Waking up on our first day, I made haste to prep my things after breakfast. Told to expect pickup at 7, I was ready to go without a minute to spare. We were sending out two vans, one to the local school where the non-medical branches would do their work, and the other to the medical centre. Despite my punctuality, it was for naught, as the drivers showed up later than expected. Once they finally did, Alex and I as well as the surgical team made up of Susana, Pradeep, and Julie unceremoniously piled into the van heading for Health Centre IV.

Health Centre IV was the largest medical centre in the settlement, with the most sophisticated inpatient services. They had blood products and a handful of IV medications for treatment, and access to a basic lab for blood counts, kidney function, and malaria testing (bloodwork could be done once daily and results took a day to come back). An ultrasound sonographer was also available during regular hours. The health centre’s census was fed by patient referrals from the smaller outposts in the settlement, or by patients seen through the outpatient clinic. We arrived just after 8, and the surgical team branched off to their pre-op tents while Alex and I entered the wards.

The inpatient department was an old, concrete, single story building arranged in three arms. Entering, there was an office squarely in view of the front door. To the left, there was the female ward, and to the right, the male. The wards themselves were three large rooms each, with several beds on either side and no dividing curtains. The partially oxidized metal beds blended into stained concrete floors with matching walls. Patients and their families clustered around the beds, spilling into the hall wrapped in brightly coloured blankets. I took a look around the female and male wards before walking through pediatrics; they were all identical in setup, although the pediatric ward could only be accessed through the female side.

In the office we found a staff member. He was the ward nurse, Ben, and led us to the adjacent pharmacy room to store our bags. In there I found a wooden cabinet with all of the medications available to the inpatient service. It was only two shelves. I saw anti-malarials, a diuretic, steroids, a few different anti-convulsants, two anti-psychotics, two or three antibiotics, and some anti-nausea drugs. Despite the lack of variety, they had all of the essentials. Ben, it turns out, was the only nurse for the whole building. Whether there were 20 patients or 55, there was only one nurse at a given time. His primary job was to give medications and blood products. It was actually the patients’ families that tended to things like patient hygiene, feeding, and comfort. After some time chatting with Ben, Alex and I discussed the game plan for our morning.

The reason we were brought here was to leave something of value through ultrasound. As clinicians, treating patients is lovely, but I could treat all the patients in the camp for two weeks and leave behind nothing sustainable. The portable ultrasounds now allowed easy use by relatively novice personnel, which could augment the physical exam to make diagnoses at the bedside. Having been here several times previously, Alex had trained the medical officers as best he could and left them a probe and tablet in years prior. So, our plan was to tag along during the ward rounds and use the ultrasound on real cases to demonstrate its utility and train the staff in the process. This would prevent us from taking them away from their clinical duties and also give them hands-on practice to inform real cases. Sound in principle yes, but through experience, Alex had told me he found great difficulty getting the medical officers to retain the skills and use the probe after the training. After asking Ben some more questions, it seemed like the device was functionally collecting dust, having not been used much at all. Unfortunate.

After some time waiting around, Dr Brian arrived. He was the medical officer covering the inpatient department. We got access to the sonographer’s room for the ultrasound, and despite a few cables missing, things were intact. Thankfully we had our own power banks and cables to plug it in while we got set up to start rounds. Alex also brought his own probe from home, so functionally we had two working machines, one to assist in ward rounds and another if the surgical team radioed us to scan somebody for them pre-op. Ben then loaded up a stack of papers onto a metal cart with some gloves and hand gel as we started towards the men’s ward some-time around 930.

The first patient we saw was a gentleman in his late sixties. He laid in bed with his adult son next to him, looking comfortable but tired. Dr Brian picked up a lined sheet of paper from the cart and began reading out his history.

‘This man, age sixty-three, was admitted yesterday after referral from one of the nearby health outposts with fevers and a headache,’ he said. ‘His blood count showed a hemoglobin in the 2-3 range, with a white cell count in the high 20s, malaria test negative, blood smear negative. He received blood products and was admitted for anemia secondary to septicemia, currently on ceftriaxone and dexamethasone (steroid).’  

He pulled out a small strip of paper, like a shopping receipt. It was the blood count. His white cell count was definitely high, and notably he had a large proportion of lymphocytes – the kind of white cell that typically responds to viral infections, fungi, or tuberculosis. I didn’t even start to ponder what this meant because I wanted to hear more of the story. So I waited, looking at Dr Brian. He looked back at Alex and I, saying nothing. For a moment the three of us stood frozen in time like a few dorky statues. I realized quickly that he had nothing more to say, but I wanted more information.

‘What’s his blood pressure?’ I asked.

Dr Brian turned to Ben and said something in Swahili. They said a few words and then Ben walked off towards the main office.

‘We have a blood pressure cuff, Ben is going to get it,’ he said.

That’s weird, I thought. How am I the first person to ask for this? Also how is there only one blood pressure cuff and its locked away somewhere as we are starting rounds? If this guy doesn’t have a blood pressure charted it’s probably likely that none of these patients do. Noted.

Alex remained silent, so I continued.

‘What more do we know about his story?’ I asked Dr Brian. ‘How long? Does he have any other symptoms? Has he been eating? Bleeding?’

Dr Brian turned to the man and started asking questions, although he quickly stopped, signaling for Godfrey, the interpreter to join us. Godfrey was a Congolese refugee who worked as an interpreter in the health centre. He was young, with a big beard and a soft spoken demeanor. He pinged some questions to the patient to help characterize his symptoms. It sounded like his issues were likely more long-standing than I had thought. His decline had been over a few months, with relatively poor appetite. The fevers were new, as were the headaches.

I stepped towards his bed and put on some gloves. Alex joined me and we examined the patient together. Notably Dr Brian stayed back at the foot of the bed. His abdomen was notable for a big liver, although his spleen was normal size. Otherwise his exam was fairly unremarkable with heart, lungs, and limbs intact without any gross abnormalities. I also felt for lymph nodes in all of the places I could, getting nothing. Dr Brian was now talking to Ben, so Alex and I had our own discussion about the patient.

‘Lymphocyte predominance, he has lymphoma?’ Alex said.

‘Maybe? Would that give you a big liver without a big spleen?’ I asked.

‘Would be weird to,’ he answered

‘Could always scan the liver,’ I said.

‘Good idea.’

What a perfect opportunity to showcase the utility of point of care ultrasound on the first case of the day, I thought. We plugged probe into tablet and got some jelly before scanning both the spleen and the liver. In the process we got Dr Brian to try and use the device, explaining all of the things we were looking for. While we were at it, we scanned the patient’s heart, given that congestive heart failure can also be the reason for a big liver.

‘Brian, what would the process look like to get someone evaluated or treated for lymphoma?’ Alex asked.

Brian paused to think. ‘This would have to go to Hoima,’ he said.

‘Can these patients go to Hoima?’ we asked.

‘Yes, the camp pays for them to get transport,’ he said. ‘We can send one a day.’

So we agreed. outside of malaria, schistosomiasis, and the two most basic bloodwork tests, our hands were tied when it came to a workup. This guy could have had any number of things. It was impossible to even know if his anemia was from blood loss, an impaired bone marrow, or blood cell destruction. It was made more difficult when I understood that not many questions were asked by the clinical staff. It was only after seeing several more patients that I realized Dr Brian wasn’t even carrying a stethoscope. I found this difficult to get my head around.

When I travelled here I was expecting the complete opposite. One of the things that’s always worried me as I embark on this career is that my US training was too focused on the data-points to make me a solid clinical physician in low-resource settings. How could my physical exam ever be as good as someone who relies on it every day to make complex diagnoses without imaging? I nearly felt that coming here I would have little to offer in terms of teaching, and it turned out the inverse was true. Most medical officers employed at these health centres complete an intern year after medical school and then enter unsupervised practice, this is relatively common in Africa. Combine this limited training with staffing shortages, cultural differences in practice, and poor compensation (this was a refugee camp after all) meant that the quality of clinical skill was far different than what I expected. Not so much as a blood pressure, an exam, or even a proper history happened for any of our patients on ward rounds that morning without being incited by Alex or I. Thankfully, there was one test that remained tried and true: the malaria smear, for which we saw a dozen or more patients back to back to back.

The first was a man in his twenties, he had fit musculature but was tired and sick appearing. His story was the same as nearly all the others.

‘Admitted as a referral with complaints of fever and headaches. Found to have a hemoglobin of 4. Malaria test positive with high parasite count on blood smear. We gave blood products and he is on anti-malarials,’ Dr Brian would say.

On exam I found him to have a large, palpable spleen. That morning I examined more large spleens than I had in five years of the wards across Europe and the US. For a time, I doubted my abdominal exam as I never feel confident feeling the major organs. I realized after examining the sixth or seventh patient with splenomegaly in a row, that it was just because I had seldom seen a patient in the US with a spleen so freaking huge. I saw spleens just barely below the rib cage, some all the way down past the belly button, I even saw one poking outwards towards me like it wanted to say hello.

We saw one lady, she was older, likely in her sixties, who came in also with anemia and a massive spleen. Her only complaint was fatigue. She had no infective symptoms, fevers, chills, appetite changes, or signs of cancer. Her bloodwork was only notable for a low red cell count. Her parasite tests were all negative. We knew that she had been diagnosed with malaria several times in her life, and treated appropriately every time. One possibility was that her anemia was a downstream consequence of her big spleen, which is something that can happen as the extra-large spleen recycles blood cells at an accelerated rate (part of the job of a normal spleen is to do this). After some reading on the subject we concluded the patient was likely suffering from something called hyper-reactive malarial splenomegaly syndrome, which is a pathological immune response to chronic or repeated exposure to the malaria parasite. It is often synonymous with ‘tropical splenomegaly’ described in malaria-endemic countries. Many of these patients are at risk of spleen rupture, which can cause major internal bleeding and death, as well as infections and anemia. The team at the health centre had been diagnosing these cases over time and referring them for spleen resection for repeated bouts of anemia. We discovered in our readings that there are medical options that can be trialed first, so we put her on weekly chloroquine long-term with plans to follow up at the clinic to see if it effectively shrunk her spleen.

As physicians in the occidental world, I think we appreciate the impact of malaria world-wide. We appreciate it conceptually, from a distance, the same way that we do tuberculosis or cholera. However, it’s only after being here that I truly understand what a monstrous burden it is. Everyone had malaria. Every mosquito that bit me in the guesthouse probably bit hundreds of people with malaria over the week. 9 out of 10 units of blood given were for malaria. The social and economic burden from the disease is unique in its severity. The day we make a vaccine publicly available, it will change the world. At a more individual level, malaria causes immense suffering, like one girl that we saw who I thought was going to die when I first saw her.

She was probably 11 or 12, pediatric by American standards, although in Uganda they divide adult and pediatric medicine differently due to the high rate of infantile infectious disease—for those in the health centre, adult medicine started at age 8. From the foot of the bed, she looked ill. She was on an oxygen concentrator, pale, heaving breaths with her head turned over, drooling. I always say when seeing children that I don’t get worried until they flop like a dead fish. This girl was so floppy she was nearly melting.

‘This is a girl referred in from a local outpost with history of fevers, weakness, and difficulty breathing. She was found to have a hemoglobin around 3, with an elevated white cell count and malaria test positive. She had a high parasitic burden on blood smear. She is hypoxic, requiring 5 litres of oxygen. She received blood products, and malaria treatment was started yesterday.’

I tried to examine and listen to her, but she had no strength to sit up. I felt her abdomen and to no surprise her spleen was massive. Enlisting the help of the others, we sat her up. Her lungs sounded oddly clear, which was puzzling given her hypoxia (real when measured with a finger probe). I listened to her heart as well, before setting her back down. Her sunken eyes were expressionless, too weak to display emotion or pain. We even scanned her lung bases for fluid buildup or tissue density, all appearing normal. I turned to Alex.

‘She looks like shit,’ I said quietly. ‘Why is she hypoxic?’

‘I don’t know,’ he said. ‘Malaria can cause pulmonary edema but her lungs are clear? It’s not like her hemoglobin being low should impact her pulse ox reading.’

‘Pulmonary embolism?’ I said.

‘Maybe.’

‘Can we get a blood pressure on her please?’ I asked Ben.

Despite our efforts to find an explanation for her low oxygen, we couldn’t. Pulmonary embolism remained the only reason I could find to explain her hypoxia, but nobody on the team was all that convinced. Malaria was the culprit, despite not understanding how or why. This girl sat in bed creeping closer to death’s door. We agreed to give her more blood, two units, despite the scarcity of the resource. I didn’t feel good about her outcome, and had to hope that with more blood and anti-malarials she would turn the corner. Sometimes that is all you can do.

Ward rounds took us to around noon, and I remember walking towards lunch with mixed feelings. My head was swimming with ideas of how I could help improve the inpatient service: establishing a structure for rounding that was more thorough, training the nurses on the importance of vital signs for every patient and having them available before rounds to expedite efficiency, using balloons for incentive spirometry, training physicians on history taking and physical exam to inform decision making, the list was endless. I thought about how implementing meaningful change would take more than me being here for a week. I don’t know that I could do it being here for a year, and even if I did, that’s one clinic in a region full of hundreds more just like it. I was talking about a complete shift in the cultural practice of medicine, adding work for a nurse that already covers 40 patients and for staff that sometimes goes months without pay. The obstacles felt too insurmountable for a lifetime. I can’t fix any of this here, I thought to myself, this runs deeper. This goes back to medical school, to nursing school, to infrastructure and standards of care upheld at a national level. In theory, the appeal of having a group like Medical Teams International here is that they can uphold an international standard, and yet it didn’t feel that way. I wondered what medicine looked like at other hospital sites; maybe in Hoima or in Kampala things were different, but who knows.

One of the doctors that was on the mission with us, a Cuban named Lazaro, was as seasoned a physician in the realm of humanitarian work as I had ever met. More than a decade ago he left Cuba to do clinical work in Burkina Faso, spending years before moving elsewhere in Africa. He then undertook graduate training in public health from Paris, and after some time with the WHO now lived and worked in Ethiopia as a regional director for pre-hospital care. I remember taking my ruminations to him.

‘I wasn’t expecting this Lazaro’ I told him. ‘I didn’t see a single exam or history taken if it wasn’t coming from us. What is that about?’

He shook his head, like a parent to a young child.

‘Forget a history taking.’ he said. ‘This is systemic. In the low-income world this is commonplace. The reflex in these places is to give everyone dexamethasone and antibiotics, and then the work is done, you can rest easy. I have seen this all throughout Africa.’

Seems like a tall task for one bozo born in Buenos Aires with big ideas. This placed me in a predicament, and so at lunch I sat in silence, chewing on pot-cooked lamb and my own ruminations. My gloom worsened when after planning ultrasound training for the midwives in the obstetrics tent at 2pm, I showed up to find nobody was ready. After giving them some time I came back 30 minutes later and was denied again. The session would have to be post-poned to the next day, they told me, and agreed to start at 9am. I remember coming over to tell Alex, who was sitting on a bench near the surgical tent.

He shrugged. I could see he was not surprised.

Trying to find other ways to get involved, Alex and I joined the surgical team as they evaluated patients pre-operatively. We scanned a spleen or two, and this took us into late afternoon when things began to wind down before the van collected us to return to the guesthouse.

That evening before dinner at the guesthouse, several representatives from the local partners came by. In order to maximize our efficacy on the ground, day to day feedback was encouraged and acted on. We had the first of our nightly meetings, where everyone from our team and the local partners went around giving their impressions of the day. Several people had a lot to say, in particular our surgical team who wound up having a late one, arriving back at the guesthouse well after the rest of us, around 8pm. When time came for me to speak, I felt underqualified to give any real opinions and kept most of my thoughts to myself. This would change as the week went on and I grew more comfortable within the mission.

In true Dr. Bozo fashion, I treated myself to a cold shower (no hot water), and a few glasses of wine after dinner with the rest of the team. I then laid to rest under the cover of a mosquito-net. I had so much food for thought after only one day.

We were just getting started.