STUDENT INTERNSHIP & EXTERNSHIP REFLECTIONS
PLAYING THE HAND YOU’RE DEALT: REFLECTIONS ON A
MONTH SPENT IN RURAL UGANDA
A
AUTHOR Carter Richardson
fter just finishing our first year in
medical school, a dozen of us spent
a month learning about medicine,
public health and culture in Ka-
bale, Uganda. A far cry from the
stereotypical sub-Saharan African
climate, Kabale features an abun-
dance of rolling mountains not much different
from Appalachian country. What’s key is that
each hill is organized into small patches of land each family owns
for farming; 90 percent of the population eats the crops they grow
themselves daily. One evening as I sat on the balcony enjoying the
picturesque view, I opened up the book “The Last Lecture” by Dr.
Randy Pausch. Recommended to me by several of the other students
on the trip, the book was written by a professor dying of cancer. It
documents all the wisdom that Dr. Pausch wanted to give to his
children in his little time left. The advice that struck a chord with
me as a perfect description of Uganda was this: “We cannot change
the cards we are dealt, just how we play the hand.” Africa is noto-
rious for its lack of resources, and Kabale is no exception. For the
health care provider, the patient and the average citizen, resources
are scarce. Ugandans cannot change the hand they’re dealt, but the
way they play this hand is both humbling and inspiring.
For a clinician, the foundation of patient care is the health and
physical exam, the framework for diagnosis and treatment. In Ka-
bale we had that, plus a couple labs and an ultrasound. There is no
operating room and only a few medications. At the maternity clinic,
pregnant women were asked to come in once a month for checkup.
As part of this visit, they would typically be given a month’s supply
of iron and folic acid. However, supplies were running very low. We
were only able to give each woman a week’s worth of supplements.
We had to stress the importance of eating vegetables for the rest of
the month leading up to their next appointment. In all, the scarcity
of resources meant that clinicians needed to be both confident in
their diagnostic ability but also cognizant of their limitations.
Access to affordable health care is a huge obstacle. The Kigazi
Healthcare Foundation (KIHEFO) Clinic, the organization we part-
nered with, is private. However, the patients pay on a sliding scale
depending on what they can afford: often nothing. The founder of
the clinic, Dr. Geofrey Anguyo, is the only physician in town. The
clinic is also staffed with several clinical officers, a role similar to
a nurse practitioner in America. Even though the clinic can offer
services free of charge, many people still cannot afford to be seen.
A day spent in the clinic means a day not spent tending the farm
or taking care of the children. In America, patients expect you to
diagnose and treat disease at the earliest stage possible. In Uganda,
patients do not have the luxury of finding time to see a provider at
early stage in disease, so many of the patients we saw were already
very sick.
If a patient’s sickness is too advanced for our outpatient clinic,
they have one of three options. As an example, a 66-year-old man
came into the clinic in clear distress. After a detailed history and
physical, Dr. Geofrey feared this man may be suffering from prostate
cancer. However, our clinic did not have the resources to do a biop-
sy to confirm the suspicion. Patients like this man could either be
referred to a private or public hospital. Public hospitals will provide
free care, but have very limited supplies and it can take months to
restock even essential drugs. For our patient with suspected prostate
cancer, the overcrowded public hospital will not accept our referral
without a confirmed diagnosis, but we have no biopsy capability.
We can refer a patient to a private hospital, often stocked with the
best diagnostic tools and treatment options in Uganda, but they
are very expensive. Very few patients can afford care in a private
setting. Our most common option is to begin palliative care for
what in America is a potentially treatable diagnosis. Explaining
this sad reality to patients is a daily part of the job when working
in our outpatient clinic. The man was given a month’s supply of
pain medication and told to come back if his symptoms worsen.
Pharmacies have become an increasingly viable health care
option for citizens and a frustrating option for providers. Like back
home, the government states that a prescription is required to get a
variety of medications. However, this rule is not enforced. If the law
is not enforced, private pharmacies have no incentive to follow it. You
can walk into any pharmacy in Kabale and pay for any drugs over
the counter, for a relatively cheap price. Because many citizens do
not have the time to go to the clinic, many people quickly and easily
choose to self-medicate. For example, the clinical officers explained
to us that people will come into the clinic with malaria. When they
are eventually diagnosed, they receive the proper medication. The
problem is that next time they experience similar symptoms, they
assume they have malaria again. It is a lot quicker to go straight to
the pharmacy and purchase the same medication as before. The
obvious result is that many Ugandans do not remedy their ailment,
but still experience the side effects of the drug they chose to take.
Having few and poor resources is the everyday expectation
of most Ugandans. The difficulties in giving and receiving health
care are just the tip of the iceberg. The reality for many families is
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JANUARY 2020
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