me you and everyone we know: Dancing the rains

“I danced the rains down in Africa,” by Toto seems to be a local hit. I have heard it about 3 times since I arrived here. And surprisingly I am one of two Mzungus in the Acacia Guest House, so I know they are not playing it just for me.

They can’t play it enough, as far as I am concerned.

Acacia Guest House

My first few days working have largely centered around trying to understand the specific processes involved in assessing individuals with HIV for tuberculosis- from the time they walk through the door and are evaluated with the "four-symptom screen" (cough, fevers, night sweats and weight loss) to the time their sputum results are returned to the clinic and they are either transferred to the TB-HIV clinic or kept in the "ISS" (Immunesuppression Syndrome) clinic. The goal is to determine where there might be gaps in management.

The hard part is trying to get as much work done in as little time as possible without being an imposition or appearing rude.

Ugandans are extraordinarily polite and will not make any attempts to correct any faux pas- cultural or otherwise. (By the same token, Americans are forever ingratiating- mostly stemming from sincere guilt, sometimes a bit less genuine in intent.) I was acutely aware that I might be asking too many questions and imposing a bit too much and so every question I had was often followed by an apology. I would often catch my data management colleagues exchanging glances at one another as we went through the steps of data entry. I imagined it was the polite Ugandan equivalent of the eye-roll.

on my walk to the university campus: a coffin making shop

On the way to work

I take it women don't drink Guinness in Uganda
(Note the billboard in the background is an advert for a radio program "Wassup Mbarara!")

I spent a bit of time in the ISS clinic with a co-fellow from Harvard who had been living there since August. Like many of my colleagues, he was already incredibly accomplished- had several dozen publications, helped start an NGO in Liberia, had transformed HIV-TB care in Mbarara by creating a "TB suspect room" whereby individuals who reported a cough plus one of the other 3 symptoms were promptly shuttled to a separate room, had a mask placed on them and then sent to the lab to submit a sputum specimen.

"Surprisingly, I've never converted (developed latent TB)," he marveled. I suggested that the open windows, which let in fresh air and sunlight and allowed for decent ventilation, might have had something to do with that....a comment which might have undermined his efforts. I quickly followed with a praise of his amazing efforts, which I genuinely believed. It is so hard to figure out what is the best way to direct your efforts and know how much of an impact it will have and how futile it will be in this part of the world. You don't want to be just some other guy making big sweeping changes that will yield little. I am not 100% sure of the reduction in transmission rates that his TB suspect room will achieve, but overall the process has become so much more systematic, that invariably the effort has likely improved other outcomes.

I had lunch at "the best Indian restaurant in town" with an expat who serves as the MUST-MGH Harvard Collaboration Program Director. (Sadly, though there are many Indian families in the area, few have invested in good restaurants, and Hem’s is one of the newer establishments.) A family physician who worked in an HIV clinic for 22 years (at a time when HIV was the domain of primary care providers, internists and FPs alike), she decided that she wanted to try something new. So she applied for this job posted by a former UCSF ID faculty member who is now at Harvard and now largely serves as an administrator in Mbarara. She has lived here for about a year and will likely be here for another one or two. She spoke of the fact that it took her several months to learn and understand some of the cultural nuances here, and even now there are times when many things are lost in translation. I laughed at her stories of cultural missteps. She keeps a cat at home (which is strange for them) and when she was buying bedsheets from a local vendor, the vendor showed her bedsheets with cat prints thinking that such was her cup of tea...when in fact all she wanted was "nice clean white German sheets."

An hour and a half later, we received our meal of chapattis, paneer and masala pappadum:

That afternoon I traveled with Sara, a research assistant and nurse, to do a home visit on one of the patients enrolled in the UWARTO project which uses a wireless device to track adherence. Enrolled patients have a pill box that sends a signal to the researchers every time it is opened. We traveled only about 15km to get to a patient's home, but it was 15km into the bush, including a short hike up a steep hill.

Fieldwork with R our Driver. On the road he mentioned that the Indian population never intermarried here, only the Americans...

My plan was just to observe the interaction, but I soon found myself assuming a more comfortable role. She was complaining of profound fatigue, lightheadedness and a sore throat. I looked in her mouth and it was heavily coated with thrush (a fungal infection). Her heart rate was normal and this reassured me that she was taking in enough food and drink to keep herself relatively hydrated. But we advised her to go to the hospital regardless. She was hesitant to travel the distance because she didn't have an appointment and she was afraid they would reprimand her for not disclosing her symptoms earlier. It was true that she would not be able to be seen in the clinic without an appointment- the clinic, which saw 20,000 patients last year, 9,000 of whom are considered "active patients," is simply too overwhelmed and understaffed.

(A brief note on the Ugandan brain drain: a well-paid nurse gets a monthly salary of $90. Most graduates of Ugandan medical schools seek employment outside of Uganda. NGOs in neighboring Rwanda and distant Swaziland pay 6x as much than the Ugandan government. The real kicker is the training- residents have to pay to be a resident and often wind up having several side jobs (running pharmacies, nursing homes, etc) to make ends meet.)

I wrote down the name of an antifungal treatment which is likely quite expensive, but she said that she would have her husband pick up a prescription. I advised her to not take the antihistamine she was given by the pharmacy lest it make her dizzier. And I again reiterated the need for her to be evaluated more thoroughly. I wondered if I was actually doing a disservice by examining her, giving her perhaps false reassurance about her condition.

I asked Sara what would have happened if she needed to go to the hospital emergently, because for a while I wasn't sure if she merited a more thorough evaluation. Sara said that all they could do was advise her to go on her own- there was simply not enough money for the researchers and field workers to transport all patients who would need to be seen in the hospital. I felt better after having watched her for a bit, but the thought was greatly troubling. We gave her the bag of sugar that is offered as renumeration for her participation in the study and left.

The following day was busy touring the campus again, and then having several meetings with the data entry folks as well as the lab technicians. Part of the tour I took was given by the Associate Dean of the university. The “Professor” was lovely and charming and would often ask questions which we were not meant to answer- though we probably could have responded, he would answer them quickly for us. It was as though we were his pupils. “And why is it that the sun rises in the morning and sets at night? (Brief pause) Because the earth rotates around the? (Brief pause) Sun.”

Giant storklike birds on campus

I spent the early part of the evening at the plush MGH guest house. Built by one of the researchers at Harvard who previously worked at UCSF, it was reminiscent of a suburban home in Marin or Sonoma, complete with Spanish tiles and granite countertops. It boasted an incredible upper-level veranda that overlooked the southwestern hills and a garden that was filled with fruit trees of all shapes and sizes. My original plan was to have dinner with some of the folks who were residing there, but I had to hurry home for a late night conference call with my mentors in California. I was envious of those who were residing there and couldn’t help but wonder how much easier it would be for an American to live in this part of the world if you had a home like this. Though I am grateful that my own current living quarters is clean and well tended with good service, the lack of a fan (which prevents me from using my stifling mosquito net) the loud soft rock in the late evening and the early morning buzz of mosquitos by my ear has kept me from a good night’s rest in several days.

My sad dinner consisted of a cheese sandwich and fries, but the lovely wait staff at Acacia, who had noted that I had not eaten my crust the night before, removed the crust for me even though I had not asked.