Greetings from Gulu - Reflections on Soc Med Course from Aarti Bhatt (MP3)

Posted on behalf of Aarti Bhatt, MedPeds 3rd year resident

Greetings from Gulu, Uganda!

What is Social Medicine and how do I implement it into my practice and day to day life? How do I truly work for social justice and health equity? These are the questions that led me to Gulu.

I have the privilege and the opportunity to spend 4 weeks learning and teaching about the social determinants of health with medical and nursing students, physicians, anthropologists, sociologists, economists, allied health professionals, village health workers, and patients. The course is called Soc. Med, and is crafted by Amy Finnegan (Sociologist) & Mike Westerhaus (Physician/Anthropologist). This is the 5^th year of the course which is held here in Northern Uganda. The 27 medical and nursing students taking the course bring their perspectives from various regions of Uganda, as well as from Rwanda, Zimbabwe, Argentina, USA and Lebanon. 

The Soc. Med experience challenges my understanding of why injustice exists in our society and subsequently leads to health inequity. We dissect topics ranging from colonialism to neoliberalism to intellectual property and the WTO. It is emotional, exciting, confusing, eye opening, awe inspiring, and an exercise in humility. It is also really fun. 

  

I’m still processing a lot (which is part of the reason it has taken so long to write this post), but will briefly offer some reflection. Additionally, I invite the broader community of health professionals to engage in critical, reflective and constructive dialogue about health equity that goes beyond the biologic basis of disease.  

Students come together to “look upstream” at the structural and societal factors that influence biologic illness

The “3Ps”, and unofficial mantra of Soc Med.

Getting Personal

The Danger of a Single Story. (this is a link to an awesome TED talk)

Part of my role as a facilitator for this course is to help incorporate concepts of narrative medicine into the Soc. Med curriculum. Narrative medicine shakes up the traditional structure of the doctor-patient interaction by challenging (as well as complementing) the biomedical model. In an era where health professionals are busy, focused on diagnostics, and patients don’t feel listened to, this method of of history taking deserves some attention. It involves bearing witness to the patient’s story (referred to as an “illness narrative”) while at the same time pushing the provider to examine his/her own biases and assumptions which are inevitably carried into the encounter. Students are encouraged to make statements like “Tell me about your health” or “What worries you?” instead of the more traditional questions which focus on symptoms and reason for admission. In debriefing, many of the students bear witness to stories of suffering, poverty, living through war, and injustice in the health system. Equally as important, students learn who their patient’s are, what is most important to them, and what brings them joy. Narrative Medicine is intensely personal, and getting personal is part of social change.

Social Medicine students visit Paimol and take a walk through the community with local village leaders. They learn about the  economy, daily life, the effects of the war on the area, and some cultural health beliefs. We discuss the ways in which community members negotiate their health  by engaging with local healers as well as government health services.

You may or may not know that the place where I am right now sitting, as well as the place the students above are walking, was in the midst of a bloody civil war from 1989-2011. The war was between the Ugandan government and a rebel group called the Lord’s Resistance Army (LRA). Many women and children were displaced from their homes to IDP camps. Young boys were coerced into becoming child soldiers. Human rights atrocities were committed from both sides. I feel mildly ashamed that my only prior exposure to the conflict was a youtube video created by an organization called Invisible Children. But I think it is safe to say that the narrative about the war created by Invisible Children was the dominant narrative (and sometimes the only narrative) most Americans were exposed to. Now, I have seen the movies Uganda Rising and War Dance (highly recommended), and I have engaged in dialogue with historians. I have listened to the stories of student colleagues and friends in this class who lived through, navigated, and are personally affected by the conflict. I am beginning to really understand the danger of a single story.

I will end here for now, though expect more to come. 

Love from Gulu! 

Aarti

Shapiro In Bugobero

The following was written by Miriam Shapiro, 3rd year pediatric resident at University of Minnesota.



The rains have started here in eastern Uganda. The storms can be brief and, despite the significant amount of rain that comes down, the red dirt soaks it up in little time, leaving just a hint that it was here at all - the scent of dampness, a few puddles, a bit less dirt kicked up on the roads as we drive.

I am working at a rural health center in a village called Bugobero. It is about a 45-minute drive along these red dirt roads from Mbale, the largest city in the area. My primary task here is a clinical investigation of a syndrome of malaria, severe anemia and hematuria.

Though both severe anemia and hematuria are known complications of malaria, they were being seen at an increased frequency and with increased mortality in January and February of this year.

The health center in Bugobero is unique because it was adopted by an American health care NGO, which has partnered with the government to improve care delivery. Because of the extra funds provided through the NGO, the clinic is able to hire more staff and have a more reliable and wider supply of medications. The community has responded to the increase in services with a huge increase in patient visits.

The health center includes adult and pediatric inpatient wards, a
maternity ward, an operating theater and a steady stream of outpatients
seen daily on a first-come, first-served basis. It is now drawing
patients from all around the vicinity.

The health center has one doctor, who spends most of his time working on surgical cases, and is otherwise staffed by clinical officers, midwives, nurses and nursing assistants.

There is a laboratory here, which can do rapid HIV tests, thick blood smears for malaria, urine microscopy and urine dip stick. Usually they can do hemoglobin estimates, but of late have run out of the slides required to run the test. This limitation has required that I rely more heavily on history and physical exam findings than ever before. It also means there are several children here whose diseases fall outside the ability of the health center to diagnose or treat, even if they were diagnosed properly.

Our primary role here has been the malaria investigation, though we also see patients on the pediatric ward and outpatients, as time allows. Though the numbers of patients are not huge, the investigation is taking much of our time because, in addition to taking histories from the patients' parents and doing physical exams, we also draw the blood samples and prepare the thin smear slides. We also must leave from Bugobero early enough each day to deliver the samples to the research laboratory and have them run prior to its closing time. Because we are relying on an outside laboratory, we rarely get results back in time for them to be relevant to clinical care.

It is a stark contrast to the help we get in the hospitals in the U.S. - write an order and (usually) our work is done. Here, we rely heavily on the nurses and nursing assistants for aid in translation. Few of the villagers speak enough English to get through the detailed interview, and medical records as we know them do not exist. Each patient has a small notebook that is usually purchased upon arrival to the clinic, though occasionally is brought from home with information from previous clinic/hospital visits. When we are lucky, we can read about half of what is written in the notebook; generally the amount of clinical documentation is minimal.

Occasionally we are asked to see a child who is particularly sick. Last week, it was a 6 year-old boy with pneumonia who presented in severe respiratory distress. By the time we were called, they had already put him on supplemental oxygen via the one concentrator available. Despite the oxygen, he remained tachypneic and in significant distress, with an O2 saturation in the mid-80s. He was given a dose of ceftriaxone, which is sometimes present in small supply, and given fluids. The oxygen concentrator was then required in the operating theater, so he was taken off oxygen.

Given his persistent distress, the decision was made to transfer the child to the district hospital in Mbale, where hopefully more resources would be available. We made the 45-minute drive with him in the backseat, off oxygen; by the time we reached Mbale, his saturation was down to 59%. He was admitted in Mbale, placed on oxygen (delivered by an intranasal catheter, which was not very effective; at least at first, his O2 sat had only increased a small amount).

When we checked on him again later, it turned out that the hospital was out of the drugs that they had prescribed for him, so he wasn't actually getting them. We went to the pharmacy, purchased more ceftriaxone and paracetamol and brought it back. While we were there, the power went out, which meant that the oxygen also went off. In the end, this child was not getting much more at the district hospital than he was at the health center. Despite it all, he steadily improved, and a couple days later was asking for chapattis.

Sometimes these stories end well.

Miriam Shapiro poses with some children at the health center in Bugobero.