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OCMC News - A Rookie in Africa

by Dr. Ted Christou (Posted 8/31/2009)

OCMC News - A Rookie in Africa

After returning from Uganda, a colleague asked me, “Did you really do any good?”  My response was “Yes.”

Clinical medicine includes routine events that you manage by reflex, as well as challenging events requiring adaptability where your knowledge and outside resources guide your management. There also comes a time for resolve, when you step away because there is nothing else that you can do. The rookie, having not yet learned you can only do so much, becomes overwhelmed and shows disquiet instead of resolve.

In Africa I was a rookie, reliving my first call night. This time I wasn’t walking down a well-lit disinfectant scented hall with a Washington Manual in my pocket, instead, I was sitting on a hand-hewn wooden bench in a hut with no water or electricity wearing a red dirt stained lab coat with Oxford Tropical Diseases in my pocket. As an Internist in a teaching hospital, I care for adult patients working with carefully selected members of team. In Africa I treating children and working with a team that could not have been more random. Clinicians slowly build trust and proficiency at the bedside not with team dynamic exercises in a lecture hall. While in Africa, the process was accelerated by our team seeing up to 450 patients, and filling up to 3,000 prescriptions in a single day.

Given a patient with a migraine or a patient with cerebral malaria, the process and the response is the same every time - SOAP - (Subjective, Objective, Assessment, Plan). While in Africa I found myself adding the letter “E” for emotion. My first emotion was frustration due to the inevitable delays. There were meetings, and visits, and speeches, and performances. After a traditional Ugandan dance, performed by school children, one of the team turned to me and said, “This makes it all worth it.” No, I thought in my attending predatorial inner voice. I smiled a vapid acknowledgment, I’ve seen the  singing dancing thing in HD on the National Geographic Channel. We have only a few weeks to wipe out Malaria in the district of Gulu! Let’s get started already.

My frustration was replaced by apprehension while at dinner later that day at the convent in Monde. I was sipping red pineapple wine from a cordial glass that sat conspicuously on a white hand crocheted doily. Making a doily requires a plan. It takes about 200 yards of size 10 Ugandan cotton crochet thread, training, and technique for one of the nuns to complete the doily. What would it take to slow down malaria? The anopheles mosquito undaunted by our presence will continue to feed twice daily. Even if we had enough malaria medication, how will we know who needs it?  This finished doily in an Orthodox Village housing more than 800 children orphaned by war and HIV triggered a synapse for apprehension because I realized we had not been given a plan.

Perhaps it was apprehension which kept me awake the night before our first clinic. That and the discotheque next door playing a Michael Jackson tribute until 4:30 AM.  The electricity was out, so I reread my CDC treatment guidelines by flashlight. Knowing the correct dose of a medication that might not available seemed only a small pot hole in an African dirt road. Not having a reference for the correct dose of the exotic medication I could be handed at dawn to treat symptoms of the unfamiliar, unconfirmed tropical diseases I had reviewed these past weeks, while relying on an interpreter seemed more like driving through a road block and hoping nobody gets hurt. 

Uncertainty alternated with apprehension because I could not use western medical habit and protocol in a hut in the sub-sahara. Prayer and clinical reality would soon calm me as I reset my expectations and performance to what was correct for each particular situation to benefit my patients who had walked to wait three hours in the sun. WHO and CDC references  report malaria in 16 million of the 25 million Ugandan residents with an estimated annual related death rate of 70,000 children. Compared to HIV, three times as many children die from malaria and twice as many children die from diarrheal disease. Life expectancy is 51.

Day eight in the bush. Relaxed and ready in the well kept and friendly village of Koro. As a patients sits across from me under the shade of a tree, my translator and I strike a familiar rhythm in taking the history for this outpatient visit.  As I listen to the patient and my translator, I  understand some of the patient’s words for headache, waist pain, worms, and malaria. I can pick up the body language of a unpleasant rash “down below” and I’m in the medical zone. Easily, without distraction, the five minute sub-saharan consultation begins with a smile and ends by handing out a prescription, a tablet of Melbendazole and a small icon - the size of my business card back home. Diseases and probabilities are weighed, calculated, confirmed by history and physical exam, then treated with a new level of comfort.

The medicines are now familiar and there is less backup at the pharmacy. Today I can stop without feeling the need to treat the entire district - happy and satisfied are not the only emotions for the day. This day ends in hope; even though we are running out of money for medication, we will continue to treat 300-400 patients a day after a vote to kick in some team emergency cash reserve, as well as anonymous donations from team members.

At the end of the second week we drove silently into the IDP (Internally Displaced Persons) camp Ajonga. There were 1.8 million people moved to camps for safety during a 20-year war in Uganda waged my the LRA (Lord’s Resistance Army) against the tribes in northern Uganda. Since 2007, IDP camp residents are down to about 450,000 and this was sadly more camp than village. It was similar to other locations we visited through an association with the local Orthodox priest: the architecture, the placement of the huts, and the need for health care. What was different and unsettling was the oppressive poverty of the children who have little to nothing, pigs wandering and defecating along the barefoot worn paths, and barren yards without a hint of green. Huts were sparsely furnished - a chair with a missing back, a chunk of foam to sleep on, and tattered clothes washed and tossed on the dusty thatched roofs to dry.

As yet these residents had not reestablished their prewar farming and crafts skills. Even in this wretched place the people were friendly, open and hospitable. We engaged in conversation with local health and military personnel and treated their aliments. We discussed crops, water and sanitation issues and how the local priest might be a liaison for future cooperative endeavors. We also offered medication for the local clinic to be distributed after we left. They accepted. What we had started would continue after we were gone. Some of this camp would soon be sleeping without the rigors of malaria or the cramping from the “germs in the stool.” The medicine we left would last only a few months but hope can make a change and perhaps next year this place might be more village than camp.

I had no parallels or revelations that day. I could not recall any sage words to uplift me or help me make sense of what I saw. So instead I prayed. That night at dinner we said goodbyes, hid our regrets, but mostly ate in silence. Two of us were leaving the team. I sat on the unlit hotel balcony for several hours, unable to reconcile the disparity of life within the district of Gulu. I always knew frustration and ambivalence were relative and could be replaced by hope, but this night I felt it. In a few hours it would be feeding time for my nemesis the anopheles as I headed to see the origin of the Nile and some of God’s most beautiful sc

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God of truth and love: Father, Son, and Holy Spirit, Hear our prayer for those who do not know You. That they may come to a saving knowledge of the truth, and that Your Name may be praised among all peoples of the world. Sustain, inspire, and enlighten Your servants who bring them the Gospel. Bring fresh vigor to wavering faith; sustain our faith when it is still fragile. Continually renew missionary zeal in ourselves and in the Church, and raise up new missionaries who will follow You to the ends of the world. Make us witnesses to Your goodness full of love, full of strength, and full of faith for Your glory and the salvation of the entire world. Through the prayers of all the missionary saints, Have mercy on us and save us. Amen.
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