Dr. I is a gentle and unassuming man with a penchant for elegant patterned ties, which he wraps around his spectacles when they are not in use. He presides over one of four pediatric wards at Mulago Hospital, each of which rotate in turn as they try their best to admit the hundreds of extremely sick children who arrive at the acute pediatrics unit every day.
The children range in age from newborns to young teenagers, and they fill up the waiting room, resting on their mothers' laps. Frequent crying punctuates the air, as a child suffering from sickle cell anemia struggles in pain. Sickle cell anemia is a genetic condition that occurs when some or all of the red blood cells produced are abnormally shaped and can easily form the shape of a sickle. These blood cells cannot move properly through the circulatory system and easily form clots in the smallest blood vessels, triggering the painful crises that the children are experiencing. Even more troubling is the anemia, or lack of red blood cells, that occurs when the spleen filters out these defective cells.
A rare moment of silence in the waiting room belies the dangerous condition that many of the children are facing. Without a sufficient number of red blood cells, the anemic body cannot bring enough oxygen to the tissues throughout the body, and severe illness and death is imminent.
The on-call responsibilities are taken by Dr. I's ward today, and he scans the waiting room area, triaging the patients to find the sickest ones. It's a simple test: he pulls down the eyelids to see the color of the conjuctiva lining the inside of the eyelid. If you look at your own in the mirror, it is probably a shade of pink or red, depending on how long you have been staring at the computer screen. In the sickest children, the color is a blank white. The same test is done for the tongue and palms of the hands. Similar results are found.
The mothers are instructed to bring their children inside, and Dr. I begins writing the patient's charts. A cursory diagnosis is given, for the first priority is for the patient to receive blood. More detailed treatment options can be discussed later. So Dr. I begins to jot down the patient's history. Other than the genetic sickle-cell anemia, the other common cause of anemia is infectious-pediatric malaria.
Malaria is a disease caused by tiny protozoal parasites. After a nighttime bite from an infected Anopheles mosquito, the parasites enter the blood stream, invade the liver, and spread to red blood cells. The parasites multiply within the blood cells and rupture their hosts when their numbers are sufficiently high.
The patients in the acute care ward arrive only after prolonged waiting and even transfers from other hospitals, so their conditions are often very severe. High fever, anemia, and a marked increase in size of both the liver and spleen can be seen. To confirm a diagnosis, however, a blood smear must be done. Without a lancet, the laboratory technician finger-pricks hundreds of children a day, and smears the blood on a glass slide. A blue field stain and red malarial parasite stain is added, and the slide is viewed under an oil-microscope.
The P. falciparum species of parasites are endemic to Sub-Saharan Africa, and are easily seen. Infected red blood cells present with an ominous red dot, and malaria parasites swimming freely in the blood can be easily spotted. Based on the number of parasites seen in each microscope field, a diagnosis is given: no malaria parasites seen, +, ++, +++, or ++++. Many of the children present with +++ or ++++ malaria.
After the diagnosis is confirmed, the children are moved to the emergency treatment room, where there are cannulated. A plastic cannula tube is inserted into the veins on the back of the hand, but not without much screaming and crying. The plastic screw top is removed and a small sample of blood is drawn to determine the blood type. Four drops of blood are placed on a white tile, and four different antibodies are dropped on each blood spot: anti-A, anti-B, anti-AB, and anti-Rh factor. Swirling the tile around reveals clotting in the anti-A, anti-AB, and anti-Rh spots. The child has A+ blood.
Blood shortages at Mulago are a constant worry. Some of my colleagues witnessed a child who did not receive a transfusion in time and passed away on the table. Each bag of blood is precious and contains life. Gingerly, Dr. I removes a bag of blood from the refrigerator and brings it to the child's mother, asking her to warm it under her arms. The child is transfused, a dose of quinine is given to kill the malaria parasites, and one life is saved for today.
Tuesday, July 21, 2009
Sunday, July 5, 2009
Benevolent Dictator
If you are familiar with the film, The Last King of Scotland, you will have heard of Idi Amin, the ruthless dictator-president of Uganda in the 1970s. Amin seized control of the country in a military coup, beginning almost a decade of tumultuous rule. Political rivals were purged, disobedient military officers were executed, and intellectuals were killed. The Ugandan economy was turned upside down as the merchant class Asian Indians were exiled from the country, taking their entrepreneurial abilities and capital with them. Amin was a brutal ruler who left a legacy of blood and destruction.
Or did he? If you talk to present day Kampalans, you will find a very different opinion of the man. In contrast to the negative view of Amin shared by Westerners, many Ugandans I have spoken to find Amin to have been quite a good leader. Amin was a patriot, they say, who was not without his flaws, but loved his country and did his very best for it. My colleagues and professors who have lived through Amin’s time speak of private secondary schools which only allowed entrance to white or Asian Indians, government agencies headed by those with British heritage, a commercial center with only two African-owned business, and entire hospital floors at Mulago Hospital, where I work, reserved for VIPs – Europeans and Asians. Amin ended all of these practices, they say, and Africanized the country. The schools were open to all, businesses were given (forcibly) to African owners, and an African nation was truly given to Africans. For what was independence, if Uganda was still to live under de facto colonialism?
Sure, there were costs of this transition, as the Uganda replacements were not always as competent or ready to accept the responsibilities of their new posts. But, as Amin said, to learn to swim, one must be prepared to take a few gulps of water before the skill is mastered. Perhaps the African businessmen were not as efficient as the Asian Indians, but at least Uganda is run by Ugandans, a fact that may not be as evident in neighboring Tanzania and Kenya.
My colleagues’ views are not without merit. If I had grown up in what I viewed to be such an unfair environment, it would only be natural to feel resentment toward the European and Asian outsiders who were benefitting from the country’s resources, while local Ugandans suffered. Seen from this point of view, Amin’s populist policies can be judged as not only understandable, but even just.
The younger generation I spoke to, however, emphasized a more negative view of the dictator. Amin was a rash man, they said, who acted on impulse. He would wake up one day, claim to have a dream which called him to exile all the Asians, and then pronounce a law requiring them to leave within ninety days. Many of these Asians were Ugandans by birth, having been in the country for generations. They had nowhere left to go, and the results were devastating. Many ended up committing suicide. Other, more dubious stories abound, such as Amin telling the national football team not to return from Kenya after their World Cup qualifier loss, or face execution, and ordering a brutal murder of his own wife.
There are many views of the man in Uganda, all of them quite strong. Amin’s legacy is quite a complicated one, which surprised me very much, as I expected a strong hatred toward such a brutal dictator. But the public’s views did remind me of another leader who commands a complex legacy, whom I often talked about with my friends while in China. Speaking to the local people about their own history reminds me that human events seldom occurs in black and white, and the Western view is not always the objective view I assume it to be.
Or did he? If you talk to present day Kampalans, you will find a very different opinion of the man. In contrast to the negative view of Amin shared by Westerners, many Ugandans I have spoken to find Amin to have been quite a good leader. Amin was a patriot, they say, who was not without his flaws, but loved his country and did his very best for it. My colleagues and professors who have lived through Amin’s time speak of private secondary schools which only allowed entrance to white or Asian Indians, government agencies headed by those with British heritage, a commercial center with only two African-owned business, and entire hospital floors at Mulago Hospital, where I work, reserved for VIPs – Europeans and Asians. Amin ended all of these practices, they say, and Africanized the country. The schools were open to all, businesses were given (forcibly) to African owners, and an African nation was truly given to Africans. For what was independence, if Uganda was still to live under de facto colonialism?
Sure, there were costs of this transition, as the Uganda replacements were not always as competent or ready to accept the responsibilities of their new posts. But, as Amin said, to learn to swim, one must be prepared to take a few gulps of water before the skill is mastered. Perhaps the African businessmen were not as efficient as the Asian Indians, but at least Uganda is run by Ugandans, a fact that may not be as evident in neighboring Tanzania and Kenya.
My colleagues’ views are not without merit. If I had grown up in what I viewed to be such an unfair environment, it would only be natural to feel resentment toward the European and Asian outsiders who were benefitting from the country’s resources, while local Ugandans suffered. Seen from this point of view, Amin’s populist policies can be judged as not only understandable, but even just.
The younger generation I spoke to, however, emphasized a more negative view of the dictator. Amin was a rash man, they said, who acted on impulse. He would wake up one day, claim to have a dream which called him to exile all the Asians, and then pronounce a law requiring them to leave within ninety days. Many of these Asians were Ugandans by birth, having been in the country for generations. They had nowhere left to go, and the results were devastating. Many ended up committing suicide. Other, more dubious stories abound, such as Amin telling the national football team not to return from Kenya after their World Cup qualifier loss, or face execution, and ordering a brutal murder of his own wife.
There are many views of the man in Uganda, all of them quite strong. Amin’s legacy is quite a complicated one, which surprised me very much, as I expected a strong hatred toward such a brutal dictator. But the public’s views did remind me of another leader who commands a complex legacy, whom I often talked about with my friends while in China. Speaking to the local people about their own history reminds me that human events seldom occurs in black and white, and the Western view is not always the objective view I assume it to be.
A Day in the Life
Ward 4A is the Infectious Diseases in-patient ward. As you enter, you pass through a long corridor that looks like every other wing in the hospital, with a nurses’ office, doctor’s office, tea room, pharmacy, and laboratory. At the other end of the hallway, you come into an atrium which separates the men’s wing on the left with the women’s wing on the right.
Immediately after stepping into the atrium, you realize that this is not a normal wing of the hospital. Patients are packed into the wards like sardines, with some spreading some sheets on the floor in between beds and using it as a make-shift space due to the overcrowding. Tuberculosis patients are placed in the open-air atrium, so as to isolate them from the other patients. The efforts are probably futile, however, the area is so cramped that nearby guests and attendants readily breathe in the bacterium-filled air.
As you walk into the women’s clinic, the first thing you notice is the silence. There are no cries, just silent, raspy breathing. As the intern doctor, you walk to the first bed and introduce the patient. Because HIV/AIDS is still a stigmatized disease, the patient is introduced as “seropositive” so that the surrounding patients cannot hear. Not that it makes a very big difference, as 90% of the patients on the ward are seropositive. In the US and Europe, we begin treating HIV/AIDS patients with antiretroviral therapy at a CD4 count of 350 or lower. The Ugandan standard is 250 because of lack of resources, but in the ID ward, patients present with counts of 50, 20, 4, and even 2. This would be considered late-stage disease in the West and a rarity to see, but patients are arriving at Mulago with little or no treatment, and a low CD4 count is the norm, rather than exception.
HIV/AIDS weakens the immune system, and it is the opportunistic infections (OIs) which inflict the most damage. Almost every patient is suffering from multiple OIs. On one female patient you can see candidiasis on the base of her tongue and roof of her mouth, presenting as a white carpet-like growth. Another has a large, baseball-sized wart growing on her forehead, possibly caused by herpes. Of course, many have tuberculosis, mostly pulmonary, but also presenting in various other parts of the body. But for many, the infections can’t be seen or heard, and are infecting the central nervous system.
Meningitis is the most common OI seen in the ward. The covering of the brain, the meninges, becomes inflamed due to viral or bacterial infection. For most individuals without AIDS, the immune system does a tremendous job of protecting against invaders which can cause meningitis. But for those weakened by AIDS, any household bacteria or fungi can invade, and the symptoms are sudden and severe – blinding headache, fever, seizures, altered mental status, and impending death. Even the best available antibiotics in the West are not particularly efficacious against the common meningitis-causing pathogens in AIDS patients, and as a physician in Uganda, you do not have access to many drugs. Antibiotics and anti-fungals are administered and lumbar punctures (spinal taps) are given, but many of the patients do not have a very good chance at survival. Even if they recover somewhat and are discharged, the relapse rate is extremely high and survival rates grim.
But you are an overworked young physician and do not have time to ponder these spiritual and philosophical issues. You move on to the next patient, trying to manage the massive room full of dying patients, hoping to save a few and prolong or at least make more comfortable the lives of the rest in your ward, with what little you have. Half the time there is no anesthetic available on the ward, and you have to perform the lumbar punctures without it. There are barely enough clean gloves and needles for you to draw all the necessary blood from the seropositive patients, some of whom are combative and increase the chances of you accidentally sticking yourself with the needle, something which has already happened a few times in your career.
Your thoughts are interrupted by a loud, howling scream. You rush over to the men’s ward. A gentleman is lying on the floor on a makeshift mattress, with drool and vomit on his right shoulder. His eyeballs are turned upwards in his sockets, and he is screaming at the top of his lungs. His body shakes uncontrollably, and his hands claw into the air. The screaming turns into moans, final cries for help. As you approach him to see what is wrong, his body snaps toward you. You jump back just and time and call for the senior health officer. The patient has late stage rabies and has completely turned deranged. You watch as the senior officer dons gloves and sedates the patient. Before you arrive for rounds tomorrow, he will have passed away. Remembering the moanings and cries, you realize that it is probably for the best, and say a quick prayer before tackling the next roomful of patients desperately needing care.
Immediately after stepping into the atrium, you realize that this is not a normal wing of the hospital. Patients are packed into the wards like sardines, with some spreading some sheets on the floor in between beds and using it as a make-shift space due to the overcrowding. Tuberculosis patients are placed in the open-air atrium, so as to isolate them from the other patients. The efforts are probably futile, however, the area is so cramped that nearby guests and attendants readily breathe in the bacterium-filled air.
As you walk into the women’s clinic, the first thing you notice is the silence. There are no cries, just silent, raspy breathing. As the intern doctor, you walk to the first bed and introduce the patient. Because HIV/AIDS is still a stigmatized disease, the patient is introduced as “seropositive” so that the surrounding patients cannot hear. Not that it makes a very big difference, as 90% of the patients on the ward are seropositive. In the US and Europe, we begin treating HIV/AIDS patients with antiretroviral therapy at a CD4 count of 350 or lower. The Ugandan standard is 250 because of lack of resources, but in the ID ward, patients present with counts of 50, 20, 4, and even 2. This would be considered late-stage disease in the West and a rarity to see, but patients are arriving at Mulago with little or no treatment, and a low CD4 count is the norm, rather than exception.
HIV/AIDS weakens the immune system, and it is the opportunistic infections (OIs) which inflict the most damage. Almost every patient is suffering from multiple OIs. On one female patient you can see candidiasis on the base of her tongue and roof of her mouth, presenting as a white carpet-like growth. Another has a large, baseball-sized wart growing on her forehead, possibly caused by herpes. Of course, many have tuberculosis, mostly pulmonary, but also presenting in various other parts of the body. But for many, the infections can’t be seen or heard, and are infecting the central nervous system.
Meningitis is the most common OI seen in the ward. The covering of the brain, the meninges, becomes inflamed due to viral or bacterial infection. For most individuals without AIDS, the immune system does a tremendous job of protecting against invaders which can cause meningitis. But for those weakened by AIDS, any household bacteria or fungi can invade, and the symptoms are sudden and severe – blinding headache, fever, seizures, altered mental status, and impending death. Even the best available antibiotics in the West are not particularly efficacious against the common meningitis-causing pathogens in AIDS patients, and as a physician in Uganda, you do not have access to many drugs. Antibiotics and anti-fungals are administered and lumbar punctures (spinal taps) are given, but many of the patients do not have a very good chance at survival. Even if they recover somewhat and are discharged, the relapse rate is extremely high and survival rates grim.
But you are an overworked young physician and do not have time to ponder these spiritual and philosophical issues. You move on to the next patient, trying to manage the massive room full of dying patients, hoping to save a few and prolong or at least make more comfortable the lives of the rest in your ward, with what little you have. Half the time there is no anesthetic available on the ward, and you have to perform the lumbar punctures without it. There are barely enough clean gloves and needles for you to draw all the necessary blood from the seropositive patients, some of whom are combative and increase the chances of you accidentally sticking yourself with the needle, something which has already happened a few times in your career.
Your thoughts are interrupted by a loud, howling scream. You rush over to the men’s ward. A gentleman is lying on the floor on a makeshift mattress, with drool and vomit on his right shoulder. His eyeballs are turned upwards in his sockets, and he is screaming at the top of his lungs. His body shakes uncontrollably, and his hands claw into the air. The screaming turns into moans, final cries for help. As you approach him to see what is wrong, his body snaps toward you. You jump back just and time and call for the senior health officer. The patient has late stage rabies and has completely turned deranged. You watch as the senior officer dons gloves and sedates the patient. Before you arrive for rounds tomorrow, he will have passed away. Remembering the moanings and cries, you realize that it is probably for the best, and say a quick prayer before tackling the next roomful of patients desperately needing care.
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