Today I was sitting in the park, watching my 5 year old play on the swings while listening to a smaller child complain about having to finish her lunch. Two weeks ago, I wouldn’t have given this a second thought. Spending time in a region where the children eat the same staples every day- hoping they will get three meals a day, has certainly changed my perspective.
Our first days in Uganda were full of excitement and curiosity, which quickly came to a halt when we arrived at Tekera and met the children at Bridgitt’s school. It was quickly obvious that we were surrounded by a poverty that is unparalleled in the United States. As much as I’d read about the region and despite all of the pictures I’ve seen, nothing prepared me for what I saw. Small children wandering around without a grown up in sight, wearing clothes ripped beyond repair, covered in dirt, wandering amidst large animals and near passing cars was the norm. Still, the children had a happy twinkle in their eyes. Five year old Rachel gladly took my hand, my BlackBerry and my camera and showed me around her space. She made me laugh and as soon as she was out of site made me cry.
I was initially more optimistic after arriving at Mbiriizi Advanced Primary School- the site of our clinical work for this trip. We were to examine and treat as many of the 1000 students as possible in four days. When we arrived at the school, I had a sense of hope that things were not “that bad”. The kids were all wearing uniforms and from a distance, appeared well nourished, clean and vibrant.
At 10 am Monday, we opened the doors to our clinic. Already, there were 30 of the “sickest” children waiting to see us. Within the first 2 hours, we had diagnosed and treated two cases of pneumonia, two with severe ear infections, gastrointestinal disorders likely from worms and parasites, severe bronchospasm, malaria, dental abscesses, bone infections and AIDS. These were all children who were not sick at home- they were brought from their classes, and returned to class when we finished our assessments and treatments.
Next we called for all of the students, one class at a time. At first the kids were afraid but this seemed to subside as the week went on. We know that the kids talked all about us at recess because after a while, they would dutifully take a seat in the exam chair and open their mouths without coaching!
We found most of the children complained of headaches. I was naïve enough to do a full neurological exam on the first few with this complaint, before realizing that it was a daily complaint for most- from hunger, dehydration and sun exposure.
Most also had stomach complaints- belly pain, constipation, nausea and most of all hunger. As one little girl stated, “My stomach cries all of the time.” We were told that most had recurrent worm and parasite infections from contaminated water, soil and food. A regular regimen of “de-worming” was recommended and the children were due and we did this on the last day, serving each child albendazole and mebendazole with their lunches.
Mixed with our “routine” checks, many walked in with acute complaints- injuries, vomiting, fevers. Most were reassured and sent back to class after a Band-Aid , ibuprofen or a drink. One boy had a temperature of 104 and was vomiting. He rested on our cot for an hour and as soon as he was able to stand he was told to go back to class. At first I thought this was cruel but it was explained to me that he had no other options. He would walk home at the end of the day with a group of other students when the sun was not as hot. If I sent him home at that point, he would walk by himself in the heat of the day. Only in extreme cases is transportation arranged for a child and it can be costly to the family.
HIV is another problem. We met seven year old Mary on the first day. She was one of the “sick” children designated to see us first. She had what looked like a fungal rash all over her body, a distended and tender abdomen and a productive cough. Despite this, she was happy and playful. We took her to the clinic in Masaka for HIV testing and a clinical examination. She was confirmed to be HIV positive. No therapy was discussed and no CD4 count was done. She was given topical cream for her rash and an antibiotic for her cough.
In Uganda, treatment through various agencies is readily available- and free. Unfortunately many choose not to be tested as HIV is considered a “gay-disease” and an HIV infected individual must be gay and is often shunned by their community. There is proposed legislation that will make homosexuality punishable by death. A caveat to this is an HIV infected person, a doctor treating HIV and therefore aiding a homosexual are both subject to prosecution.
We asked Mary’s mother to meet with us. We learned that Mary had been sickly her whole life. Mary’s father was dying of AIDS. Mary’s mother and two siblings had never been tested for HIV, nor was her mother aware that there were free centers where she could have delivered her babies and received perinatal anti-retroviral therapy. We gave Mary’s mother information about free HIV testing and medications and we gave her money for transportation to the facility. Immediately she had questions about what this would mean for her and her children- she felt nobody with HIV would be accepted in her community. I tried my best to reinforce that the medicine does control the virus and extend life but was not convinced she would follow through with my recommendations. There was too much at stake and her reality was not one that I could comprehend.
Another boy, Derek, came to us with a painful arm. His arm had obviously been fractured- it was deformed, exquisitely tender and had several areas that had foul drainage. We took Derek for more tests and discovered that his fracture was not healed and that he had infection in his soft tissue and bone. We also learned that his fracture occurred one year prior- his bone was not set and surgery was not offered despite severe bony displacement and obvious open wounds. He was started on oral antibiotics and we arranged for him to have surgery thanks to a generous donation to Sylvia’s Children. Derek was at risk of losing his arm but the surgery could have bankrupted his entire family.
Medical care is largely fee for service- especially when procedures and tests are required. Many families make difficult choices regarding health expenses. Derek’s father was trying to avoid surgery and his son was at risk of losing his life or limb. In the United States, Derek could have walked into most emergency rooms and he would be cared for.
We saw unimaginable dental disease. There are no regular dental exams, no tooth brushing and no fluoride treatments. Every child had cavities. Most had broken teeth and mouth pain. Those with abscesses or severely necrotic teeth were taken to the dentist by our group. Dental exams with extractions were less than $15 and the children we brought were able to be free of mouth pain by the end of the day.
I was monitored closely by the owner and staff at the school. One girl complained of vaginal discharge- from her symptoms, it sounded as though she might have an STD. I asked if she could come back at the end of the day for a vaginal exam when we could have more privacy. For two days I called for her. I was told by the head mistress of the school that the nurse examined her in the evening and that her discharge was normal. So what happened? Was she examined? Was she normal? Was there an STD and was it treated? It was obvious to me that I had crossed a line. This was a deeply religious community- largely Pentecostal Christian and Muslim- both communities would frown on a teen with an STD.
One dilemma that we faced was the possibility of diagnosing diseases that we could not treat. I detected 10 heart murmurs on exam. Cardiac surgery is only now being trialed in Uganda- those who can pay for an operation are being flown to India at a cost of $10-15,000 US. What is the point of diagnosing valvular or congenital heart disease in these kids? The nurse from Tekera, Bridgitt, told me she doesn’t even listen to heart sounds because she can’t do anything about abnormal findings.
Realizing this was probably an exercise in futility, I sent 8 of the kids for ECHOs. One eleven year old had severe mitral regurgitation and I was told would need surgery in the next few years. Two had mild valvular heart disease and should be monitored clinically. The others were “within normal limits” which I’m certain means something quite different in the US as I heard these murmurs myself.
The school had a child pass away within the year of heart failure. I’m glad we did these ECHOs as we now have identified a child who may benefit from an intervention. We will meet with her family when Sylvia’s Children sends another group to Mbiriizi school in June. She will need to have a clinical examination by the physician in Masaka and be HIV tested and started on medications if appropriate. We are now in the process of researching possibilities for this child to have surgery.
We left feeling we still had so much more to do. We did examine all but 8 of the children. We have a sense of what needs to be done. De-worming has to be ongoing. The kids need to stay hydrated and nourished and avoid excessive heat exposure. We need to find a way to have all of the children HIV tested and treated without posing risk to their families. We need to educate the children and empower them to be their own advocates especially regarding HIV diagnosis and treatment. We need to educate the nurse that resides there so she can be better equipped to handle the medical needs of the community.
We need to pray and be thankful for the opportunities we have here in the United States for our children.