Health Care in Uganda

I've been meaning to sit down and write this for a while, but the holiday season has been a busy one, filled with dear friends, lots of baking, and a litter of kittens.

A couple weeks ago I got my first real glimpse of the medical system here. Don't get me wrong, it's not like I didn't know what kind of crazy stuff happens here, but this time I was right there in the middle of it. When I first got to Jinja in September, my roommate Kate introduced me to a pregnant 16 year old girl (Sandra) she was working with because she was concerned for her health and safety once labor started. I first came to see her in the small shack she lives in in one of the villages down the road. She told me that she thought her baby was due sometime in October but wasn't sure of the exact date. One look at her belly and it was obvious that her baby was not coming anytime soon. After a bit of digging in her medical records (with was nothing more than a notebook with a few bits of chicken scratch in it) and asking her a bunch of questions, I gave her the due date of December 4.

On December 10 the call came that she was in labor at Jinja Main (the main hospital in town) and they were wanting to do a c-section because she wasn't dilating. Luckily, Kate was smart enough to recognize the giant red flag and asked me to come and see her. Upon my arrival I found a very comfortable Sandra walking around the grounds with Kate hoping that labor would pick up.

A few little details for my OB friends....

• She was 2 cm since the previous night when she arrived at the hospital
• She was not contracting other than the occasional mild one
• She had a possible ROM but no tests had been done to confirm and no further fluid was coming
• Positive fetal movement and good heart tones by fetoscope
• No ultrasound had been done (despite the fact that they had an u/s machine there)

After I got there we waited for a few hours for the doctor who was supposed to come and assess her and decide whether or not to do a c-section. We waited and waited and I did everything I could to try and bring some contractions. Finally, after seeing that the doctor was not going to come and see her and that we would be sitting in the hospital all night waiting for something to happen and would then most likely go to c/s in the morning, we decided to check out of the hospital. I spoke with the nurse and told her we would like to leave and would bring Sandra back when her labor picked up. Of course, the nurse was not particularly happy with this plan and said that we needed to wait for the doctor to see us... in the morning. So we left.

Labor ward in Jinja Main Hospital

After bringing Sandra home for further assessment I determined that she was indeed 2 cm and that her water had most likely not broken. So I sent her home for the evening with instructions to call if anything changed. That night, unbeknownst to us, her roommate brought her back to the hospital for fear that she would not be treated later since she left the hospital against the doctor's advice.

The following morning we received a call that Sandra was there and the doctor's wanted to do a c-section because the baby was too big for her pelvis. She was 16, after all, and everybody knows that teenagers can't push out babies (note the sarcasm in my voice). After debating whether I should even get involved again since things were all ready in motion for surgery and I didn't want to risk making the staff angrier than they already were (the supplies were being purchased already... because in this country you have to go and buy everything that's needed for surgery at the pharmacy before it will happen. So basically, there's no such thing as emergency surgery and if you don't have the money you're not going to be treated) I finally, with Kate's encouragement, headed back to the hospital.

“Be nice. Be nice. Be nice.” That's what I kept saying over and over again in my head. Anyone who's ever worked with me knows that when it comes to my patients and disagreements about their care I tend to come at it with fists flying and that's not the way to get things done in a country like this. One wrong move and they would torture and abuse Sandra to get back at me. So as I entered the OB ward I just kept saying to myself, “Be nice!”

And, I'm proud to say, I was. I didn't insult anyone's intelligence or tell them they were a bunch of idiots who had no idea what they were doing. I calmly stated that I would like to take her to get an ultrasound to get an estimated weight on the baby and check his condition before we made any decisions. At first, the doctor agreed, though not particularly happily. I'd discussed the plan with Sandra and her mom, who both agreed. But somehow from the time I walked over to talk to the doctor to the time I returned, Sandra had changed her mind and decided she wanted to proceed with the c-section. She was terrified. Terrified that the doctors and nurses were going to abuse her out of anger.

And so back to the doctor I had to go to tell him her decision. At this point, he's pissed. I mean really mad. And so I got to stand there while he yelled at me, while the head of the OB department yelled at me, and while a big angry nurse both yelled at me and physically was trying to drag me through the ward. “Be nice. Be nice. Be nice.” And so I stood there and I took it. Madder than I've ever been because I knew everything about the situation was wrong.

And so a c-section it was, later that night.

I wasn't going to go back to the hospital because of what I knew would happen if any of those doctors or nurses saw me. But I got a call that morning saying the baby was on oxygen in the nursery. I still debated going, but my plans for the day had been cancelled due to rain so I decided to just go check on mom and baby to make sure everything was OK. They told me the baby was doing well, just weak. So when I walked in and saw a dusky, blue-tinged, barrel-chested baby laying there struggling for breath, I was shocked.

Meconium aspiration.

My theory: At birth his apgars were 5 and 7. Which meant they had to resuscitate. But, as I discovered later, the entire town of Jinja is without a neonatal sized laryngoscope. So how could they have properly resuscitated him (OB friends.... that question's for you)? Most likely, they just put an O2 mask on him and pumped the meconium right into his lungs.

So, to spare you the minute-by-minute account of what happened that day, I'll summarize. After many phone calls and running about town to try and find a western-trained doctor to help, Sandra's baby was finally transferred to Kampala where he could be properly treated. We managed to get one of the only ambulances in Uganda that had oxygen on it, found the only place that could intubate a baby, and sweet-talked our way into getting transferred to another hospital.

All I can say is that when that ambulance pulled up 7 hours after I'd arrive at the hospital that morning with a well-trained doctor on board who immediately started properly treating the baby, I felt like I could finally take a breath again.

I am happy to say that baby Hansel returned home from the hospital on my birthday (the 27th) and is doing very well!

Those few days were a fight, a struggle, both for decent medical care and for life. I saw the corruption. The bribes. The lack of equipment. The horror that is Jinja Main and having a baby in this country.

So for my medical friends who have been wanting to know what it's like here, here are a few notes for you...

• Even though some of the technology is here, doctors don't want to use it
• If you don't have the money to pay a bribe, you aren't going to be treated well
• The OR smelled like urine
• There isn't a neonatal sized laryngoscope in the entire town of Jinja
• You can't ask questions about your care
• C-sections are possibly more common here than in the US
• You have to bring your own medical supplies to the hospital if you want treatment
• They can refuse to treat you if they want, even though they aren't supposed to be able to

*Side note: Another friend here just went into labor last week and they tried to do the same thing to here. The doctor's told her the baby was too big and she needed a c-section. She was smart enough to run and went to a village clinic where she delivered a healthy baby boy.