who were designated “cured” (as opposed to drop-outs or children who died). The goal of this adventure was to see if their health had been maintained since graduating from the program and learn about ways to improve our approach.
 
At 8:00 am Hannah, Cynthia, and I split up the villages with our counterpart translators- Julius, Dickson, and Vallence- and made our way up the rocky path that the driver managed to tame into a road. Vallence and I had a list of 20 kids to meet in two days. The VHW met us at the village center and led us to the first home.
 
Waraye… (Good morning.)
 
Yego… (Yes.)
 
Mezute? (How are you?)
 
Daho… (I am fine.)
 
Mr. R was young, slight, and spoke in a controlled, cautious, and calming manner.  He’d just woken up and exited the house while putting on his shirt. He, Vallence, and the VHW sat on small hand-carved stools less than a foot high. They looked like something you would see in a museum exhibit of African art and artifacts. I sat on the steps to the front door. We introduced ourselves, why we had come, and spent some time trying to understand the relationship of this man to the children we were tracking.
 
It turns out that Mr. R’s brother had gone to the city to find work. He lived there for most of the year for many years. Most likely, this is where he had contracted HIV, which later infected his wife and at least one of their four children. Two of the children and their mother were enrolled in the Nutrition Program. The supplements had helped for a while, but when the husband died of pneumonia the family lost much of their financial security. The wife died soon after, having become hopeless, depressed, and alcoholic. After she died, the youngest child lacked a primary caretaker and soon passed also.
 
This was going to be an intense day. I wondered how Mr. R felt about answering my questions. “Good morning, please tell me about your dead brother, sister-in-law, and niece.”
 
Mr. R was now left to care for the four remaining children in addition to his own. Vallence and I asked him about his own health and support system.
 
“I have not shared this story with anyone. I must study the villagers. It may be that my worries are not as grave as theirs. I do not want to contribute to another’s burden when it may already be worse than my own.”
 
We recommended that he meet with the hospital social worker to seek out additional support services.
 
“I want to test the children for HIV, but I don’t know how to tell them…”
 
Vallence dove in to answer this one and was a total pro. He works with many NGOs and knew exactly where to find help. They made plans for another meeting.
 
I offered what I could, “You know the stigmas around HIV. Once the children know what happened to their parents, it will be very important for you to remind them that you love them, that you will take care of them, and that their parents were good people who loved them very much.”
 
It seemed obvious, but needed to be said. So many children orphaned by HIV are seen as burdens, resented for their circumstance.
 
We found the surviving child from our Nutrition Program at school. She was very thin, shy, and several grade levels behind. It is common for malnourished children to fall behind- it is hard for them to focus and often the underlying problems affect their attendance. This girl had to help care for siblings at home, so she often missed school. We measured her in the headmaster’s office to provide some privacy and moved on.
 
While walking to the next home, Vallence delivered a passionate monologue on the cycle of malnutrition. “These kids are malnourished, fall behind in school, get discouraged and drop out. Then they marry young, have many children, and produce more malnourished families.” The solution seems to be immediate financial support for food, family planning counseling, and tutoring to help the kids keep up with their grade level. All of this costs money and the Ugandan health and social services sectors are already grossly understaffed.
 
We traveled to a few more homes, walking carefully between the volcanic rocks, through the dust of dry season, and avoiding the fresh animal droppings in the road.
 
The next parent we met with was Mr. Q. He was strolling to town with a group of friends who joined him for the consultation (privacy is relative here…).
 
Waraye…
 
Yego…
 
Mezute?
 
Daho…
 
We talked about his children, asked why he thought they were malnourished, and what advice he had for improving the program. He explained that around the same time that his first child started having chronic diarrhea and entered the Nutrition Program, his wife stopped breastfeeding because she was pregnant again. He believed that pregnancy made the breast milk dangerous for his first child.
 
This reminded me of an experience in Togo- people believed that eating too many mangoes could cause malaria. In reality, the unwashed mangoes (or unwashed hands ripping into the mangoes) carried intestinal parasites and bacteria that led to some of the same symptoms as malaria. The mangoes came when the rain came, which is also when the mosquitoes brought malaria.  People assumed they were connected.
 
I suggested to Mr. Q that perhaps the breast milk wasn’t causing the illness, but that it might be that the child’s newfound mobility was introducing her to parasites in the soil, carried by animals in the compound, or through the new foods she was trying. We talked about home sanitation and family planning. His friends had many questions about the side effects of birth control methods. Mr. Q told me all about what he had learned in the nutrition program: the importance of eating greens, diversifying the diet, and heating food. We wrapped up and moved on to the last home.
 
Ms. M had six children under seven years old, including a set of twins. Two had been in the Nutrition Program and we screened the others who were under five years old. The kids were sweet and agreeable. It was nice to complete a visit sans mzungu tantrum (children screaming in fear of foreigners).
 
At the end of the visit, I noticed a depressed fontanelle in the youngest of the children and asked to hold him. The baby was chubby and his skin didn’t tent when pinched. His eyes were not sunken, but I have never seen pupils so small.
 
“He is sick,” Said Ms. M.
 
“Yes, I see that… Has he been vomiting or had diarrhea?”
 
There was a pause.
 
“He had Gapfura for a week, with a cough… we took him to the local surgeon.”
 
I’d heard about this from the MSIVs, but hadn’t actually encountered it yet. Gapfura is a kind of folk illness that is cured by a crude tonsillectomy. A traditional surgeon cuts the back of the baby’s throat and often this procedure results in infection. The parents bought Ampicillin and Paracetamol at a local shop, though they hadn’t been instructed with regard to dose. I couldn’t find a pulse.
 
Vallence explained the dangers of improper dosing to the parents. They were afraid for the baby, but also fearful of seeking medical attention. Vallence told me about how many parents travel long distances to the hospital only to find that the doctor is unavailable or censures them so harshly that they fear seeking attention in the future. They knew that taking the baby to the hospital could have similar outcomes- a day of work wasted, five other children left home alone, the expense of transportation, along with being shamed by an authority. Life was already stressful and money was tight. Yet, the traditional healer is always available, more kind, and not as expensive as transport to town.
 
“Let’s take the baby and Ms. M with us to the health center. He needs fluids and surveillance.”
 
This was a tough sell, but after 30 minutes of negotiating, mom and baby came with us. We promised that one of us would go with her to make sure the nurse treated her well.
 
When we arrived, the nurse at the health center was in a meeting. We stated the emergency and he placed an IV.
 
“She is very nervous to admit that the baby had a crude tonsillectomy, so let’s be gentle with her.”
 
This was not necessary. He knew.
 
“Have you seen this often before?”
 
“This is very common. It is rare that the parents want to tell you they went to a traditional surgeon. It’s good she came in so soon. Usually, they are much worse by the time they get here.”
 
It was 3:00 pm. We left Ms. M with the nurse and drove home. Only after sitting back in the van did I realize how tired I was, my feet caked in dust, that I hadn’t eaten all day… It didn’t matter. Though only an MSII, I was a part of a medical team. I had known enough to do some good. That’s why I wanted to join medicine in the first place. It’s easy to get bogged down in the mental strain of medical school in the first two years and I’m so grateful to have had this re-centering experience.
 
Follow-up: Vallence is organizing an HIV screening day for the whole village where Mr. R lives and arranging for several special consultations with social workers and nutritionists. Ms. M’s baby was released from the health center the next day and is recovering well.

July 16, 2014

This is Hannah again from Kisoro, Uganda. We’ve been here for about 5 weeks now. In my last blog post I talked about many of the good things about the VHW program in Kisoro, and this time I’m going to talk about some of the things I’ve struggled with while being here. Lately we’ve been focusing on two nutrition projects, one where we go out to villages and screen children for malnutrition, and a second project where we follow up with children who were previously malnourished to see how they’re doing now. This work has been very interesting because it’s given me a much different perspective of malnutrition and its causes.  I used to think that malnutrition in developing countries was just from children not having enough to eat, but now I realize it’s much more complicated than that. For example, many children are picky and will only eat Irish potatoes, the staple food here, which leads to malnutrition because of lack of nutrients. Also, many mothers stop breastfeeding children earlier than they should for various reasons, one being that they become pregnant again and think it’s unhealthy for either the fetus or the young child. Despite these reasons, there is definitely still an association between malnutrition and poverty, because a lot of mothers will say they know they should be feeding their children beans and vegetables instead of potatoes but can’t afford to buy them.   

One of the saddest things for me personally here has been seeing children who are not enrolled in school.  In Uganda, parents have to pay school fees every year for their children to be in school and buy school uniforms, which some parents cannot afford. A six year old who is not in school now will probably have a difficult time catching up to her peers if she ever does eventually enroll, and is more likely to marry younger.  I’ve tried to counsel a few families about the importance of enrolling their children in school but I’m not sure if we were really on the same page. I do think that getting every child into school, and keeping them in school, is one way to break the cycle of poverty for some families, the question is how to achieve this.   

One thing that’s been difficult for me is that a lot of villagers don’t really understand that I’m a medical student, not a doctor, so they come up to me with all their medical problems, expecting me to help them.  I’ve had parents bring their sick children for me to examine, but best I can do is advise them to go to the hospital.  In one village the other day, an elderly man kept asking me to see a psychiatric patient in his village, and I said over and over that I have no training in psychiatry and wouldn’t know what to say, but I felt bad that I wasn’t able to help. I’m going to try to connect him with one of the hospital psychiatrists so hopefully he will get the help he needs.   

 The thing we’ve been doing that I think has helped these sick villagers the most is transporting them to the hospital in our work van on our way home, since we’re going in that direction anyway and the hospital is a very far walk for many of the villagers. We’ve brought quite a few patients to the hospital by now, mostly children along with their mothers.  Two days ago we brought a very malnourished child who was being looked after only by his 11-year-old sister at home.  A few days before that we brought a child who had just undergone a crude tonsillectomy, which is when parents hire a local villager who is not medically trained to scrape out the child’s tonsils and cure them of “gapfura” which is more of a folk illness here. This usually does more harm then good and many children acquire infections from this procedure and sometimes become septic if not taken to the hospital early enough. It was difficult to convince this family to bring their child to the hospital because hospital workers have a reputation for yelling at parents for doing crude tonsillectomies on their children, so parents don’t bring their children to the hospital after the procedure for fear of being insulted. This is dangerous for the children because the longer the parents wait to seek medical care, the higher the risk of death for the child. Luckily, we found this child only one day after the procedure and were able to bring her in while she was still relatively stable, so it seemed like she will be fine.  I think that in order to eliminate this dangerous procedure, there needs to be a combination of greater education for parents and also better treatment of healthcare workers towards families that underwent the procedure.   

Another thing that has been different for me here is the amount of freedom that medical students in Uganda are given to see patients and do surgeries and procedures on their own, versus in the US where medical students are much more restricted about what they can do and what must be supervised.  I shadowed a medical student on the pediatrics ward and we were seeing patients, he needed a break and asked me if I could finish up seeing the last few of his patients for him. I felt uncomfortable telling him no but had to explain that I did not have the training at this point to do that. I also spent a day shadowing with Marie Stokes, an NGO that does family planning work. I was observing a doctor inserting implants, which is a hormonal device that goes into a patient’s arm. He injected lidocane, inserted the implant in the first patient, and then turned to me and said “your turn for the next one!” Again, I had to explain that this was not something we would be allowed to do in the US and I didn’t feel comfortable doing it. It’s been hard to find a balance between wanting to learn new things and also knowing what my limits are and when to say no.  

Week Five 

Cynthia from Kisoro, Uganda 

July 16th, 2014. Week 5 has been an interesting mixture of nothing happening at all and then a lot happening at once. First, we have a nice group of new friends here in the form of two residents, a fellow, and a nurse from the US. The residents, Nate and Sean, are from the family and social medicine program at Einstein/Montefiore, and they are here for one month. They are both really awesome people with great stories, and they are a lot of fun to hang out with and learn from. Having them here helps a lot, since for the last month the hospital really hasn’t had any doctors at all. The fellow, Nori, is literally the most awesome and impressive person who has ever lived. I couldn’t invent a more incredible life story for someone if I tried. He works at Montefiore also, very closely with the global health faculty, and he has been coming here a few times a year for the last couple of years so he is very familiar with everything. He is exceptionally helpful at making the hospital run more smoothly, and he is a wonderful teacher, so it is spectacular to have him here. Adam, the nurse, has just arrived, but he has also been here in Kisoro before and seems really great too. So we are all pretty happy with the crew that we have, and it has definitely made all of our group dinners more exciting.

Unfortunately, while we are saying hello to all of these great people we are saying goodbye to Liz. As great as all these new guys are, there is no one and nothing that can replace Liz. The three of us girls have spent so much time together these last five weeks, and Liz has taught us so much, I just don’t know how we will finish this trip without her. I’m really happy that we got to have a celebration for her on Sunday though. Since Sundays are our only days off, we dedicated the whole day to Liz. In the morning we hiked over to the nearby lake, Lake Mutanda, and we relaxed and swam for a few hours. Then we came back to our house and cooked a giant dinner. We had all of our Ugandan friends over as well as all of our American friends, and we had a nice big celebration. It was pretty great, and Liz was extremely happy. It is so sad to see her go, but I think we have learned enough to make her proud the rest of the way here.

Up until Sunday, we had a pretty normal work week. Tuesday, Friday, and Saturday we had nutrition follow-up surveys. They have been going well generally speaking, we have seen a good proportion of the kids we want to find in each village and we are collecting data that we think will be really helpful at evaluating and improving the nutrition program. Wednesday we had our focus groups, and we did a session about sanitation and diarrhea. It may not sound like it, but it was a lot of fun. We had drawn out some comic strip-type stories to illustrate different methods of the spread of germs that cause diarrhea (the four F’s: fingers, flies, fields, fluids), and we did a demonstration of how to make oral rehydration salts (ORS). The villagers were laughing and having fun and definitely learned a lot, so I felt like it was a good session. After that we just did a lot of data entry and analysis work, it is really never-ending.

Thursday was a lot of fun because we got to shadow in the chronic care clinic with the residents and Nori. I feel like I learned more that day than I have in weeks at school. I saw some really interesting cases, learned how to tell the difference between malaria and typhoid fever, heard some very bizarre heart murmurs, and generally was reminded of how great medicine is. I am so happy every day that this is the path I have chosen. One of the best things about days at the hospital is that everyone goes out to lunch together at a restaurant right across the street that we just call “beans place.” As the name implies, we eat beans there, and they are bloody marvelous. It’s a huge amount of food for less than a dollar, and it is just great. After lunch, the residents and Nori went back to work on the wards and we had a meeting with some of the administrators here to present our findings from surveys we did earlier in our stay. We had interviewed all of the new VHWs to get an idea of what their experience has been so far and any issues they are having. They had a lot of good suggestions and some recurrent issues, so we presented all of those findings to Deus (the head of the VHW program), Sam (one of the other program leaders), and Dr. Michael (the medical director of the hospital). It was a really great meeting, and I think that we were able to share a lot of helpful things with them and that we came up with a good plan to keep the program moving forward. After that, as always, Thursday is market day. We had a particularly good market day at the big market where we were able to find a lot of great fabrics and get some gifts for people.

Friday was the big day that kind of still has me unsettled. I have not included names of people or places involved to protect their privacy. We went to do more nutrition follow-up surveys, and since this one village had a huge number of kids, we all went together. The surveys went well and everything was good until the end of the day when we were finishing up and getting ready to leave. There was one little boy who we found was malnourished, but there were no parents or anyone around. The villagers told us that the boy is 9 years old, and that his 11 year-old sister is his primary caretaker. This was disturbing information for several reasons. First, the fact that he is 9 seemed nearly impossible because he is the size of a small 3 year-old. Second, an 11 year-old girl taking care of 4 other siblings is generally appalling, and very worrisome for the future health and wellbeing of all of them. There is no way that she can go to school, it is unlikely the others will go to school, there is no way for them to get money to buy food, it is extremely improbable that they can raise enough crops to feed themselves, and the whole situation can easily spiral into early marriage, disease, death or one of several other depressing outcomes. We learned that the parents had divorced and the mom left the village while the children stayed with the father. They told us that the father was sick and incapable of, or unwilling to, care for the children. Looking at this 9 year-old boy, we knew we had to take him to the hospital because his malnutrition was severe. So we began a quest to find an adult who would be able to accompany him to the hospital. The villagers thought that maybe a grandmother would be able to go with us, and they sent someone to find her.

While we were waiting for someone to come, we tried to find out what we could about the family and the boy. All of it made me really angry. I could not and cannot understand what would ever make parents completely abandon and neglect their children. Seeing these 5 kids all sitting there dirty and hungry and afraid, the poor oldest girl doing her best to look and act like an adult while having no idea what to do, was one of the most heartbreaking experiences I have ever had. This is not, of course, unique to Uganda. There are children neglected in much the same way in the US. But I have never seen it, and this first experience with such a situation will not leave me anytime soon.   

Eventually, much to our surprise considering what the villagers had told us, the father of the children arrived and agreed to accompany us to the hospital with his son. When we went to walk to the car, the boy did not seem to want anything to do with his father, and when Liz went over to him, he was more than willing to let her carry him. That may be the greatest understatement in the history of time. He clung to her desperately, in a severely needing way that seemed to indicate that he may die if she ever let go. When we got to the car again, one of our friends/translators, Julius, got the boy a snack and a drink from a shop along the road. Then we began the long car ride back to the hospital. We tried to have the boy sit with his dad, but he was not happy there, so he sat with Liz for a while. Eventually she decided that since she would be leaving soon, it would be better for the boy to bond with someone who will be around longer and can see him in the hospital, so he came to sit with me. I cannot describe the way it felt when he held on to me. I have held very many children before, and never have I experienced anything like this. He wasn’t holding on like “oh this is a nice place to be, I can stay here” like most kids do. He was latched on with an iron grip, and if my arms around him were even slightly slacker than his own arms around me, he would whimper and squeeze that much tighter. The intensity of being needed this way gave me feelings I don’t know how to put into words. There were a lot of feelings, and they included that same anger that I felt toward his parents earlier, because what kid is more comfortable with complete strangers than his own father? What is going on in his life that he responds this way? How long has it been since he has felt a caring touch? The dominant feeling that surfaced through all the others, however, was a fierce determination to do whatever may be necessary for this child. I was ready and willing to fight to the death for this boy. I have never had anyone need me the way he thought he needed me, and I refused to betray that kind of trust.   

When we got close, we stopped by our house and Liz collected a kind of care package for them for their stay at the hospital. Then we finally arrived at the hospital, and we brought him to the pediatrics ward to get him admitted and start evaluating his condition. This proved to be more difficult than anticipated because we couldn’t find anyone on the pediatrics ward at first. Eventually a nurse arrived, but she refused to believe that the boy was actually 9 and that he needed to be there. Thankfully, we found some of the 4^th year students and Elena came to help us and get his admission note ready. Nori was concerned about possible HIV and had us do a rapid test, which was thankfully negative. Liz went to go get dinner for the boy and his father while I stayed with them. After going through a full interview and part of a physical exam so that they were ready to be admitted and get settled, the father told us that he is HIV positive and didn’t bring his anti-retroviral medications, so they would have to go home. I begged and pleaded and argued as hard as I could in every way that I could think of to keep the boy with us at the hospital. It had taken so much to get him there, he was clearly scared and confused, definitely not a normal size or at a normal developmental stage for a 9 year-old, chronically malnourished and mistreated, and they wanted him to leave and come back on Monday. I lost this battle. I was terrified that the father would not bring the boy back on Monday. I did not trust him at all, the way the boy did not seem to even like him disturbed me intensely, his contentment to allow his 11 year-old daughter to run his household infuriated me, and I felt it nearly equal to endorsing abuse to let this boy leave with him. But we took every possible precaution, informed the village VHW, and sent our own transport service to pick them up on Monday to bring them back. This was successful, and the boy is now at the hospital being evaluated and treated. On Friday evening when I watched them leave, though, I was utterly distraught. This whole encounter has really made me extremely grateful that I am going into medicine, but it has also made me think a lot about where I want to work later in life and who I want to be helping. I don’t know the answer to that question yet, but this boy has given me a lot to think about.

Saturday was another nutrition follow-up day, as were Monday and Tuesday. They were not really remarkable in any way, except that on Tuesday not one of the children we weighed or measured cried at all! That was a first, and a very welcome one. Last night was Liz’s last night here, so we went on one final hike together and Wanda made a spectacular cheesecake to celebrate. Early this morning we woke up to say goodbye to Liz, which was very hard. But the day has gone well since then, and we had a good session with our focus groups, beginning a discussion about domestic violence. Later tonight when we have dinner without her I think we will really feel Liz’s missing presence. At least the last few weeks we will be really really busy so that it will be hard to notice how much we miss her. I’m definitely missing everyone at home too, but I am appreciating my experience here more and more every day. I never expected that this trip would change me so much, but I know that I am not going to go home the same person I was when I started this journey. I don’t think that’s a bad thing, and I am kind of excited to see where the new me finds herself going after this.

July 11, 2014 

 

Week One in Uganda 

We have been here for one week now! It’s kind of crazy. It feels like we’ve been here much longer since we’ve settled in so much. I thought adjusting would be more difficult, but it actually hasn’t been bad at all. I’ve gotten used to the no refrigerator or microwave, no kitchen sink, no hot water, boiling everything, brushing teeth with bottled water, tucking in my mosquito net all around my mattress at night etc etc so it all feels pretty normal and natural already. I’m probably going to get back to the states and do weird things. But life is really good here. The weather has been very mixed, and not what I expected at all. Since we are up in the mountains, it isn’t very hot. Some days it can be quite chilly. The rainy season is supposed to be over, but it seems to be clinging on a bit, so we have had more cloudy days than sunny days, and it is supposed to rain most of this next week. I’m hoping we get some more sun soon though, because when the sun is out and the clouds burn off it is hot and lovely and all the mountains that have been hiding behind the clouds and mist are visible. Attached is a picture from one of the sunny days of our biggest volcano! I really hope that it does start being warmer more consistently since we had a rough winter at home and I just want to be warm finally.

The week was really good, I got to do all different activities and see many different aspects of the system and get a lot of varied perspectives. On Wednesday we led focus group discussions in a couple of villages, and that was so much fun and very interesting. We were supposed to lead the groups in pairs, but one of our group has been sick  most of the week so  I led our group by myself. It wasn’t really by myself though because we each also had a counselor from the hospital and a translator with us. Joseph and Julius were the two who worked with me. The village where my groups are is called Nyagihenge. It is exceptionally beautiful, pretty much right in front of the volcano. I was super surprised at how many people showed up for the group, especially because this program was new to this village. We had expected maybe 8 each for men and women, but we had 25 in the men’s group and 18 in the women’s group. We spent 1.5 hrs each with a group of men and a group of women. The topic was stress and how to manage it, and it was so interesting to hear everyone’s thoughts. When I asked them at the beginning to define what stress is, they gave some really eloquent and poignant descriptions since the word itself was very foreign to them. My favorite response was from one man who said “you have one worry and then another worry and then another worry, and they are all in your head at the same time. This means they keep crashing into each other over and over so that it is hard to make any of them get better.” I found it very interesting that the men and women listed almost identical stressors in almost exactly the same order. I thought is was profound that the worries these people had in a tiny village in rural Africa were the same worries most people have back home. Their biggest concerns were about their children – children being healthy, children behaving well, children doing well in school, being able to pay for school. I really loved how much our discussion emphasized how undeniably alike all people are in the end. The biggest surprise for me came when we asked the groups at the end of the discussion what topics they would like to talk about in future sessions (we will be there every Wednesday). It blew me away that the men said they wanted to learn more about family planning, pre-natal care, and domestic violence. Even though these sessions are some of the most work that we have to do here because we have to spend a lot of time making plans for them well in advance, I know that they are going to consistently be high points of my week.

Thursday was a pretty quiet work day because we stayed at the compound and worked on organizing data from the nutrition program here. We are going to be going out to the villages where the nutrition program for malnourished kids has been going on for a long time and try to follow up with the kids who finished the program to see how they are doing now and how they/their parents think that the program impacted them. In order to do that we had to sort through all of the data that has been collected over the years and find all the kids who have been cured along with their identifying information so that we can locate them in the villages when we go to do the surveys. I’m really excited about this project and the other work we are going to do with the nutrition program because it can have a huge impact and save/improve the lives of so many children. The nutrition program itself consists of identifying children who are malnourished, delivering regular nutrition supplements to them, educating their caregivers about nutrition, and monitoring the children’s progress. If they do not improve with the supplements at home, they are sent to the hospital where they can be treated on an in-patient basis until they are more stable. We are hoping that our follow up surveys will show that the program has made a positive difference to the children and the families. Later this month we are gong to expand the program to new villages, starting with big screening days weighing and measuring all of the children in each village.

The best part of Thursday was going to the market in the afternoon. Monday and Thursday are our market days, and I know that is what I will miss most about life here when I have to go back home. Getting pounds of fresh fruits and vegetables for a few dollars total is amazing. It is way more fun and way better tasting than supermarket shopping, especially supermarket shopping in the Bronx. We got so much food this time because on Monday we were way too timid and ran out of everything super fast. There is so little we need to go to the supermarket for here, basically just peanut butter, dairy, and canned things. In addition to raiding the vegetable market at the end of our driveway, we went down to the big market in town, which is like an explosion of people and colors. Anything you could ever need you could find at the big market. Liz is experienced in all these things, so she showed us how to pick out nice fabrics that we then took to the local tailor who is now making us our own traditional Ugandan clothes! I will be sure to send a picture of that once we pick them up. To buy the highest quality fabric and have my own custom dress made, it cost me a total of $12. It is going to be impossible to return to New York. We had a great big potluck dinner with all the students here that night, and the girls who have been here for the year really know how to cook with the food and materials here. I took the easy way out and made guacamole, which is awesome because the hardest part was making sure the raw vegetables were clean and no one will ever complain about there being lots of guac. I am definitely going to apprentice myself to Wanda though, she knows where to get the best of everything in town and has some of the most delicious recipes.

Friday was a more interesting day because I went out with a project assistant named Jerome for the chronic disease follow up program. What we do there is go out to the villages and find people who missed appointments in the clinic. We see how they are doing and try to find out why they missed the appointment and try to convince them that they should be in treatment. I really liked it because we got to go to so many different places, and the process of finding patients means we got to talk to lots of different people. It was really remarkable seeing where people live and being invited into their homes. Almost everywhere we went we had to park when we got kind of close and then hike over to the patient’s house. There was definitely a range of homes, some larger or smaller or multiple buildings, but most were made with mud walls with wooden skeletons and metal roofs. We didn’t have a great success rate, unfortunately, only finding 2 out of 7 patients on our list. It was a very sad day because 2 of those we didn’t find we learned had passed away. This was my first experience sharing in someone’s loss here, and I found the language barrier more frustrating than ever. I think that in these times words are not really the most important though, and I felt that just being there sharing in grief together was meaningful. I am looking forward to my next day out with Jerome, and I am hopeful that we will find more of our patients in better health.

I’m still not used to being a sort of celebrity presence. Having people stare at us and chase us and yell after us all the time is totally crazy. When I was out with Jerome even just driving by, people along the streets were yelling “Mzungu! Mzungu!” (the word for “white person”) and sometimes “How are you?” which is the only English phrase many people know. When I went running in the afternoon, I ran by one of the schools when the kids were getting out (which is late here, around 5:30) and about 20 of them swarmed around and ran with me for about 10 minutes. It made it a little harder to run because all the kids wanted high fives or to touch my arms or hold my hand, and one figured out I was ticklish, but it was definitely a lot more fun than running by myself (which is a real pain here still because of the altitude).

I was lucky to have the day off on Saturday, but without everyone else around it was pretty quiet. I would have gone adventuring, but it was rainy and cold, so I stuck around the compound and got things done here in the morning. Thankfully it cleared up a bit in the afternoon, so once people got home from work Liz, Hannah, and I went on our first hike up Hospital Hill, led by Emma. It wasn’t a terribly long hike, but the ascent was very steep and there wasn’t exactly a real trail. The view was amazing though. On the way up we got a spectacular view of our town and the hills and mountains all around us. If it had been a clear day we could have seen for miles and miles. At the top we could see the other side of the hills to the beautiful lake. I attached a couple of photos from the hike also even though the clouds and mist make it hard to see everything. It is so beautiful here, I’m not sure it is a real place sometimes.

Today we are going to hike to the beautiful lake we saw from the hill with the older students and some of our Ugandan friends from work. I am sure it will be another lovely day. I am looking forward to all that this next week will bring, and I will try my best to keep you updated. I hope things at home are good and that someone is watching the World Cup for me, since we don’t have tv here and we’re missing it. So much love to everyone, look after the USA for me. 

 

Week Two in Uganda 

It is hard to believe we have been in Kisoro for two weeks now! In some ways it feels like so much longer because we are so comfortable and settled in, and in other ways it feels like a blink. We are getting to be very busy, so the time is really flying. This week has been extremely packed and exciting, it feels good to be getting into a routine and starting to understand everything better.

On Monday and Thursday I went out to do interviews with some of the new Village Health Workers (VHWs) that are currently in training. It was a lot of fun to get to talk to them and hear about their experiences. Most of the VHWs are women, and a lot of them bring their children with them to things, so that is lots of fun because I got to play with babies while we did the interviews. In asking the VHWs about their work, I was really pleased to see that they are all so enthusiastic about everything. I didn’t realize until I talked to them how much work they actually have to do, and it was extremely impressive how they are able to balance everything. As I mentioned, most of the VHWs are women, and most of those women are pregnant or have several small children in addition to their duty to work their land and then be responsible for the health of up to 700 other households. None of those are small tasks, especially because the average household in the villages has at least 8 members. I was truly inspired by their dedication to the program, despite any challenges they have faced and sacrifices they have had to make. All of them describe their position as one of honor and privilege. Several described it as a calling, and something they hope to spend the rest of their lives doing. This hit home for me in a big way because it resonates with how I feel about going into medicine. So many of the VHWs talked about how important it is to them to serve their community and educate people who don’t know about important health issues, and they all truly believed in their ability to make big impacts and save lives. I understood their feelings so easily, and looking at many of these women who are so close to my own age, I wondered if they had been born into circumstances like mine, maybe instead of 5 children they would have 5 years of post-secondary school education like I have now. Such thoughts don’t seem to ever cross their minds, and they are some of the happiest people I have met here, which means easily some of the happiest people I have met in the world. But I thought about it because their spirits and convictions about their purpose were so strong, and I feel like medicine could definitely use more people with that attitude. After speaking to them, I feel ashamed for ever thinking I have had a lot of work to do. They are beyond incredible, and although I am here to teach them, I think they are teaching me a lot more so far.

 

Monday was otherwise only significant in that it was the first clear night since we have been here and I finally got to see the stars. If you are not aware (doubtful if you’ve spent any measurable amount of time with me), I am mildly obsessed with stars. The greatest present I have ever received was having a star named after me. In the Bronx, the unfortunate reality is that the stars are simply not visible. The most stars I saw at one time this entire year was 5. So since the minute I got here I have been watching the sky exceptionally intently. Because of the cloudy weather we have had most days, this was completely unsuccessful for a full week. But Monday it was finally clear, and it was worth the wait. It was like sitting under a great, glittering dome. There really aren’t words for it, but it was marvelous. I sat out there for a good amount of time, just enjoying the sky and the quiet, drinking hot chocolate and thinking that heaven might be something like this.

On Tuesday I went out to two villages for what we call “supervision.” Twice a month, a supervisor visits each VHW and checks on how they are doing and verifies that they are correctly identifying and treating cases. For some of the VHWs who have been working for 6 years now, that can involve some pretty impressive stuff. I went to two villages with two of the new VHWs I had interviewed who are still in training. That meant they didn’t have too much going on yet, but it was fun to go around with the supervisor, Evary, and learn along with the new VHWs. We got to visit a few mothers who gave birth within the last two weeks, and that was wonderful. I think that in many ways it was similar to what would happen in the US when the baby visits the pediatrician, but I think that the emphasis on nutrition and family planning were probably a bit heavier than we see at home. While we were walking around, Evary asked me about malnutrition in the US. He was completely shocked to learn that malnutrition the way they have it here is a very rare occurrence, because here it is at near epidemic levels. Evary works on the pediatrics ward, mostly with malnourished children, and when I tried to explain to him that we have a problem with obesity in children under 3, he really struggled to understand how a really fat baby could be a bad thing. I tried to explain to him that it’s not so terribly different than the malnutrition in children here—that in most cases it isn’t because they don’t have food to eat, but that they don’t have the right food. I tried to explain that families in the US have too many options, and they often choose the wrong ones, so that children still don’t get the good and important things that they need. It was a very interesting conversation, and I think that we both learned a lot about the issues we’re facing.

In the village that day shortly after our malnutrition discussion, we visited a home with many children where I was given food from a family for the first time. I was extremely touched because I know that they don’t have food to spare, it was a very bad year for all of the crops, and the yields have been very poor. I would have refused it, but that would have been taken as extremely rude. Everyone here is always so kind, and they all go out of their way to show me the greatest hospitality already, when they brought out a huge bowl of food I was nearly brought to tears. It was very simple, the food that everyone in the villages eats – beans and yams (the white and purple ones, not the American kind). But it was very tasty, very plentiful, and very timely because I was getting quite hungry. I don’t think that I have ever felt so welcome and so appreciated as I did in that moment. And I really hadn’t done anything to deserve it. I’ll never forget how happy they were that I ate everything, and they couldn’t stop thanking me for thanking them. It was extremely humbling, and likely to stick with me for a very long time.

Wednesday was time for focus groups again! This week was even more fun than last week. This session was about family planning, a very important topic here where most people know very little and having children too close together is a big factor in the malnutrition problem. We had a lot of fun talking about the advantages and disadvantages of family planning, answering questions, and clearing up misconceptions. Some of the commonly held beliefs were really interesting and crazy, such as a condom can go inside a man’s body and travel around causing problems. By the end of the session, I think everyone learned a lot and they were really excited to tell other people in their village about what they had discovered. We had a lot of people there again, just a few less men the week before because a bad thunderstorm a few days before had damaged many fields and they were trying to salvage whatever part of the harvest they could. When I was sitting safely at home watching that storm, I was just enjoying the lighting show like I usually do. Hearing the stories from the villagers about how it had flooded their roads, destroyed part of the small harvest they had this year, and that there were even several deaths caused by lightning strikes, really changed my whole perspective on it. I don’t think I’ll ever watch thunderstorms the same way again.  

In the afternoon we hiked up Hospital Hill again, which we are trying to make part of a regular exercise routine. The ascent is super steep, so it definitely gets the job done. We also got to pick up the clothes the tailor made for us, which was super exciting. I love the dress I got! It’s so cool having something that was made just for me. There will definitely be more trips to the tailor soon. Pictures to come soon too, I promise I’ll work on that. Our afternoons this week have been pretty busy with meetings and planning because we are getting more into the projects we are working on now and there is just so much data that needs to be analyzed. Most of the week, our free time was spent on that.

Friday was a different kind of day because we shadowed the VHW training day. It was a lot of fun to see how our friends, the 4^th year students and Ugandan friends from the hospital, teach and make the whole VHW program run. The classes were all really well taught, and it was cool to see how they taught medical concepts to people who don’t have any basic science foundational knowledge. Everything was extremely practical, and very relatable to real life situations that the VHWs experience all the time. It was a long and intense training day, from about 8-5.  But even in just one day they covered so much material, with classes about patient interviewing/taking a patient history, mental illness, family planning, high blood pressure, and tuberculosis. I learned a lot from the classes too, so it was a pretty nice day. I have always loved going to school. But really the best part of the day was playing with babies again, particularly the 1 year-old son of one of the VHWs. We were already buddies from Monday when I first met him, Josephat, and his awesome mom, Dorothy. We also were together on Tuesday when I went for supervision in his village, so by the end of Friday after 3 days playing together this week we were totally best friends for life.

Saturday I went out to one of the villages to help with a health census. There isn’t too much to say about it because it was not super exciting. We went from home to home doing a comprehensive check of all of the health issues of everyone in each family. Everyone over 25 was screened for high blood pressure, and every child under 5 was screened for malnutrition. It was a long day, and no one was really available to translate for me, because everyone on the team was actively involved in the process itself, so I didn’t get to be extremely involved. It was really nice to be able to see many different homes and learn more about how people go about most aspects of their lives. It was interesting to me that a lot of people couldn’t say for sure exactly how old they are, and that most people have to walk 3 miles to get water. Just a couple of the simple things that are so unquestioned in our lives in the US and are totally different for people here.

The last question in the census set is about what health topics the family would like to learn more about from the VHW. I was really surprised and excited to see that every single household we interviewed wanted to learn about any and every health topic they could. I wish that our patients in the US were as interested and involved in their own health as people are here. They know much less on average than people in the US to start out with, but everyone I have met so far is so eager to learn and be able to better take care of themselves and their families. For the people out in these villages, the hospital is far away, medications may not be available or may be too expensive, and some treatments we really take for granted are just not present in Uganda at all. For example, the only option for cancer treatment here is surgical removal. If it’s not operable (and less things are operable here than are possible to operate on in the US), there is nothing at all that can be done. If someone needs heart surgery, they have to go to another country if they want to get it. Women want to deliver babies in the hospital because they know it’s safer, but some end up delivering on the side of the road because they didn’t start their 3-hour walk early enough. I think that these realities make people here more aware of the potential impact they can have on their own health, because the vast majority of the time they are the only ones who can manage their health.

I was kind of surprised to see that, even with far less resources, people here live very long lives where they are active and healthy to the end. I have met several people who are well into their 90’s who are still working in the fields all day. I think that the fact that they take responsibility for themselves so much more plays a role in this. I don’t know if there is a way to bring some of that spirit back to the US, but I am definitely more inspired than ever to try and get patients to invest in their own health and improve their knowledge of health-related issues.

My favorite part of Saturday was getting to Skype with some friends from Einstein. Although things are fantastic here and all the people are great, nothing compares to the kind of family we have there. I am truly blessed to be part of the AECOM Class of 2017.

 Since we have the day off on Sundays, we decided to do a different hike this week that we traveled to. It was a beautiful sunny morning, so we were really excited when we headed out. The hike was really cool, it started in a bamboo swamp, and then as we moved up we entered the rainforest canopy. Unfortunately, by the time we got higher up it had become cloudy and cool again so most of the animals hid from us. But the view from the top was still really awesome. We could only see 4 of the 6 lakes that are technically visible from there because of the clouds and mist, but it was still pretty great. Pictures of that to come soon too.

Things are definitely picking up in terms of activity and work here, so sorry for the slight delay in the update. I’ll try to stay on top of things so I write once a week, but I may slip a little here and there. Overall, life here is great. I am learning a lot every day, and I am so happy I decided to spend my summer this way.

Week Three in Uganda 

That’s good morning in the language here. I’m getting spelling now, really making progress. It’s been another amazing week, including an incredible adventure climbing a volcano and meeting gorillas! But we’ll get to that later. It is generally best to begin at the beginning, and I also like to save the best for last.

So this week started with our first big nutrition screening day on Monday. This is one of our most important projects, and something that we are almost entirely in charge of on our own. We are going into villages in the Kisoro sub-county of Nyuarusiza to identify children with malnutrition so that we can hopefully start a nutrition program there like we already have in the sub-county of Maramba. This program provides children who are malnourished with regular nutritional supplements and follow-up in addition to counseling for the family on how to provide proper nutrition. In order to make this happen, we have to go to all of the villages and screen all of the children under 5 years old. This involves measuring the mid-upper arm circumference (MUAC, a standard measure of malnutrition) and weight for every child and talking to the parents about their past nutrition history. It is a pretty large project, but we can screen a huge number of children in one day when everything is working properly. It didn’t exactly work out that way on Monday, because there was some miscommunication. We were missing a translator, so we could only go to two sites instead of three. And the VHWs didn’t totally understand what we were trying to do, so they tried to screen kids ahead of time and only bring us kids they already thought were malnourished. So when we got there they only had two kids ready to go. But it ended up being ok, we went from house to house and screened as many kids that way as we could, and still saw about 60 kids. I didn’t anticipate how hard it was going to be. Measuring MUAC is just putting a measuring tape around their arm and weighing is a scale with a hook that you hang a kind of pair of pants/diaper-looking thing that is most reminiscent of a baby swing from and put the child in it. Neither of these processes is painful or even uncomfortable, and if I could fit in the weighing thing I would hop right in because it looks pretty fun. But some of these kids scream like we are cutting off limbs. I have been toying with the idea of working in some kind of pediatric field, but this has made me question that a little bit. That’s mostly my eardrums talking, especially since I also had a screening day today. I can’t speak for sure about the nutrition status of a lot of kids or the rest of their health, but their lungs function spectacularly.

As always, Monday is market day and is therefore a great day. We all went down to the market together with the 4^th year girls too, and I ended up getting a few more pieces of fabric to get more clothes made. I decided to try something crazy and gave Mama Beatrice (the lovely woman who makes clothes) a pair of my shorts to copy so that I’ll end up with some crazy patterned shorts. I also got a shirt and a skirt, went a little bit overboard. I am really excited to see how things come out this week when we go pick everything up.

Tuesday was one of the most significant days of my trip so far. Liz and I went out with one of the 4^thyear girls, Elena, and the Family Planning outreach team, who was also working alongside a family planning NGO called Marie Stopes. We all went to a big health center in a sub-county called Busanza, and we had a really mind-blowing day. We got there ahead of the Marie Stopes team, so we had some time just hanging around (kind of the story of life in Uganda). That was pretty great though, because we taught all the kids who were gathered around staring at us how to play “duck, duck, goose.” We modified it a little to be “cow, cow, goat” because those are animals that they actually have here. I have never seen such a simple game get such a huge spectatorship before. After just a few minutes there were at least 40 kids playing and a group of at least 75 kids and adults watching. It was an absolute blast. The greatest way to start a day for sure. Once the team got there though, things started rolling fast. There were educational sessions about family planning, cervical cancer screening, and HIV, and there further breakout sessions about the details of each topic for anyone who wanted to receive services related to any of those things. At the same time that we were there, there was another group performing circumcisions on teenagers and young boys because studies have shown that circumcision helps decrease the transmission of HIV. It was an exceptionally busy place with so much going on, and we were fortunate to be able to see a little bit of everything.

The first thing that Liz and I saw was a tubal ligation by the Marie Stopes team. I have never seen a surgical procedure in the US, but I am guessing it goes a bit differently. The procedures happened in a side room, the size of a small exam room in a doctor’s office in the US. The patients only had local anesthesia, and the doctor and nurse wore gloves and aprons over their tshirts.  The tubal ligation happened through one small incision in the abdomen, and then involved a lot of fishing around with a hook to find the fallopian tubes... I had expected the differences in technology, but I had not been prepared for the difference in attitude toward patients.  I have not found that to be the case everywhere I go here, but I have noticed a difference in the kind of relationships between doctors and patients. I like the way that we try to make things about a partnership at Einstein, and that we do our best to ensure that patients understand everything that is going on and that they have their concerns and questions addressed. Things are a lot more authoritarian here, and people rarely know what disease they are even being treated for, but usually, care is given well and kindly. 

Things improved from there. Liz and I went over to see our own team doing cervical cancer screenings and IUD insertions. We got to observe a few patients, and then Liz and I both got to perform one cervical cancer screening. It was really awesome, and it was nice to remember why we’re going to school for such a long time. One day, it’s going to be worth it to be able to help people like this. After that we also got to see the placement of birth control implants, that are injected into the upper arm and last for 3 years or 5 years depending on the implant chosen. They are very popular for women here, so it was good to understand that better. The last thing that we saw was the circumcision room. There were five tables and five boys all being circumcised at the same time. It was way too overwhelming for me, and so I didn’t stay in there for very long. I understand that it’s important for public health and Uganda as a whole as they work to combat HIV, but I feel like they could do it differently. I’m glad I experienced everything that the day had to offer though, and I definitely learned a lot. We got home pretty late, but it was ok because we went out to dinner with our Ugandan friends and didn’t have to cook.

On Wednesday I was sad because our focus group got canceled. That was sort of alright because I got a lot of work done, but it was frustrating because we traveled all the way out to our village (not a short or easy journey) before anyone told us that the group wasn’t happening. It ended up alright though, I got to exercise a bit and accomplish a lot. In the evening we celebrated Elena’s birthday by decorating the whole yard and making a cake and sangria. She was really surprised when she came home and saw everything decorated, and it was a really nice night enjoying time all together.

On Thursday we all shadowed in the chronic care clinic (CCC) at the hospital, which was a great experience. Patients who have chronic diseases come once a month to get checked on and have their medications refilled. I shadowed with Emma, and it was wonderful. Pretty similar to shadowing in a clinic at home, just a little bit more difficult when someone needed to be admitted to the hospital or if a certain medication ran out. We are going to start shadowing there regularly soon, so I am pretty excited about that. Friday was also a nice day, I went out with Jerome to some of the most beautiful villages I have seen so far. Every day is an adventure here, and I feel so lucky to be able to experience it all. On Friday night we went out to dinner and met a British law student who happened to be visiting Kisoro. He was really friendly and fun, so we invited him to come to dinner at our house on Saturday before he headed back to his summer internship job in Kampala.

Saturday my work ended up being canceled again, so I did more work at home until the afternoon when we started making dinner. We made a kind of jambalaya, and Liz created an oven on the stovetop, so we baked banana bread. We also made guacamole and our own hummus, so we basically had a feast. It was great. After our British friend left, it was time for bed because we had a big day on Sunday. That big volcano I talk about? We went to go climb it. We left home at 6:15 in the morning. As much as we tried to prepare, there was no way to really prepare for what we faced. It took us five hours to reach the top, a summit of 4,137 m (13,500 ft). We were literally above the clouds. I have never seen anything so amazing or so beautiful. The volcano is dormant, and so the top is a giant crater with a lake. We could see exceptionally far, across Uganda and Rwanda. I am putting loads of pictures on facebook, so try to check them out. There is no way I can even begin to convey how incredible it was. The pictures don’t do it justice either, but they come a lot closer. The way down took a lot longer because we were tired, hurting, and I twisted my ankle a little bit. But we got really lucky that the mountain gorillas happened to be nesting when we were reaching their level, and our guides let us go see them. They were gorgeous. And we got extremely close to them. They are so human-looking. We sat and stared at one of the males for ages, and he just stared right back. I was surprised at how comfortable and welcoming he seemed, but I guess they are used to people coming and staring at them by now. Suffice to say, it was an unbelievable day.

This week so far has been good, we are heading into a nutrition-heavy rest of the trip so it’s basically screening days and follow-up surveys all the time. It’s going well though, we saw over a hundred kids each day in each village for the past two days. I am really excited about being able to bring such important services to families who really need them. I know the rest of the trip will be busier than ever, but I cannot wait for everything that is coming. Next weekend we are going on safari in Queen Elizabeth National Park, so the next email will definitely be late. But it will have a lot more awesome stories for sure.

I miss the USA sometimes, mostly just you wonderful people though. And ice cream. I could really use some ice cream. I hope all is well back home! Do the 4^th of July extra big for me!!!

June 21, 2014

This is Hannah writing from Kisoro, Uganda! I've been here for two weeks, and finally feel like I have a good enough understanding of the program here to write a little bit about it. It's been very exciting working here so far, and an amazing learning experience. Our biggest role (myself and the other MSII's, Cynthia and Liz) has been to help out with the Village Health Worker (VHW) program. So far I've found this program to be really incredible. Basically one or two people are selected from every village and trained with basic primary care skills to deliver health care to their communities. So far I've been to some of the villages to meet the VHW's, I've helped in the chronic disease clinic at Kisoro District Hospital (KDH), and yesterday we were able to sit in on a training session given to the new batch of VHW's at KDH. Today I traveled to one of the villages to help supervise a VHW, so I was able to understand his day-to-day responsibilities. Each VHW is responsible for identifying patients with acute illnesses (malaria, pneumonia, etc.) and referring them to KDH for treatment, and then following up on them after they are discharged. They are also responsible for identifying new chronic disease patients and checking up on older ones to make sure they are receiving and taking their medications. These medications are usually delivered through a program called CDCom (Chronic disease in the community), where a van drives around to villages and VHW supervisors, along with VHW's, deliver medications to chronic disease patients. The most common diseases I've seen so far have been pretty similar to those in the Bronx, such as hypertension, asthma, epilepsy and diabetes. One surprise on these visits has been seeing a few young patients with heart failure, probably as a result of rheumatic heart disease. On CDCom visits we take the BP and HR of every patient. I've been a little surprised at the number of patients with hypertension and diabetes, I didn't expect there to be so many. On Thursday at the clinic we had a woman with a BP of 225/120 (!) Overall I've been very impressed at the amount of monitoring and follow-up care given to chronic disease patients. The patients who don't show up to their appointments are promptly visited to see why they didn't show up and to make sure they have their medications. It's a lot of effort to visit every patient with a missed appointment at their home, but I think it really shows that the health care workers care about their patients in a more personalized way. I had one day of accompanying a supervisor on follow-up and it was a really cool experience riding through the mountains on a motorcycle to visit patients at their homes. Mostly (from the few patients I saw) the reason that they missed appointments has been that they were able to get their medicines at a different health center, but this isn't always the case, and I think the follow-up component is really important to make sure chronic disease patients don't slip through the cracks. I also saw a few patients with TB, which is something I haven't seen yet in the Bronx. Yesterday at the VHW training, there was a session on chronic diseases, and Wanda (an MS4) brought in a patient with diabetes for the VHW's to interview (reminded me of ICM!). They learned some basically interview questions the same way that we learned them at Einstein, such as asking the patient about her symptoms, her medications and so on.

Another amazing thing about the VHW program is that it is so comprehensive. For example, the VHW's are trained in domestic violence counseling, and are supposed to identify and counsel victims of domestic violence every month in their villages. They're also supposed to identify children with disabilities, and women to counsel about family planning and refer to the health clinic. In addition, they are supposed to identify all the pregnant women in their villages and counsel them on antenatal care and the importance of delivering in a health center or hospital. In fact, the VHW's get paid a bonus for every women they counsel who delivers their child at a health center. They are also supposed to identify children at risk of malnutrition and refer them to the hospital or enroll them in KDH's nutrition program. This is one of our projects for the summer, on Monday we're going to four villages to take MUAC's (middle upper arm circumference) on children with possible malnutrition, and get children enrolled in the nutrition program. This has been an interesting experience for me because I haven't seen many malnourished children in the US. The children qualify as moderately malnourished with a MUAC between 11.5 and 12.5 cm, and severely malnourished with a MUAC less than 11.5. So far I've gotten to take weights and MUAC's on some children, for the weight we bring a hanging scale that we just have to find a tree branch to hang it on, and then there is a seat attached that the child sits in to get weighed.

The VHW's are also trained about the importance of mental health and how to identify mental health patients in their villages. I've probably forgotten a few other aspects of the program, but I'm sure you can tell by what I've written how great and comprehensive it is. It's like having a primary care provider for every village, who makes home visits and can even give out some basic medications, and are trained about when to refer patients to the hospital. I also think it's great the the VHW's receive an incentive (a small amount of money) for every patient they refer to the hospital, and every malnourished child, pregnant woman, domestic violence victim, person for family planning or chronic disease patient they identify and counsel. (I'm probably forgetting a few other incentives). I think this is such a great way to encourage the VHW's to go out in the community and help the villagers. They're also encouraged to makes sure all young children receive proper immunization. I think it's also important that the VHW is usually nominated by their own village to become a VHW, which infers that they are usually a respected member of the community.

I also forgot to mention that the hospital care is free, including medications, (I’m not sure that everything is free, I’ll have to double check what is and what isn’t), but there is also an insurance program called TPHP that gives extra benefits to members, including transport to the hospital. This is a much needed service because many villages are very far away from KDH.

One other project that we MSII's are involved in has been leading focus groups, which has been really interesting so far. We go to the same villages every week and help write and facilitate a session along with some of the KDH staff, who translate for us and mostly lead the session. Our first session was about stress and second one was about family planning. The common methods of family planning used by villagers here are the implant (goes into the upper arm, lasts about 3 years) and Depo injection (lasts 3 months). Condoms are rare here in the villages, but I think more commonly used in cities like Kampala. I've learned a lot of interesting things from the focus groups, especially about the different perspectives of men and women here. This is going to be the subject of an entire paper at the end of the summer so I won't go into too much detail here.

Kisoro is a really beautiful place and it's been fun exploring so far! Last weekend I hiked to a nearby lake and tomorrow we're going on a hike through a bamboo forest. We're doing a safari at Queen Elizabeth park in two weeks, and will hopefully do some bigger hikes and will maybe see some gorillas before we go! Kisoro has market day every Monday and Thursday, where people brings in their crops to sell, and I've really enjoyed going to the market and trying new foods. That's it for now!I'll update soon about the nutrition project and hopefully some women's health shadowing and other projects!