The Life of a Ugandan Doctor

The purpose of this blog is not to give the reader the impression that working as a doctor in Britain is easy; with endless targets to meet, increasingly high expectations from the public and often incorrect criticism from the media (and this is before you even start to consider the responsibility of having to look after acutely unwell patients whilst trying to complete a never-ending amount of assessments and reflections for your portfolio), it is no wonder that it is a profession with one of the highest levels of stress and rates of burnout. In comparison, although a Ugandan doctor may meet with these pressures to some extent, the main barriers and difficulties that they face in their everyday working life are vastly different to ours. Therefore, the main aim my blog is to help my fellow colleagues realise that whilst working as a doctor in the UK is a highly stressful job with its own set of problems, there are some aspects of our daily lives that we often take for granted, and I therefore hope that my subsequent musings will help them (myself included) come to appreciate certain aspects of the NHS that we have never really considered before. 

Money and Resources

One of the biggest factors that influences healthcare in Uganda is money (or rather, lack of), and whilst medical care is free in the government hospitals (although the patients still needs to pay for the transport to get there), Kagando is a private hospital where patients have to pay for everything. This includes the operation that they underwent, the drugs that were given, and even the rubber gloves that were used to examine them. The final bill is paid at the end of their stay; if they don’t have the money they simply have to stay in hospital until they can raise enough funds (thereby increasing their fees further by using the hospital bed for longer than they need to). And it is not just the patient’s treatment that is affected by lack of money, but also their decision to come to hospital in the first place. It is so often the case that due to lack on money a patient will delay coming to hospital until there is no other option; they will try traditional remedies and local health clinics, all without much benefit. It is only when their illness has reached the point that they can no longer live with it that they eventually come to hospital; the end result of this is that we often see patients with diseases that are just too far advanced to treat. This was sadly the case for a ten year old boy that I saw during my first month in Kagando who had presented with over a year’s history of abdominal pain and swelling. Despite the realisation that something was wrong, the boy’s father just couldn't afford to bring him to hospital sooner. He subsequently underwent an emergency laparotomy and was found to have a large mass (roughly the size of a football) attached to his right kidney with similar smaller masses in his scrotum. Whilst the surgeon did his best to remove all the masses, ultimately there were small bits that he had to leave behind. This biopsy result came back as showing that he had a high grade Burkitt’s lymphoma, and he was referred to one of the government hospitals for chemotherapy. The sad reality is that this form of lymphoma usually responds well to treatment, and if caught early enough he would have been expected to have made a full recovery. Unfortunately his presentation was too late, and the chemotherapy was more than likely going to be for palliative measures only, rather than a cure. 

Once a patient has presented to hospital, and after a history has been taken and examination performed, the next logical step is to perform the investigations that will help to confirm or rule out a diagnosis. In the UK where most investigations are available to us, it isn’t unusual for a patient  to have a whole host of diagnostic tests performed upon them, irrespective of whether they are really needed or not. Whilst this no doubt means that we normally (but not always) find a diagnosis and can therefore start treatment as soon as possible, it does make you wonder whether we are losing our clinical ability to make a diagnosis from signs and symptoms alone. In a dramatic contrast to the UK, where we never really consider the costs implications of the tests that we order, in Uganda money is always at the forefront of your mind when deciding what investigations to perform.  Of course, this largely depends upon what tests you have available to you in the first place, and with a lack of money and limited resources in smaller rural hospitals, you can only perform the most basic of tests. In Kagando we can perform x-rays, abdominal ultrasounds, basic microscopy and a small selection of blood tests (including malaria diagnosis , blood sugars, HIV screening, and a full blood count); in theory we should be able to test for renal and liver functions, although due to a lack of money the regent has been out of stock since I arrived. Outside of this rather limited supply of investigations you either have to refer the patient to larger hospitals if they can afford it (although many can’t), or, more commonly, rely upon your clinical judgement to make a diagnosis and subsequently decided upon what treatment to give. Although this definitely helps to improve your ability to interpret clinical signs (and perhaps become a more well-rounded doctor in the process), it often means that you have to make decisions without as much confidence as you would like. Whilst this is something that I still struggle with (despite having worked in Kagando for almost three months now), the Ugandan doctors manage to use what little information they have to make sensible, and often correct clinical decisions. For instance, it was only last week that we had an eighteen month old boy brought into us with an acute onset of abdominal pain, distension and bloating. Whilst we suspected intussusception from the history and examination findings (this is where part of the bowel slides inside of itself, thereby causing an obstruction), the radiographer was off sick and we were unable to confirm the diagnosis using an x-ray or ultrasound. Intussusception is a surgical emergency, and we didn’t have time to wait around for the radiographer to return to work. With nothing more that her clinical findings to go on, Naomi made the tough call to take the child to theatre for an emergency laparotomy where the diagnosis was confirmed and the obstruction removed. Although it was nerve-racking to have to make that sort of decision without any radiological investigations to back it up, it was obviously the correct one as the child would have almost certainly have died if we had waited around long enough for the radiographer to return and take the x-ray.  

Whilst we were able to use the clinical signs to make a reasonable attempt at the diagnosis in this young child, there have been many patients where we have not been so fortunate. I cannot begin to describe how infuriating it is to have a patient in front of you who you know is sick, but without the appropriate investigations there is no way of knowing what the correct treatment to give is. Instead you have to stand by and watch them deteriorate in front of you; blindly treating can sometimes help, but more often than not they pass away without a diagnosis ever being made. An example of this that is all too fresh in my mind is of a sixteen year old girl who came in just under a month ago following a road traffic accident (she had fallen off the back of a motorbike, and, like most people in Uganda, had not been wearing a helmet). She had a reduced conscious level on admission and we eventually managed to persuade her parents to pay for a CT scan at the nearby government hospital; there was no obvious injury on the scan and her symptoms were therefore attributed to concussion. However, whilst her conscious level improved over the next couple of days and she had no obvious signs of an evolving intra-cranial pathology (i.e. a head injury that only becomes apparent some days after the initial accident), there was something that just wasn't quite right about her. She kept complaining of feeling hot and was unable to stand by herself; after a week she became more and more drowsy, and was persistently spiking temperatures and vomiting. Whilst we were concerned about a head injury that was not picked up on the first scan, her parents were unable to pay for her to have repeat CT. Worried that this potential head injury could have been causing an electrolyte disturbance we tried to test her sodium and potassium. Unfortunately the reagent was still out of stock and we had to treat her blindly, based purely upon her clinical signs. Despite our best efforts she continued to deteriorate and subsequently developed severe breathing problems, vomiting and high blood sugars. Again there was a whole magnitude of conditions which could have been causing these symptoms, but without any appropriate tests we were forced to treat her for every possibility; we didn't succeed and she died several days later. However, the sad reality is that if we had just the few simple tests that we needed (such as the ability to measure her serum electrolytes), we may have been able to diagnose her correctly, thereby allowing us to give the correct treatment. However, even if I find out that the investigations that I want are available, I always have to think twice about whether they are really necessary or just something that I am doing to make myself feel better.  Although it wouldn't always be acceptable practice in the UK, if the diagnosis is obvious from clinical signs alone and the patients don’t have much money I will often treat without investigating. Whilst this is by no means ideal, it has meant that I have had to think a lot more about the cost implications of everything that I ask for; perhaps when I go back to the UK I may actually stop to consider whether an investigation is really necessary, rather than ordering every possible test that I can think of.  

Compared to our hospital where there is a very limited set of investigations, the larger government centres have more advanced diagnostic tests and can perform procedures such as CT scans and endoscopies. However, the patients still has to pay for these investigations and whilst the cost may not appear to be too much to us, it is almost always unaffordable for most of our patients in Kagando (who generally fall into the category of the rural poor). For example, a head CT scan costs around 100,000 shillings (equivalent to £25), and when you start to consider that the average cost of food for an entire day is less than one thousand shillings you can begin to appreciate why so few people can afford these expensive, yet lifesaving investigations. Even if a patient can afford to pay for an investigation in one of the larger hospitals, their relatives are often reluctant to spend such a large amount of money (irrespective of how much time you spend trying to persuade them otherwise). Instead the patient will sit on the ward and deteriorate right in front of you, and it is only when it is all but too late that the relatives eventually agree to pay for the test. Sadly, this decision may come too late for some patients, like the young man who was admitted to our ward several months ago following a road traffic accident. He had been the driver of a motorbike that had collided head-on with a car, and after being rushed to hospital was found to have signs of an obvious head injury with a significantly reduced level of consciousness. Suspecting that he had sustained an acute intracerebral bleed (i.e. bleed in the brain) we tried to convince the relatives to take him to the nearby government hospital for a CT scan; if the diagnosis of a bleed was confirmed they would have been able to operate on him immediately. However, despite having enough money available to them, the relatives were reluctant to pay for the scan and leave Kagando, believing instead that he would get better on his own (in spite of our best efforts to convince them otherwise). We tried to treat him conservatively over the next few days with mannitol, a diuretic that helps to reduce the pressure within the brain. Unfortunately this was not successful and he continued to deteriorate; he had developed a definite left-sided weakness with a fixed and unreactive pupil on the right (all indicating a right-sided bleed), and after the fourth days he started to have uncontrollable epileptic seizures. It was only now that his family finally agreed to pay for him to be transferred to the nearby government hospital for a CT scan. We later discovered that the scan had confirmed a massive right-sided intracerebral bleed; unfortunately he had died on his way to theatre, something which may have been prevented had he been transferred just a day or two earlier.  

Whilst I appear to have written a mini-essay on the influence that poverty has upon the patient’s decision to come to hospital and the subsequent investigations that they will undergo, the biggest effect of this scarcity of resources is often seen when deciding what treatment to give. The most common occurrence is that the treatment that I would want to give just isn't available here. Sometimes there may be the option of being referred to one of the government hospitals which have a greater selection of resources, but this still costs money and the patient is often unable to pay for the transport there (even if the treatment itself is free). A rather sad example of this is when I got called to the paediatric ward to see a two year-old boy who was thought to have inhaled a bean. He was having severe difficulties in breathing and every time we removed the oxygen his saturations dropped to a dangerously low level. The only treatment for an inhaled foreign body is to perform a bronchoscopy (which is where you insert a camera into the windpipe and remove the offending object). We were unable to provide this service in Kagando, but the government hospital in Mbarara could offer it for free. Because he was dependent upon the oxygen he would have needed to have travelled in an ambulance (rather than on the back of a motorbike, which is the usual mode of transport to and from hospital). However, this journey would have cost over six thousand shillings (around £150), which was just too expensive for the parents. Without the means to get him to Mbarara, all that was left for us to do was to give him oxygen and treat the other possible causes of his breathing problems, such as malaria or a severe chest infection. Not wanting to stand by and watch him die, we had to make the heart-breaking decision to turn and walk away, fully expecting him to be dead by the following morning. This child was fortunate and he recovered without a bronchoscopy (either because the foreign body had moved, or, more likely, was never there in the first place and the cause of all his problems was severe malaria); others have not been so lucky.

Although there have been many patients who cannot afford to be transferred to a nearby hospital for treatment, there are some who are so poor that they can’t even manage to pay for their treatment in Kagando; in the worst cases you have to stand by and watch them die, all the while knowing that you could quite easily have cured them - if only they had had the money to allow you to do so. Whilst this is upsetting enough with adults, it is even more heart-breaking when it is a child. Even when the parents have the money, if they refuse to fund their child’s treatment you have to respect this wish, rather than overruling them as you would do in the UK. Furthermore, it is always the father who has the deciding vote; despite the fact that the mother may want to save her child’s life, if her husband won’t pay it is his word that is final, not hers.

As frustrating as it has been to have patients who cannot afford the available treatment, what I have struggled with the most are the patients for whom there is no treatment. By this I do not mean the patients who have reached the end stage of a chronic disease that nothing more can be done for; I have come across plenty of these during my time in England. What I am talking about here are the ones for whom the treatment exists in the UK, but just hasn't made it across to Uganda yet. For instance, we currently have had a ten year-old boy on our ward with a high output enteric-cutaneous fistula following an emergency laparotomy six months ago. This basically means that he has a connection between his bowel and the outside world through a hole in his abdominal wall; it also means that he has become incredibly malnourished as anything that he eats comes straight back out again through this defect. Whilst we want to operate on him to close this hole, his poor nutritional status means that anything that we may try to do will almost certainly fail. Instead we have been trying treat his malnutrition with high energy feeds and milk; sadly we have made no progress as he has lost pretty much everything through the fistula. We really don’t know what to do next; in the UK we would be able to give ‘Total Parental Nutrition’ (i.e. TPN, which is where all the required nutrients are infused directly into the veins, thereby bypassing the bowel and fistula). Unfortunately TPN isn't available anywhere in Uganda, and I cannot begin describe to how frustrating it is to know that a potential solution to this child’s malnutrition exists but we are physically unable to get hold of it. At times like this I really appreciate how lucky we are in the UK, both as doctors and patients; if a patient needs an investigation or requires a certain treatment they will often receive it, with little or no thought given to the actual cost. Maybe the average ‘Daily Mail’ reader should come and spend some time in an African hospital before they start to criticise the NHS again. 

The Surgical Ward at Kagando

One of the things however that I admire most about the Ugandan healthcare system is how resourceful the people are; if a patient is unable to afford the best cure or the most appropriate treatment is unavailable, healthcare workers will always try to come up with an alternative option. Even when we run out of the basic hospital supplies, such as gauze or iodine (which happens a lot more frequently that you would imagine), rather than causing a fuss and refusing to work, people here just accept it and look for an alternative with what they already have. This is not to say that I haven’t had to make some difficult decisions during my time here. With a limited number of oxygen concentrators in the hospital I have lost count of the number of times that I have had to decide which of our critically unwell patients need the oxygen more; when their needs have been equal I have had to ration them to a couple of minutes each with the face mask, something which is unheard of in the UK.

The Practicalities of being a Ugandan Doctor

One thing that I am immensely jealous of my Uganda colleagues for is the amount of paperwork that they have to do (or rather, lack of). In the UK I can quite easily spend the best part of an afternoon sat in front of a computer screen mindless typing out discharge summaries, referral letters, or anything else that my seniors deem important but are unable to do themselves. With no computers and only small pieces of card and paper to write a patient’s entire discharge history on, paperwork takes up significantly less time in Uganda; there are no computers to book investigations on, and referral letters need all the briefest of histories (unlike the UK where you have to include everything from where the patient does their weekly shopping to how many times they have had a cold in the last ten years before someone will even consider looking at it). The flipside of having no computers in the hospital is that you can’t look things up; whilst this definitely has its advantages as it has encouraged me to go back to using good old fashioned text books rather than relying upon ‘Google’ all the time, there have been several occasions where what I have wanted to know just hasn't been in any of the books available to me. For instance, about a month ago I was called to see a critically unwell patient who had taken an overdose of Aluminium Phosphate (a form of rat poison). In the England I would have been able to access ToxBase (the UK’s national poison register), where I would have instantly found out exactly what this drug was and how best to treat it; in Kagando there was no internet access in either the hospital or our accommodation, and none of the books that I tried listed this poison. Instead I had to treat symptomatically, assuming that aluminium phosphate was a form of organophosphate. Despite the best efforts of the team that I had with me, the patient continued to deteriorate in front of me, and eventually arrested. It was only later that I found out that aluminium phosphate was not an organophosphate, and although I wouldn't have changed my management in this case as there was no known antidote, it still reminded me of how lucky we are in the UK to be able to instantly look up almost anything on an endless supply of online resources.

I think it’s fair to say that a Ugandan doctor has to work hard each day to earn their wages (which is significantly less than what we get in the UK). However, the sad reality is that all of those who are employed by the government have not been paid in over three months. Although they are unsure exactly why, it is thought to have something to do with the government running out of money. Whilst they should have been protected by a contract, as it turns out not many doctors in Uganda have one. However, they don’t seem too worried about the lack of a contract, and even appeared quite upset last week when there were rumours in Kagando that the management were going to make everyone sign one if they wanted to remain employed.

In the UK the public’s expectations and awareness of the NHS has increased over the past few decades, and as a result the rate of litigation has also risen. Whilst a doctor should always be cautious and only act within their competencies, the threat of being sued has meant that even if a trainee is fully competent with a certain procedure, they are often less willing to perform it without someone more senior being present (or at least nearby). Although this is by no means a bad thing, it does however mean that things can frequently take twice as long to complete (and that is before you even start to consider the endless pages of paperwork that need to be filled in once you have finished). Unlike the UK, this culture of litigation doesn't exist in Uganda; even if a person wanted to take a doctor to court, in most cases they wouldn't be able to afford the legal fees. This is not to say that doctors don’t get sued, but it is such a rare occurrence that hardly any of them have indemnity insurance. The consequence of this is that the doctors here have a greater sense of freedom with what they can choose to do. This is not to say they are irresponsible or act outside of the competencies; nothing could be further from the truth with regards to the doctors that I have been fortunate enough to work with Kagando. What I mean instead is that with fewer doctors and less senior support they frequently find themselves in the situation where they are the only ones who can do something for a patient. If there are no other doctors and a patient requires an operation that they are unfamiliar with, they will show a tremendous amount of initiative by going away to learn about the procedure; if after this there really is no other alternative and they feel confident with the technique the doctor will often attempt the operation themselves. For instance, we recently had a lady on our ward who had had her lower lip bitten off by another woman following an argument. Whilst this made eating and drinking very difficult, she was unable to pay for a referral to a plastic surgeon for reconstructive surgery. Realising that no one else was going to operate on this lady, Naomi went away to learn about the procedure herself. Despite having never performed reconstructive surgery before, her attempt was highly successful and the patient was able to eat and drink again with no difficulties. During my time in Kagando I have had multiple opportunities myself to learn how to do several different procedures, including caesarean sections. However, I have had to decline theses offers; I would not be allowed to do these operations in the UK at my current level of training, and I don’t see why things should be any different just because I am in Uganda.

Kagando's Operating Theatre

Fellow Colleagues

In the UK I have grown accustomed to working in a large team of other doctors; even when you think you are on your own there are always people nearby that you can ask for help. Unfortunately the luxury of working in large teams doesn’t exist in Uganda; with so few doctors in the entire country they will often find themselves having to look after a ward of forty or more patients by themselves. Whilst this may happen occasionally in the UK, you always know that it is only temporary as your consultant will be back the following day. However, in Uganda there is often no senior support, and the doctors (who are often at the same level of training as myself) have to work alone for months on end. Whilst the sheer workload of looking after a ward by yourself is hard enough, with nobody to double-check their work, the doctors here have the constant worry that they have missed something important or made a mistake that will never be corrected. If this isn’t bad enough, the lack of other doctors means that the ones that are here have to be on-call almost all of the time; even when they are meant to be off, the nurses on the ward are almost always guaranteed to call them in for one reason or another. 

The Surgical Ward at Kagando

Whilst there may not be many other doctors to work with, there are always other members of staff that help with the day to day running of the hospital. A large proportion of the workforce is made up of nurse; like in England there are those that are amazing, some that are good, and a couple that are pretty bad. However, I have too much to say on this topic to be able to include it all here and will instead save it for another blog. Also, unlike the UK where you have to be a doctor to work as an anaesthetist or radiologist, in Uganda these jobs are normally carried out by clinical officers. These are people who were usually nurses before and have undergone a further eighteen months of training in their chosen speciality (similar to a nurse practitioner in England). It is also very interesting to speak to people out here about their views of doctors. The charge nurse on the surgical ward was telling me that there are still a few old school doctors in Uganda who expect nurses and other members of staff to literally ‘stand up and bow down’ in front of them every time they enter a room; it is nice to know that we still share some similarities with Uganda.

The Patients

Of course, no doctor would be able to carry out their job without having any patients to look after. Although the population is varied, the patients that we tend to see in Kagando fall into the category of the rural poor where the main source of income is from farming. Whilst most come from the surrounding villages (where they speak the local language of Lokonzo), Kagando is only twenty or so kilometres from the border with the DRC, and as a result we often see patients from The Congo in our hospital. With such a mix of tribes in the area, even Uganda doctors (who are often multi-lingual) can’t possibly  be expected to speak all the different languages, and therefore have to conduct most of their consultations through an interpreter (i.e. a nurse). However, unlike the average British patient who has incredibly high expectations of the NHS and will subsequently question everything that you do, the patients in Kagando are a lot more accepting of what you tell them; I don’t think I have been asked even once about my choice of treatment during my entire three months here. 

It is not just the cost of the medical care that a patient is expected to pay for whilst in hospital; they must bring in their own bedding and cook their own food. As most of them are too unwell to do this for themselves, an attendant (normally a family member who sleeps on the floor besides their bed) must do this for them. If they have no relatives, they simply can’t eat. However, whilst I am well aware that I may have created a rather negative theme throughout this blog, I would like to take this opportunity to point out that not everything is so bad.  We had a man on ward several weeks ago who was HIV positive and has sustained a broken leg. Unfortunately he had no attendant, and was too unwell to cook for himself. However, rather than letting him go hungry the relatives of the other patients would share what little food they had with him; it is nice to know that even in the most deprived areas people are still able to show a small amount of compassion. 

I am due to leave Kagando tomorrow, and although I have thoroughly enjoyed my time here and learnt a lot in the process, there is a small part of me that is very much looking forward to working in an English hospital again. Amongst other things, I have come to realise how fortunate we are to live and work in the UK; all healthcare free, and as doctors we have the resources to treat anyone who is sick - irrespective of how much money they have. Whilst it is not without its faults, I personally believe that the NHS is by far the best healthcare system in world; perhaps after reading this blog some of you may start to think this too.