what Africa needs...
on Random Uganda (Uganda), 17/May/2010 11:23, 34 days ago
Okay. So I may be a little slow. It has taken a while to sink in.Maybe it should have dawned on me when I was at the Serengeti visitor center (a lovely facility funded by the $50 per person park fee paid by tens of thousands of annual visitors and kept spotlessly clean by a well fed team of rock hyraxes and dwarf mongooses—mongeese?) and half way through a much needed pee break I felt a warm sensation between my toes. The brand shiny new urinal I was using drained into a pristine stainless steel pipe, which went down to the floor… where the urine was directed onto my foot.And maybe It should have hit me when I went to Uganda Interpol to get my fingerprints done (just as I had to get fingerprinted by the California state police to get a clearance before coming over here, VSO wanted me to get fingerprinted just to make sure that I hadn’t committed any crimes during my sojourn here in Uganda—never mind that there is no computer fingerprint database in Uganda and this set of prints will no doubt be filed by date or color in an ever-expanding, completely useless collection of never to be seen again charcoal smudges). After allten digits had been smeared in tenacious ink and ceremoniously rolled in various orientations across the card I was directed ‘down the hall’ to where I could ‘wash my hands.’ As I walked down the hall I noticed that the walls seemed to be decorated with long swathes of parallel quadruple streaks of black. The sink was broken. There were no paper towels. I was wearing khaki pants and what once was a white shirt.And certainly I had a glimmer of recognition when I tried out the shower in my new housing arrangement, which, as is typical, is without a shower pan and flows directly to the floor and theoretically into the bathroom’s floor drain. The floor drain, however, seems to be situated at the high point for the entire house. So any shower lasting more than 30 seconds floods the living room.And a nascent revelation began to solidify while I was working in the casualty unit at Mulago, a four bed (and I use the word bed loosely under the definition of slightly elevated flat surface), two room unit where hundreds of injured people are cared for daily. I came to the realization that—due to a lone sink out of which, when it works, you can only coax a trickle of toxic looking black effluent—I was working in a place where blood literally flows more freely than water.But it finally hit me while I was at IHK (according to Wikipedia, an‘upscale, tertiary care medical facility’), in the A&E and I went to wash my hands and, after filling my hands with liquid soap from the dispenser which, uncharacteristically, had soap in it, I had to go from one broken sink, to another, to another, before I finally could rinse the sticky goo from my hands:VSO and all the other aid organizations are going about this all wrong.Africa doesn’t need our doctors. Africa needs our plumbers.Seriously. Africa trains a boatload of doctors a year (a boat steaming, for the most part, away from the continent). But maybe more of them would want to stay and work in their home country hospitals if they knew that they might be able to wash their hands after caring for an infectious patient, or if they knew they didn’t have to go into urinary retention during their twelve hour shift because there was a functional toilet somewhere in their workplace.And, for about the millionth year in a row, the first or second leading cause of death in children under 5 is diarrhea—or, as they like to say in England and Uganda, where vowels are cheaper, diarrhoea. I know, diarrhea isn’t as sexy and topical as HIV. The Gates Foundation hasn’t recently announced a multi-billion dollar campaign to eradicate diarrhea (as it has for malaria). But diarrhea kills kids—1.5million of them a year (and an estimated 2 billion people will suffer from diarrhea every year). And you don’t need expensive medicines and doctors to combat diarrhea (with all due respect to Dr. Paul Offit and the new rotavirus vaccine). You need plumbers. You need a safe, reliable water supply. You need a way to direct sewage away from that safe and reliable water supply. And once all that is in place, having a way to wash ones hands before meals would also be a lifesaver. Plumbing. It’s all about the plumbing.I know that by saying this, I am decreasing my chances of ever being invited back. Unless I decide to get a job as a plumber’s apprentice upon my imminent return to the states. But, in part, this has come to me because I think the doctors here have known this (plumbers, not doctors) all along. Or maybe they haven’t had the revelation, they are just tired of foreign doctors showing up and telling them how much better things could be if they only had a little running water and an MRI scanner.When I tell a Ugandan doctor that my specialty is emergency medicine the typical reaction is an amused smile or a suppressed laugh. In their world, emergency medicine is a task left to the interns—immediate post-graduates from medical school, the lowest link in the food-chain. ‘He must be really stupid,’ I can hear them thinking, or saying, ‘If he never made it out of Accident and Emergency. Who would choose a practice where mostly all you do is watch people die. And even if theysurvive, they have no money to pay you.’Not that there aren’t things a Ugandan doctor could learn from a foreign doctor. If they were willing to set aside the monster ego they have developed to shield themselves from the desperate state of medical care here.Case in point. One of our volunteers got a puncture wound to her foot. It hurt. For a few days. She went to one of the mad expat mzungu doctors recommended in the VSO Uganda handbook. She underwent what, in a civilized country, would amount to torture and medical malpractice. Her foot swelled up to twice its normal size. Two of her toes went numb and white. She wound up in the hospital on IV antibiotics. One of the drips infiltrated into her subcutaneous tissue and her arm also ballooned frighteningly.About this time Nancy visited. As most of you know, Nancy is an orthopaedic surgeon specializing in the foot and ankle. So, for the few weeks of her visit, she would have been, by far, the most uniquely qualified person to care for this problem in the country, if not all of East Africa (if she were licensed to practice medicine in Uganda). She looked at our friend’s foot and felt that, even though the swelling had gone way down and the doctors wanted to discharge her, there was still a nidus of infection. She recommended a surgery to open and wash out (we call this irrigating) the wound.Reluctantly, the medical team requested a surgical consult. The hospital’s chief surgeon was called in. Instead of a surgery, he said that all he’d need to do would be to pull the scab off the wound at the bedside, ‘so it could drain.’ When asked about how he planned to anesthetize the foot, he basically said that it was going to hurt and she would just have to suck it up. Needless to say, after having been recently tortured in a similar way by another doctor practicing antiquated medicine, our friend was reluctant to undergo this bedside procedure.In short, here was a highly regarded surgeon who, even though he now practices in an‘upscale tertiary care hospital’ that aspires to ‘international standards,’ was unwilling to put aside bad habits from his intern days at Mulago and try to learn from a visiting surgeon with years’ more experience and specialized expertise in the patient’s problem.But, I digress.My point here is. Maybe we need to rethink the model of sending doctors to places without consistently running water. Maybe we need to get the sinks in the hospitals working so that the doctors that are already there can wash their hands. And maybe we need to consider whether the host country is ready for the western (or northern, whatever) medicine specialty being proffered by the volunteer—maybe Uganda isn’t quite ready for emergency medicine yet, maybe we need to flood UTV with ER episodes for a few more years.Oh yeah. In case you were wondering about my fellow volunteer’s foot. Eventually surgery was performed. Nancy’s assessment proved to be accurate. There was an infection that went nearly all the way through the foot. And even though his assessment and initial plan were incorrect, the surgeon's ego still prevented him from learning from the experience.He refused to open the foot as Nancy recommended and refused to fully irrigate the wound. The patient is back in the UK. Here’s to her full recovery.