Inside Bugando

A typical day on the internal medicine service at Bugando begins at 8:00 a.m. at morning report. Sitting in the front of a 10x20 ft room filled to capacity with residents, interns, AMOs, medical students, and one or more attendings ("specialists" as they are called here), the intern who was on call the previous night briefly outlines the presenting complaints, physical findings, laboratory results, working diagnoses and treatment plans for the patients he or she admitted during the night. Questions may be asked of the intern regarding thought processes or treatment options and interesting teaching points may be highlighted during this time for the benefit of students and young physicians. After morning report rounds are made in the ICU with Dr. Peck, the resident covering the ICU that day, and any residents and students who are interested in joining rounds. At about 9:45 rounds in the separate medical wards begin. On Mondays and Thursdays all of the patients are seen. On other days only the sickest patients are seen. After rounds the treatment plans agreed upon on rounds are carried out (medications administered, procedures done, tests ordered) and some residents and interns who have to be in clinic leave for those duties. Residents, interns, and AMOs trickle out of the hospital as they finish their duties and the intern and resident on call for the night settle in for the long haul. A typical night is quite busy on the medicine service- often an intern admits twelve or more patients in addition to taking care of issues that may arise with patients already admitted. But if the internal medicine department is busy, the pediatric side is crazy. The average number of admissions is about 15. Several days ago the intern on call admitted 22. I have heard of as many as 27 kids being admitted in one night.

I expected to encounter significant pathology here, and it did not take long for my expectations to be confirmed. On my first day rounding with the ICU team three of the five patients had presented almost identically: 25-35 year-old male with altered mental status. One was a known HIV patient and an x-ray revealed a classic pattern of "miliary tuberculosis" with small nodules scattered throughout the lung fields. Suspicion was that he had developed cryptococcal meningitis, a fungal infection of the fluid around the brain that is common in HIV patients. He was started on an antifungal drug, but as we are seeing with many cases of cryptococcal meningitis he passed away about a week later. The second patient had had a seizure associated with his decreased level of consciousness. I was surprised to find that the hospital has its own CT scanner (though the patients' families have to pay for its use which often precludes us from obtaining CT images) and imaging of this patient's brain showed "ring enhancing lesions" classically associated with toxoplasmosis, another infection of the brain that I had not yet seen but that is fairly commonly seen in HIV infection. We subsequently tested the patient for HIV and his test was positive. He was recently sent home on treatment for his toxoplasmosis and will come back to be started on treatment for his HIV. The final patient with altered mental status had had multiple attempts to obtain spinal fluid to determine whether he had an infection around his brain as well but all attempts to get fluid were unsuccessful. A day later he developed multiple vesicles in his mouth consistent with infection with herpes virus, which gave an indication that he could be suffering from meningitis caused by the same virus. He was started on an antiviral medication and within several days was much better and has since been transferred out of the ICU.

Patients on the general medical wards are not as critically ill, of course, but quite sick just the same. I was shocked at how many of the patients we rounded on the first day had tuberculosis, HIV, or both. My guess would be that approximately 60% of the patients in one ward were HIV positive. Probably half as many had confirmed or suspected tuberculosis. Isolation rooms would be prohibitive in cost and insufficient in number and therefore do not exist here (each ward consists of 4-5 large rooms that hold 10-12 beds each) and so there is no recourse but to have patients with active TB share a room with patients who have HIV with dangerously low CD4+ counts (leaving them particularly susceptible to infections such as TB, certain pneumonias, fungal infections, etc). I have yet to see anyone, patients or health workers, wearing TB masks. Malaria is one of the most common diagnoses made both on the internal medicine and pediatric services. Whether or not the blood slide indicates malarial parasites most people who come in with a fever are treated with quinine or artemether emperically. Indeed, I have never felt so many large spleens before (a common result of chronic malaria). Schistosomiasis is endemic to this area and is an infection of the gastrointestinal or urinary tracts caused by a worm that lives in fresh-water snails (quite common in Lake Victoria) that invades the skin of people who may wade or swim in infested waters before making their way to their body system of choice. The infection often goes unnoticed for years (aside from some itchy skin) before causing liver and spleen congestion, kidney failure, or bladder cancer. In pediatric patients Burkitt's lymphoma (a disease I have never seen in the U.S.) is exceedingly common and, fortunately, quite sensitive to common chemotherapeutic agents.


But not all of the medical problems we encounter are tropical infections that I have no experience dealing with. I have been surprised at the commonality of hypertension, renal insufficiency, congestive heart failure, stroke, and arthritis. Although I spent much of the first several weeks uncertain of the role that I was meant to play at Bugando and feeling that my experience treating the types of diseases commonly seen here was grossly inadequate, I slowly settled in and realized that I was able to contribute to discussions regarding the plan of care for some of our patients who had disease processes that I was familiar with. I am grateful for Dr. David (ward clerk) and Dr. Onesmo (intern) (pictured below- Dr. David on the right) in particular for letting me join them in caring for their patients on ward J5 for the past few weeks and for teaching me about some of the diseases that I am encountering for the first time.

Settling In

Mwanza is a quaint city of 400,000 people (Tanzania's second largest) nestled among the rocky hillsides of Lake Victoria's southern shore. Although bantu tribes have inhabited the area for hundres of years, the settlement of Mwanza was not officially founded until the late 1800s by German cotton farmers. In the early 1900s the British gained control of the town. The discovery of gold and a new railroad made Mwanza an increasingly important center of trade between western Tanzania and the other nations in the lake region and Zanzibar in the East. Today Mwanza remains an important port city on Lake Victoria and there is still a significant amount of mining done in the surrounding region. The fishing industry, as expected, is an important contributor to the Mwanzan economy. Agriculture (bananas, rice, goats) is important in the region. Finally, tourism brings in a considerable amount of foreign currency as many of the game parks in the Serengeti are easily accessible from the city.
The Sukuma comprise the largest ethnic group in the lake region, but there are dozens of different tribes as well. Although most tribes have their own local dialect, Swahili is spoken nearly universally and serves as a unifying factor for most of the country. Christians and Muslims live side-by-side peacefully. It is just as common for a person to seek medical care from a medical doctor as from a traditional healer, and many patients in the hospital bear the signs of their attempts to seek alleviation of their ailments from these traditional healers before coming to the hospital.

Bugando hospital is the third largest referral hospital in Tanzania and is a referral center for all of western Tanzania (approximately 7-12 million people). It was built between 1968 and 1971 and is associated with the Catholic church. It has a capacity of 850 beds (not a good indicator of the number of patients in the hospital because two patients often share on bed) and offers services in internal medicine, pediatrics, surgery, gynecology, and opthalmology. It hosts the Bugando University College of Health Sciences and this year the first graduating class of medical students will matriculate. The hospital is also a training cite for interns, residents, nurses, and assistent medical officers (AMOs). Read more about the hospital at www.bugandomedicalcentre.go.tz .

For several years Bugando Medical Center, Weill Cornell Medical College and the Touch foundation, with the help of generous financial support from Joan and Sandy Weill, have collaborated to try to help Bugando Medical Center improve its capacity to both care for the large number of patients seen at BMC yearly and to train new health care workers to help meet the great need that exists in Tanzania, where there is only one doctor for every 25,000 people. As part of this collaboration two full-time Cornell faculty members, one trained in OB/GYN and one in Medicine/Pediatrics, are now on staff at BMC and each month cornell residents rotate through the internal medicine department to help teach medical students and AMOs and to participate in daily ward rounds in the hospital. A similar collaboration has been established with pediatric residents from Northwestern University and Anesthesia residents from several other institutions.

I did not know what, exactly, my role would be in coming to Bugando. I had med Rob Peck (the Med/Peds physician from Cornell now working at Bugando full-time) several years earlier in Boston and from the little that I had heard about his new position in Tanzania it seemed that joining him for a few months would be an ideal fit for me, as his job seemed to incorporate many of the components that I have developed a passion for over the years. I have long had a passion for traveling and diving into other cultures and since I can remember I have had a desire to practice medicine in resource-poor regions. In recent years I have discovered that I enjoy teaching very much (though I wish I were more gifted at it!). Mentoring relationships have been vitally important in my life and I am certain that I want to be for others what a handful of mentors have been for me. It seemed, at least from the little I had heard about it, that Dr. Peck's job involved all of these things, and I was excited to get a chance to see first-hand what it would be like to be involved in the medical education environment in a region of the world that has long been faced with health problems that far outweighed their health resources. That excitement, however, was tempered by uncertainty of what awaited me and fear that my medical knowledge would be so lacking that I would find myself learning from my Tanzanian colleagues but having nothing to offer in return.
I arrived at Bugando on a Saturday and had the weekend to get settled in before starting on the wards on Monday morning. I spent most of those two days walking around Bugando Hill, at the top of which sits the impressive structure of the hospital. Much about Mwanza seems familiar to me as a result of the time I have spent across the lake in Uganda. The climate is comfortable, as the tropical heat is moderated by the breeze that usually sweeps up the hill from the lake. As in other areas of Africa I have visited, wealth and poverty co-exist with extravagant mansions adorning the hilltops and expanses of impoverished neighborhoods clinging to steep slopes and resting in valleys where waste-water from more privileged people naturally flows. Children entertain themselves with rusted bicycle wheels steered by sticks held in hand and play soccer with anything that even partly resembles a sphere. Women carry everything from water to bananas to sacks of coal on their heads and their babies almost invariably silently enjoy a view of the world strapped tightly to mom's back. Men work as carpenters, fishermen, laborers transporting heavy sacks of grain or coal or cement. Throughout the city new buildings are being erected. Anywhere man has not left his mark, something green and full of life has made its stand and an array of birds has made it their playground. An army of hawks patrols the skies at all times and mavericks regularly spiral heavenward riding invisible currents of air sliding up the lakeside slopes. Songbirds invariably announce the coming of the morning light. Marabou storks populate the treetops- semblances of some prehistoric creature that somehow survived whatever force caused the extinction of the dinosaurs. And at the end of the day God seems to blaze his signature on the canvass that is his latest masterpiece in the form of a sunset that always seems to be more brilliant than the one yesterday.

Mwanza

It did not take me long to be reminded that one cannot put too much stock in making plans in Africa. This is one of the things that most frustrated me when I lived here but at the same time one of the things that made life here an adventure. On the Monday after I arrived in Uganda I went to Port Bell, only a few kilometers from the city on the shore of Lake Victoria, to inquire about taking the ferry to Mwanza, a town on the southern shore of the lake in Tanzania where I would be spending the next few months. Port Bell was once a thriving center of trade. Now it is a sleepy pier with a few old fishing boats with rusted hulls rocking rhythmically on the water and several weathered buildings with broken windows monitoring the goings-on at the port. I was told that there would be a cargo ferry leaving for Mwanza the next Wednesday and that I could catch a ride for about $15. So, on Wednesday I packed up my things and headed for the port...only to arrive and be told that, "The ferry it did not come...you come back tomorrow." And so I returned to Kampala with plans on catching the ferry the next evening. When I arrived the next afternoon I was pleased to see the ferry present and being loaded with coal and banana bunches. However my pleasure was quickly turned to frustration when a sour immigration officer bluntly told me, "The ferry is here but there will be no passengers." After talking to several officials at the dock and calling the ferry manager in Tanzania I was informed that the Tanzanian government had just that day ordered that no passengers could enter Tanzania via ferry from Kenya or Uganda, citing the ebola scare in Uganda and the violence in Kenya as reasons. I had to find another route to Tanzania.

Early the next morning I packed my things and headed downtown to the bus park. The bus park is something you have to experience and cannot accurately describe, but it is like a living organism. Hundreds of buses somehow squeeze into a dirt parking lot which on this rainy day was more like a swamp. Buses traveling to various parts of the country line up in designated areas of the park and coach-line employees call out advertisements of their destinations. The competition to have passengers fill their buses sparks aggressive solicitation. If you are not careful employees may grab your bags off your shoulders and carry them quickly toward their buses. There is no timeline. A bus will leave when it is full. During the wait vendors selling soft drinks, beer, matoke, and hot stew board the bus and squeeze their way up and down the isles seeking customers. You can also buy a nice pair of socks, a shirt, perhaps an iron or any other conceivable good that may very well find its way onto the bus. It is fascinating. It is also uncomfortable and hot and patience is requisite.

Two hours after boarding a bus heading for the Tanzanian border we were finally on the road. After leaving the city limits we made our way speedily over potholed roads through groves of banana trees, then some small areas of jungle growth that have survived being cleared to make farmland, then low-lying swampland and finally, after 7 hours on the bus, to the rolling, cattle covered hills at the Tanzanian border. Here everyone disembarked, grabbed their belongings, and walked across the no-man's land and into Tanzania. Here I caught a local taxi with room for 13 but filled with 20 and spent an extremely uncomfortable 20 minute ride to Bukoba, a town on the shore of Lake Victoria where, I was told, I really could catch a ferry the rest of the way to Mwanza.

The reports were correct. I got to the pier in time to purchase a third class ticket for the 13 hour ferry ride across the lake...and I was overjoyed! I met several very nice Tanzanians who not only gave me good company during the ride but who also gave me pointers about travel on the ferry. We all made our way into the lower hold where we found seats on the rows of old wooden benches with metal luggage racks overhead. The seats were tight, but I was on the ferry and I had no complaints. I knew I was in for a long night, though, seeing as we had 13 hours ahead of us and we were packed in so tightly that there was no way anyone would get any sleep...or so I thought...

Several hours after we left the pier there was some cue that set everyone into a flurry of activity. People began climbing up onto the luggage racks, under the benches, finding space on the floors and spreading out across the benches and settling in for the night's sleep. Before I knew it every inch of space from floor to benches to luggage racks was filled with bodies comfortably prepared for a good nights sleep. The only one, I think, who was not comfortable was me as my sense of personal space kept me sitting upright in my seat for the duration of the journey! Sometime during the night I had slouched in my seat and dozed, and when I awoke someone's head was occupying most of my seat and I was left precariously perched on the forward 5 inches of my seat. The only saving grace was that I was seated next to one of the windows and had a fresh breeze blowing in my face the whole night. As uncomfortable a night as it was...indeed I thought it would never end...I was glad that I had not arrived early enough to have been able to spend the 3 extra dollars to be in a sleeping room as the experience was memorable, and the people I met were a joy to talk to, even through the language barrier.

At about sunrise the next day Mwanza came into view. We slowly made our way past fishermen casting their nets from small canoes, past the unique rock formations that mark the southern shore of Lake Victoria, and finally to the port at Mwanza. Exhausted, I hailed a taxi and made the 5 minute drive up the hill to Bugando Hospital, where I would spend the next month and a half doing...I knew not yet what.

Long Awaited Return

I think I had forgotten how much my experience in Uganda had become a part of who I am until I found myself once again traveling along the road from Entebbe to Kampala. The familiar smell of the humid equatorial air mixed with odors of diesel fuel and dust and smoke from burning piles of trash unlocked a vault containing a flood of memories that had been sealed and pushed aside by four years of medical school, one year of graduate school, nearly three years of residency, and what seems like enough life-changing experiences to have filled up a whole lifetime. I had forgotten that a bicyclist carrying 2 passengers and a sack of flour would even consider cutting off a fully loaded lorrie on a crowded city street... let alone successfully accomplish the feat. I had forgotten my amazement at seeing women step out of dirty, one-roomed houses made of plywood in the middle of filthy slums with finely pressed and brightly colored clothes and immaculately done hair. I had forgotten that two lanes of pot-holed highway was somehow enough space to accommodate two directions of pedestrian traffic, a lane of bicyclists, the occasional wooden wheelbarrow, three or more vehicles of varying sizes squeezed side-by-side and separated by mere inches, and a constant weave of motorized scooters just to make things interesting. I had forgotten that people can seem like ants busily scurrying about their work, diving randomly into hidden road-side passages and appearing just as unexpectedly. I had forgotten that everyone has a cell phone. I had forgotten about the storks that lazily glide above the city and take turns standing watch over heaps of garbage. I had forgotten that 5 roadside shops would exist side-by-side and all sell the same refurbished weed-eaters in all the colors of the rainbow. I had forgotten how quickly one becomes drenched with sweat in the humid tropical air. I had forgotten how much I had missed Kenny and Monica, who had picked me up at the airport with their new son, Seth; and Doug and Destiny, who now have a three year old son and one on the way. I had forgotten that chaos can be beautiful and that "on time" can be relative. I had forgotten that uncertainty makes life exciting and I felt the anxiety that had resurged within me upon landing in Entebbe slowly fade away. I had forgotten how much I love Uganda and the way of life in East Africa- even though I was also remembering how very frustrating life in East Africa can be at the same time. I had forgotten that there is nothing more exciting than walking forward into the unknown with the deep assurance that a loving Father walks beside me, behind me, and before me whether through mountains or valleys, in safety or peril, with companionship or alone.
-Proverbs 3:5-6

Departure

    
For some reason I was significantly more anxious when I set out for Tanzania than I have ever been before when heading overseas. I found myself feeling anxiety over things left undone at home, anxiety over whether my medical skills and knowledge would be adequate now that I was finally going out with skills that could be called upon to significantly impact people's well-being, anxiety over the gaps in logistics of getting to Mwanza, anxiety over what I am going to do about the mountain of student loans that I have accumulated over the years, and anxiety regarding how I have handled certain relationships in my life. To make matters worse, as my departure time neared a large snowstorm bearing down on Chicago promised to add to the number of things I felt compelled to wring my hands over. On the morning of my departure I awoke with a knot in my stomach and all of these worries swirling around in my head... but I found great comfort in coming across Psalms 4 and 5, "In peace I will both lie down and sleep, for You alone make me dwell in safety," and my fear slowly turned to excitement as the words of a Sandra McCracken song sunk in: "In the arms of a good Father, you can go to the deep water where the questions we have left unspoken come out in the open. We will find shelter here. So I lay down what I cannot hold in my hand. Every sorrow and hope springs out of control, here I find sweet resolution comes in letting go..."

       By late afternoon the snow had started coming down heavily, and even though Christina (who graciously braved the storm to give me a ride) and I left for the 30 minute trip to O'Hare 3 hours before my flight time it became apparent that I  was not going to make it in time after having traveled only 2-3 miles in 40 minutes. At the brilliant suggestion of my sister, Christina pulled into a nearby subway station and I grabbed my bags out of the car and headed for the train. A mere 30 minutes later I checked in for my flight with plenty of time to grab a cup of coffee, watch the snow fall outside the window at gate 22, and wonder... now with more anticipation than anxiety... what the next two months would hold.

Introduction

I was in the middle of my internship year as a Med/Peds resident at Vanderbilt when a friend gave me a copy of Henri Nouwen's The Return of the Prodigal Son. At the time I was stuck in a depressive cloud as a result of fatigue combined with intense feelings of inadequacy on multiple fronts in my life. Nouwen's description of his encounter with Rembrandt's painting and his subsequent journey through the biblical story of the prodigal son spoke to me deeply. I came to understand that I, like Nouwen and like the young man in the parable, had long taken the skills and talents God has given me and presented them to the world in search of finding identity and recognition, only to find that when those skills and talents were no longer enough to impress those I sought recognition from I was left standing in a cold, lonely place with a vivid realization that I had labored in vain to seek the approval of men for far too long. The ongoing process of surrendering my pride and returning to the merciful embrace of a loving Father has been a sweet homecoming, though not always easy and not without a persistent and paradoxical tendency to look back longingly at a way of living that I know ultimately promises only emptiness. I am coming to know that I dwell in a sea of grace the depths of which I will never fully comprehend and that promises excitement and wonder and adventure and awe if only I purpose to seek out the treasures it holds rather than dwelling on self and my comparative insignificance in its vast glory.