Gratitude

March 3rd, 2017 by Stephanie Peace
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Prior to spending this month in Uganda, I knew that I wanted to return to work in Africa after completing my medical training, as this has been a call on my heart for many years already. This experience was both a reaffirmation of my calling to serve the world’s poorest people and a recommitment to that calling. Upon arriving at Kiwoko Hospital, I felt committed to working with underserved patients but had increasing doubts about my calling to do so internationally. I felt afraid that I would leave Uganda feeling unequipped to serve in a challenging place like this or feeling that my desire to be here, where just living life is more challenging, would have been dampened by years living in relative comfort in the U.S. What happened instead was a complete affirmation that my heart is in Africa. I feel more complete and more faithful here, knowing that this is what God has called me to do. The things that on the surface are challenging here end up drawing me closer to God’s own heart. For example, less access to internet frees up time for me to spend in worship and in relationship with people. Using a pit latrine, taking bucket showers, and being extremely careful about food waste because of the food and water shortages that surround me force me to be more environmentally conscious (in the U.S. it’s more difficult, as the effects of my wastefulness are not as immediately visible). As a result, I am incredibly grateful to have had this opportunity and look forward to the plans that God has to bring me back to serve the world’s poorest patients.

HIV Care

March 2nd, 2017 by Stephanie Peace
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Kiwoko Hospital has several different clinics for HIV+ patients, including one for adults, one for children and adolescents, and one for mother-baby pairs. There are also extensive counseling and testing efforts that happen in formal and informal ways and a special program for HIV+ women who make woven baskets sold by the hospital for income (as they have often been rejected by their partners and communities and have limited education to support them).

 

I spent 2 days at HIV clinic, one for adults and one for children/teens. The process at Kiwoko is a well-oiled machine. Patients are checked in for vitals, then proceed to a counselor who counts pills for compliance. If there are any compliance concerns, the patient goes to additional adherence counseling to talk about the family’s financial situation, medication side-effects, and anything else that may be affecting compliance. After this, patients go to the lab (as needed) for viral load and CD4 testing. Finally, the patients come to the clinical officer (similar to a physician assistant in the U.S.) for evaluation and refills. The pharmacy (where all HIV medications are free, covered by USAID and other multinational organizations) is the final stop of the day.

 

Since instituting free HIV care and more aggressive screening and treatment during pregnancy, the mother-to-child transmission rate has decreased significantly at Kiwoko (often limited to mothers who delivered at home). This is great news! However, there remain many children who are already infected with the virus. I saw two sisters, aged 9 and 11, come to clinic by themselves from another town 30 minutes away. One had a fungal infection of her scalp; the other reported anal pruritis and stated that her grandmother had seen pinworms in her stools. Although we prescribed them medications and refilled their HIV medications, watching these two young girls leave the clinic alone (despite repeatedly requesting that a caregiver accompany them to clinic) made me feel that we hadn’t done nearly enough to relieve the burden on their young shoulders. There are some things no child should have to face alone.

 

Being in the HIV clinic gave me an opportunity to ask sensitive questions about sexual practices and family planning in Uganda. The staff were generally happy to discuss with me. Encouraging condom use, even among the HIV+ patients, remains a major challenge at Kiwoko. In a culture where men remain the head of the household and women have minimal agency regarding their sexual health, condoms are not a popular form of contraception or STI prevention. The stigma has decreased for HIV testing, but is still more challenging in men who tend to come to the hospital less frequently than women (who also receive testing with each pregnancy). Despite improved education about HIV and the relatively easy access to free medications for management, there are still widespread ideas about treatment of HIV that are not scientifically based (including various natural remedies and the theory that the virus can be cured by having sex with a virgin). An emerging problem seems to be the early age of onset of sexual activity. In Kampala, girls as young as 13 and 14 are initiating sexual activity (apparently related to the negative influences of alcohol, drugs, prostitutes, and media), while in the more rural areas like Kiwoko girls may begin sexual activity at 15 or 16. All of these behaviors combine to produce a high HIV rate in Uganda – but, like in the U.S., health behaviors are often the most difficult to change.

Malnutrition

March 2nd, 2017 by Stephanie Peace
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Prior to starting medical school, I spent 2 years (plus all of my college summers) working for a non-profit organization called Project Peanut Butter, which specializes in local production of ready-to-use therapeutic food (RUTF) used to treat malnutrition in children. RUTF is essentially souped up peanut butter and contains all of the macro and micronutrients necessary for catch up growth. A key component to the success of RUTF is that it can be used as outpatient therapy, which protects children from hospital-acquired infections, enables families to stay together at home (rather than the mother having to leave the rest of the family and farming to stay at the hospital for weeks or even months), and in randomized-controlled trials even worked better for achieving cure and avoiding remission than standard inpatient therapies (milk formulas called F-75 and F-100). Needless to say, I’m pretty passionate about RUTF and malnutrition treatment!

 

While working in the pediatrics ward, I saw the typical trifecta of pediatric illnesses in Uganda: gastroenteritis/dehydration, malaria, and of course, malnutrition. At Kiwoko, they are using F-75 and F-100 for inpatient management of malnutrition. Occasionally they are able to get RUTF from their local government hospital, but there are frequent shortages so they can’t rely on that for treatment. Typically, they use the RUTF in HIV+ children to help them stay above the malnutrition curve after they have completed their treatment with F-75 and F-100. The nutritionist, a Ugandan nurse named Sister Jane, also teaches families to make a supplement they can use at home made from ground peanuts and fortified milk powder. I shared with her the recipe for RUTF so that she would be able to add some of its components in what she teaches families.

 

Having seen the major impact that RUTF can make for children (and families), it’s a shame to see shortages like those in Uganda affecting patient care – yet another challenge of low-resource medicine!

The Ethics of NICU

March 1st, 2017 by Stephanie Peace
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I completed a month-long NICU rotation earlier this year in Columbia, MO, so I was excited to see the NICU at Kiwoko Hospital (known as the best in Uganda). The facility is beautiful, though lower-tech than our NICU in the U.S., and Dr. Becca really works hard to ensure that the infants receive the highest quality of care. Kiwoko’s NICU receives a combination of infants: in-born children who suffered birth trauma especially severe asphyxia, pre-term infants (often as young as 26 weeks gestational age and as small as 800g), and infants born at home or at other facilities often presenting with sepsis. For most services at Kiwoko Hospital, patients pay a subsidized price of 1/3 the total cost of services. Because a months-long NICU stay would be astronomically expensive for most patients, families pay a total of 20,000 shillings (approximately $5.50) for all the care received for the duration of the NICU stay.

 

The challenges of operating a NICU in Uganda include:

  1. No access to surfactant for premature babies. The maximum respiratory support available is CPAP, so while it’s possible to intubate these very small babies for short-term bagging or transport purposes, they ultimately have to breathe on CPAP alone.
  2. No ability to place umbilical arterial lines or umbilical venous lines for labs and medications. This makes getting a peripheral line essential and also limits what labs can be regularly tested (though the lab requires such a large amount of blood for most tests compared with the U.S. that regular testing is not typically an option anyway).
  3. No TPN available. For patients in Kiwoko’s NICU, the only nutrient source is breastmilk, which mothers have to express (no pumps available) for tube feeds. In extremely premature infants or infants with GI abnormalities, tolerating tube feeds may be a challenge resulting in necrotizing enterocolitis.
  4. Staffing burdens. Nurses in an American NICU may have 2 babies at a time (up to 4 on a step-down unit). The NICU at Kiwoko is almost always full (25-35 babies) and there may be 4-5 nurses on each shift. Overnight, one physician (not usually a trained neonatologist or even pediatrician) covers the entire hospital, so there is no one immediately on site in the NICU for emergencies.

 

In addition to these major difficulties, there is generally less intervention including testing for future developmental issues, as there aren’t services available for children with developmental delays or disabilities (beyond physical therapy).

 

One thing that I appreciated about working with NICU was the ethical conversations (which were much more common in Uganda than in the U.S.!). I often felt uncomfortable in my NICU in Columbia, MO with the overwhelming optimism that resulted in going to great lengths of medical intervention. There were instances that I felt like we weren’t being fully honest with the parents about what they could expect from the interventions we were pursuing. There is, after all, a difference between keeping a child alive and giving him or her a life. In Kiwoko, we often discussed the realistic limitations of the NICU. We had conversations with the other physicians and midwives about options available to the mothers of extremely low birthweight infants who are unlikely to survive the NICU. Is it better for these infants, who are unlikely to survive at all and even more unlikely to survive without significant physical and developmental disability, to spend their limited time on Earth in the arms of a mother who loves them or to go to NICU, separated from the mother and connected to a multitude of tubes and lines? The answer may differ by family, but bringing the family into the honest conversation is so important. I am grateful to have worked with physicians who take their ethical responsibility to patients seriously, even when the conversations are difficult.

Low Resource Health Care Decisions

March 1st, 2017 by Stephanie Peace
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Operating in a low-resource health care setting is a huge adjustment. The physicians at Kiwoko Hospital routinely are forced to make life-or-death decisions that affect not just their own patients but the rest of the patients in the hospital. To illustrate, one patient arrived at the hospital 38 weeks pregnant with intrapartum hemorrhage. She was taken for emergency C-section for suspected placental abruption with fetal distress. The surgery was challenging (though remarkably the baby did well) with severe postpartum hemorrhage. In recovery, the patient received 2 units of blood (which already points to the severity of her condition, as they don’t routinely transfuse in adults here unless the patient is symptomatic with a hemoglobin < 5; by comparison, we would routinely transfuse at hemoglobin of 7 in the U.S.). An hour into recovery, we were alerted that she was bleeding with a blood pressure of 54/37. She was given pitocin, misoprostol, and methergine and then taken back to the OR for placement of an intrauterine foley balloon in an attempt to stop the hemorrhage. Her blood pressure became unreadable in the OR and she ultimately required hysterectomy due to uterine atony and continued hemorrhage, complicated by suspected DIC. We requested additional blood products and were told there was only one more unit in her blood type (B+), which she was given. The lab was reluctant to give up a unit of O+ blood, but it became necessary in order to maintain blood pressure. At the end of her hysterectomy, she really needed ICU-level care, which is not available at Kiwoko. The night shift is under-staffed both in terms of nurses and physicians (one physician covers male and female wards, pediatrics, NICU, and maternity and one surgeon covers any surgical patients), so it can be challenging to make sure patients get their vitals taken regularly, let alone more intensive care. Luckily a senior midwife was on the night shift and was able to carefully monitor her vitals throughout the night. Overnight, another patient, also B+ blood type, had a postpartum hemorrhage due to retained placenta following an intrauterine fetal demise. When we rounded on these two women the next morning, both were stable but shaky and pale with estimated hemoglobin of 3. We requested a unit of O+ for each of them, which they were given. This meant that the lab had no units of blood left available for any other patients who might arrive in need of blood products. The hospital was unable to get blood even from Kampala for several days. Ethically, this means that physicians at Kiwoko Hospital routinely have to make the decision to provide blood products for one patient knowing that other patients may be denied life-saving treatment simply due to lack of supplies. We discussed the option of staff and volunteers donating blood, but in Uganda blood product donation is strictly regulated due to the high HIV rate and this kind of donation is technically illegal. The entire situation was frustrating because there was so little we could do. It made me grateful, however, that we didn’t transfuse an asymptomatic patient who came in the day before with a hemoglobin of 5; had the decision been up to me, I would have transfused her based on U.S. standards but the result would have been even less blood available for the two women who required blood transfusions for survival. I have so much respect for the difficult decisions that Kiwoko’s physicians make day in and day out.

Maternity Care: Here vs. There

February 7th, 2017 by Stephanie Peace
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I’ve been really lucky to spend 2 full weeks of my time here at Kiwoko on maternity (including labor and delivery, antenatal and postnatal ward rounds, gyn clinic, and the OR). Though women’s health and the labor process is mostly the same, there are a few major differences that I’ll highlight here.

 

Prenatal care: Although Kiwoko Hospital offers a daily antenatal clinic for expectant mothers, the cost and travel distance make it impractical for many women to come regularly, if at all. The prenatal testing that is done is also much more limited for the same reasons (GBS swabbing, Rh testing, and anatomy ultrasounds are beyond the scope of this clinic, while testing for HIV and other STIs remains standard practice). In the U.S., most women receive 10-14 antenatal visits with regular monitoring of fetal heart tones and more lab testing.

 

Setting: In the U.S., each patient has her own labor room (or suite, really, with a pull-out bed for the partner and a private bathroom). At Kiwoko Hospital in Uganda, there are 8 labor beds separated by curtains in a room that’s probably the size of 2 labor suites in a typical American hospital.

 

Supplies: Similarly, in the U.S., each labor suite has its own neonatal resuscitation and all labor supplies are at bedside. In Uganda, the women come with two plastic sheets that cover the labor bed (one for during delivery and a clean one for after), a roll of tearable cotton that is used to clean and as a pad for bleeding, two pairs of sterile gloves, and a razor blade for cutting the umbilical cord.

 

Pain control: In Uganda, there is no option for pain control during labor (but they do have epidurals for C-sections thank goodness!); in the U.S., the vast majority of women opt for an epidural (though natural labor seems to be on the rise).

 

Labor management: While nurse midwives still play an active role in managing labor in Uganda, the soon-to-be mother’s family members (usually a mother or sister) do the bulk of the care during labor. In the U.S., nurses do the nursing and family members (most likely the partner) is there primarily for moral support. Labor also tends to be much more medicalized in the U.S. with continuous monitoring for fetal heart rate and more frequent examinations. In Uganda, fetal heart monitoring is done intermittently on everyone except those patients receiving pitocin for augmentation of labor (and even the continuous monitoring is less well monitored as there are no computers to watch the contractions and heart rate together so monitoring depends on someone being at bedside to hear and observe the heart rate).

 

Delivery practices: In the U.S., we deliver breech presentation in one circumstance only: a second twin. Even fully dilated patients with breech presentation typically go for emergency C-section rather than breech vaginal delivery. Here in Uganda, most breech presentations are allowed to labor and attempt vaginal delivery with one exception: primigravid mothers.

 

At the end of the day, despite these differences in setting and practice, everyone is thrilled when a healthy mother delivers a healthy baby!

A Word on Politics

February 6th, 2017 by INMED
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As an American traveling abroad, it is always interesting (especially after a new president takes office) to hear people’s take on American politics. I was in Malawi in 2009, just 6 months after President Obama had taken office and Malawians were obsessed with Obama. His face featured on fabric and aprons and hats and flags throughout the market.

 

When I was driving from Kampala to Kiwoko, one of the first questions my taxi driver asked me was where I’m from. After stating that I’m from the U.S., he immediately embarked on a tirade against President Trump and his Muslim ban, which had just been ordered two days before. The Europeans at Kiwoko have also had questions about how Americans (especially American Christians) perceive Trump and the executive orders that have recently gone into effect.

 

Regardless of where you stand politically, it has been interesting for me to see the wide effects of American politics (and humbling as folks tend to be so informed about politics in my country, while I am rarely as well informed about politics in the UK and know little about politics in Uganda). With global development and aid already relatively poorly funded in the U.S., time will tell the effects that the new administration will have on the world’s poorest people.

 

Week One

February 5th, 2017 by INMED
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One of my four weeks at Kiwoko Hospital in central Uganda is already gone! I arrived last weekend and after spending 1 day in Kampala, Uganda’s capital, I traveled north to Kiwoko. The staff and guests at Kiwoko have all be incredibly friendly and welcoming, making me feel right at home from the start.

 

The Kiwoko Hospital is organized under the Church of Uganda with support from several European physicians who are here long-term and many others who come periodically. There are also Ugandan surgeons and intern physicians in addition to midwives, nurses, lab staff, pharmacists, etc. The hospital has outpatient clinics including specialty clinics for sickle cell disease, diabetes, HIV, antenatal care, and dentistry; wards for men, women, and children; a beautiful maternity ward with space for antenatal and postnatal patients in addition to labor and delivery; an even more beautiful NICU that’s unlike anything I’ve ever seen in a hospital in the developing world; and two operating rooms. Days typically begin with a prayer and worship service at the neighboring nursing school before the physicians meet together for handoff from the night shift and teaching. After that, everyone splits up to do ward rounds and whatever else needs to be done for the day.

 

Because of my interest in OB/GYN, I spent this whole week on maternity. There is a Dutch OB/GYN here long-term as well as a visiting Irish OB/GYN here for 6 weeks. I had the chance to work with the midwives (including my first twin delivery) and assist in several C-sections in the OR. I also rounded on postoperative and postpartum patients with the team (and the fantastic Ugandan nurses and midwives as translators). It was a busy first week and a great chance to observe how things are done here.

 

I’ve been especially struck by how much the physicians here are jacks of all trades. Because there are so few of them, in order to manage the call schedule, the 2 surgeons are each on call for a whole week, every other week. The others cover the rest of the hospital (adult and pediatric inpatient, NICU, and maternity, including C-sections) for the nights and weekends that they are on call. I have previously looked at anything delaying my ability to come back and serve as a physician in Africa as a frustration; after just one week here, I perceive these delays as an opportunity to strengthen my training and knowledge so that I will be better prepared to serve when the timing is right. This will make me a better physician, a better colleague, and a better version of myself (more confident, less anxious). I look forward to what I will learn in the coming weeks!

Introduction

February 4th, 2017 by INMED
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My name is Stephanie Peace and I’m a fourth-year medical student at University of Missouri School of Medicine in Columbia, Missouri, USA. I’m at Kiwoko Hospital in Kiwoko, Uganda for the month of February doing an international medicine rotation through INMED.

 

A bit about me: I grew up in St. Louis, Missouri and have long been interested in questions of poverty and global development. In college, I got involved with a non-profit organization called Project Peanut Butter that makes a peanut butter-based food for malnourished children. After working with them in Malawi, I volunteered to set up a new branch of the organization in Mali, where I moved after graduating college. A military coup rerouted my plans a bit, and I ended up spending some time setting up a new branch in Ghana and then running the branch in Sierra Leone before coming back to the U.S. to start medical school. I knew going into med school that I wanted to incorporate global health into my future career because my experiences with Project Peanut Butter had been so impactful. I also knew that any global health endeavor would have to be sustainable, evidence-based, and goal-directed.

 

Finding a way to incorporate global health into medical school can be challenging. For me, it included INMED’s global health course, an education-based trip to Nicaragua with my school’s global health organization, and now this international rotation. My primary objective for the rotation is to learn more about how medicine is practiced in low-resource areas, observe Ugandan and ex-pat medical staff in their roles at the hospital, practice serious discernment about what my own future global health career can look like, and serve (in whatever small way I can as a medical student) the people at Kiwoko Hospital.

Introducing Myself

January 29th, 2017 by INMED
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Hello! My name is Stephanie Peace. I am a medical student at University of Missouri-Columbia, and I’m starting my INMED service-learning experience at Kiwoko Hospital in Uganda beginning in January 2017.