In Mulago

It’s funny how quickly your perception of a place can change. I smile to read back over my entry from just four days ago – it oozes with that syrupy giddiness unique to travelers in a new land. I see Kampala so differently now. What a difference a few days on an African AIDS ward can make.

To be honest, I feel too deeply entrenched in the experience of my hospital work to adequately reflect on it now. Suffice to say, it is haltingly sobering, and instructive in something that I can’t even begin to understand yet. I feel so old, so tired, and almost nauseated at the idea of going back again tomorrow, seeing the same patients, watching them die. But despite the overwhelming despair, I know that this is a good place for me to be; I am already a better doctor for being here. I am left again reminded of why I love my profession – we are privileged with a front seat on all of the greatest human experiences, the most profound joys, the deepest suffering.

And so, given that I’m still rather paralyzed by it all, I’ll stick to data reporting for now rather than any kind of analysis… med students are good at that approach, anyway. I’m working at Mulago Hospital on the women’s Infectious Disease Ward, which translates here into the AIDS Ward, although you’ll never see the terms “HIV” or “AIDS” written on a chart – they call it “ISS” here for “Immune Susceptibility Syndrome” out of concern for stigma/discrimination. Most of my patients are discovering their HIV status only upon presenting to the hospital with opportunistic infections characteristic of end-stage AIDS: cryptococcal meningitis, disseminated tuberculosis, neurotoxoplasmosis. For medical folks, the highest CD4 count that I’ve seen has been 180 – the majority fall closer to the teens/20s. These patients are so sick.

Patient care is structured so differently here – almost all traditional nursing duties are taken on by the patient’s “attendant”, who is usually her mother, sibling, cousin. And there is no social contracting for the sick here – you are responsible for paying for your health care, end of story. As we round each morning, we hand the patient’s attendant a list of labs, studies, medications that we are ordering for the day. The attendant is then responsible for finding the money, going to the pharmacy, going to the lab, wheeling the patient to the x-ray machine, cleaning the patient’s bedpan, washing the bedsheets. Nurses perform very limited duties – mainly limited to pushing IV doses, which the patient’s family has purchased and brought to the bedside. To be honest, the family role feels almost appropriate at times – at home, we distance ourselves from sick loved ones with layers of nurses, nursing aids, physical therapists. Here, your family truly cares for you, which at its best feels loving and right. But there is a dark side to this system, seen in patients without attendants who are left on their own, with no one to pay for their treatment or assist with their nursing needs. These are often women whose husbands have died, whose families have condemned them, or whose partners have abandoned them. They lie alone on their sheetless beds, with our neatly written order sheets left unfilled by their feet. They haunt me.

And there I go, reflecting without being ready. I promise that every entry won’t be quite so gloomy – at the very least, I’ll be traveling throughout Uganda and Kenya during the weekends, and should be able to come up with some good lion stories. I almost feel like it isn’t fair to Uganda that I delved so quickly into its troubles…. I know that there is much more to this country than its AIDS epidemic. And so I push through the week, rolling with the punches, and finding meaning in the raw education here. It’s a blessing and privilege to be here, and I already treasure the weeks to come.

I miss you all, and thank you for reading my musings. I am so lucky to have you all as my attendants.