Monday, 25 February 2013

My thoughts on Uganda

This is the second time I have come out to Uganda as part of the Uganda ENT project. The Project started out over 10 years ago with a group of Canadian ENT surgeons. Up until the last few years, it has focused on patients with diseases of the ear and hearing loss.

We have now started a rhinology group, manned by UK doctors and nurses, and I'm very proud of the RSCH team for whom the experience was not an easy one.

There is no doubt that the Ugandan people are in dire need of improvements in healthcare, not just in ENT, but across other specialties too. The average life expectancy amongst Ugandans is 54 years (compared to 80 years in the UK). The bulk of their healthcare provision is from the main hospital in Kampala, its capital.

The British built Mulago hospital shortly before independence in 1962, when the population of Kampala was around 150,000. The massive population explosion in Kampala since then (now estimated at 1.7 million people) has meant that that healthcare provision has not been able to keep up with the demand. Uganda is a poor country, and despite a large amount of overseas aid (£100 million from the UK in 2012 alone), the government appears not to have sufficient funding to improve or even maintain ENT services at Mulago.

Part of the problem lies in the fact that otology and rhinology are largely microscopic/endoscopic sub-specialties in the western world. Though the Ugandan surgeons are incredibly knowledgeable and hungry for experience in these more modern techniques, they are not able to acquire the specialised equipment required to perform these procedures. As much of an issue is the lack of expertise for maintaining and servicing such equipment even if it were available.

As a first time Project participant in 2011, that visit proved to be a frustrating experience in the clinical setting, albeit a fruitful and enjoyable one in the academic setting; the Sinus Surgery course that I ran during that time appears to have been well received.

The frustrations of that occasion were somewhat diminished this time, but sadly this was more to do with knowing what to expect, rather than any improvements in the running of services at Mulago. Disappointingly, politics plays a fiendish role and this is something that cannot easily be addressed by the Ugandan doctors, let alone by a group of naive ‘muzungus’ who go over once a year for a week or two.

I was pleased to have helped the local surgeons operate on 2 patients with sinonasal tumours, as well as seeing patients in clinic with other sinonasal pathology. I was less pleased about those patients with tumours that I did not have time to treat or the 3 day old baby that died overnight whilst waiting for us to operate on her the following day.

Having now returned to the UK, my feeling about my experiences, this time and last, is dichotomous.

On the one hand, the sense of frustration over a sloth-like system discourage me from giving my time, energy, and yes, not inconsiderable personal financial expenditure, to provide a hospital with a free health worker. I wouldn’t care, but the surgical skills I have been teaching are not being implemented by those that I am trying to train. The microdebrider that I wanted to use for the sinus surgery cases did not work. The last person to have used it was me. In 2011. No surprise that it had seized up whilst sat in a cabinet for 16 months!

But at the same time, a 5 minute walk around the hospital and its grounds reveals the huge numbers of patients who have ailments that we rarely see in the UK because they would be treated much earlier. I see their families camped out on the grass verges or balconies in make-shift tents in all weathers; for they are the ones who provide food for these patients, bathe and clean them in their beds, and tend to their wounds because there are inadequate nursing staff. At night, one nurse looks after the 30 patients on the ENT ward.

These patients are desperate.

So I have little doubt I will be returning to Uganda again. But our strategy needs a rethink. And I'm pleased that, with our Canadian friends, this process has already started.


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