Today on the Little Man, Joseph Glover follows up his previous article on his time in Uganda with a further piece on his experience working within the Ugandan healthcare system. Enjoy.
As I described in my previous article my elective was carried out in Gulu Regional Referral Hospital in the city of Gulu in Northern Uganda, the poor sibling of the country’s more prosperous and better-funded South. Ravaged by two decades of guerrilla warfare, I was unsure as to both the reception I would receive, and also the atmosphere to expect in an area that was, as recently as 2008, described in a guide book as “suicide” to visit. As soon as we arrived in Gulu, however, we experienced an extremely amicable reception from everyone that we met, and were enthusiastically and exhaustively shown around the entire town by the gardener at the compound in which we were staying. Having had this welcome, and copious introductions to a multiplicity of people over the next few days, I felt well placed to begin the elective proper, which was based in the government hospital just up the road.
It was clear, as soon as we were introduced to the wards, the doctors and nurses with whom we were to be working, that the placement would be extremely patient-centred, with all of my time to be spent directly caring for patients, both on the ward and assisting in the operating theatre. I had requested to be assigned to the surgical ward, to which there were also allocated two regular intern doctors, the equivalent of an English FY1. My role on the ward involved attending the ward round on Wednesdays and Fridays, assisting with seeing patients in the very overcrowded surgical outpatients clinic on Monday mornings, and then scrubbing up for full theatre days on Tuesdays and Thursdays. The clinics and the theatre days were the times I found most stimulating, but also most challenging, due to the resource and delivery of care that I will shortly describe. Ward rounds were informative in terms of clinical learning and experience in the treatment of conditions common in Gulu, of which I had had very little prior experience in the UK. On the ward round I would take part in assisting the two interns in dressing extensive burns, setting up fracture patients for a lengthy six week stay in traction, reviewing post-operative patients, and helping in the minor operations room. One of the most striking of these was the sheer volume of burns cases, seemingly affecting all age groups, and apparently so common due to the need to cook on an open fire with large quantities of flammable cooking oil and gasoline in the vicinity. Unfortunately this meant regular admissions of babies with severe facial and head burns, mothers with whole limbs left without skin, and also a very unfortunate case of an epileptic teenage girl who was not properly medicated, who had a fit and fell into a fire for an extended period of time. The scale of damage to her arms and more so to her left hand unfortunately necessitated the amputation of all the digits on the affected hand (an operation in which I assisted the intern doctor). As with so many stoical patients on the wards in Gulu, the thirteen year-old bore the trauma of losing almost all function in one of her hands with great bravery and little complaint.
There were huge contrasts in the quality and delivery of everyday healthcare on the surgical ward, many of which I felt were significant shortcomings, which unfortunately contributed to the relatively high mortality rate in the unit. One pertinent example of this was the serious lack of a pre-operative work-up for surgical patients, something so universally and scrupulously undertaken in the UK. This meant that many patients were not in fact surgical candidates, but underwent operations regardless, leading to very avoidable intra and post-operative complications and even deaths. I experienced first-hand these deaths which were attributed to poor preparation and were perhaps further influenced by the fact that the anaesthetics was carried out not by an anaesthetist, but by a local Reverend with some very basic training. The other main contrasts in care were to do with life on the ward. The way in which patients are treated on the ward seemed to me to be in many cases the polar opposite of how it is done in the UK. First of all, there does not appear to be any emphasis on confidentiality or dignity of the patients. This is partly due to the lack of resources in that there are no separately curtained bays on the wards, but also due to the frankly cavalier attitude of some of the doctors and nurses towards the preservation of patients’ dignity and modesty. This treatment is meekly accepted by the patients, who I felt did not feel that they had any say in how they were treated. Furthermore, the patients’ clinical records and details of their conditions and treatment were discussed very openly on the ward rounds, therefore denying them any individual confidentiality. These were not isolated cases, and seemed to represent a cultural attitude to patient care, at least in Gulu.
The nursing care was another primary difference that I came to notice throughout my placement on the surgical ward. There appeared to be a very limited role undertaken by the nursing staff on the ward, restricted to giving out medications on a once daily drug round (frequently done less than once daily), and writing in a large ledger for long periods of time. Whether it be a cultural or a resource-based deficiency, the nurses did not wash, clothe, feed, change patients, provide linen for bedding, do any basic observations, or dress any wounds, apparently staunch in their belief that the lion’s share of the work on the ward should be done by the interns. Inevitably, however, this unequal workload lead to numerous occasions of accidental or deliberate neglect of patients, and below-standard medical care, such as post-operative patients in much pain going for several days without the necessary painkillers, despite the fact that the drugs had been legibly and correctly prescribed by a doctor (accurate prescribing was something of a rarity in itself). This phenomenon was also observable on the medical ward, often with far more dangerous results, such as patients with a florid bacterial meningitis being denied antibiotics for days on end. The work done by UK nurses, such as feeding, washing and generally caring for the patient on a day to day patient is done in Uganda by ‘attendants’ – relatives with no medical training or experience. If a patient had no family or friends, as was the case with many older patients, they would simply have to go without these basic necessities. Obviously there were economic factors at play here as well, with many families plunged deeper into poverty by having the breadwinner of their household in hospital, normally for an extended period of time.
Sadly, economic means played a large part in patients’ treatment and subsequent survival, or lack of. The lack of resources affected both hospital and patient alike, with the hospital being unable to provide basic diagnostic and investigative services, due to the lack of funds. The hospital director himself estimated that the hospital required a budget of £400,000 a year to run efficiently. Gulu hospital currently receives just less than half this figure, primarily due to corruption, poverty and a near tangible degree of governmental inertia. For example, the WHO defines an X-ray machine as part of a minimum services list for a provincial hospital, which Gulu is. And although Gulu hospital does indeed have an X-ray department, it was functional for just two days of the eight week long placement we spent there. This meant that patients would be required to visit the main town to purchase a private X-ray from a clinic, which was often well beyond their economic grasp. Even if patients could afford to be investigated and diagnosed at the private labs and clinics in town, the next step was medication. Again, there were major issues surrounding this. Many drugs that were prescribed were unavailable in the hospital pharmacy, meaning patients had to buy them from the pharmacy in town, often at significant expense. This presented not only the problem of affording the medication, but also that of actually acquiring the medication from the pharmacy; extremely difficult without an attendant.
All of these issues left a distinct frustration in the treatment of every patient, knowing that in the UK this or that patient would have received much better and more timely care, or at worst, certainly would not have died without any treatment or investigation, as they did so frequently in Gulu. Having said this, it is also crucial to emphasise the tireless efforts of those doctors and nurses who do care about the patients, and who do make an incredible difference, even in the resource-deprived setting of a poorly-funded provincial hospital with a reputation for admittance without remittance amongst the local population. I felt that on a personal and a professional level I learnt so much in those eight weeks, not only how to manage patients with little or no resources, but also how to show compassion and level-headedness, from the interns who are on call every hour of the day, every day of the week, for every day of the year. These experiences have given me renewed appreciation of the privilege and excellence of the NHS, and all those that work within it. This realisation of the privilege we enjoy in our healthcare system has and will affect my practice indefinitely. I only wish I could have contributed more, which would have been possible had I been a more experienced doctor. I certainly intend to return several years hence, and once again immerse myself in the absurdities, mediocrities, complexities and great mysteries of Ugandan healthcare.