Stories From the Field:

UGANDA

A Day with the Global Medicine Residency Program (formally named: Global Primary Care Program)

Raquel Reyes, Matt Tobey, and Atheendar Venkataramani

The Global Primary Care Program at the Massachusetts General Hospital Center for Global Health is a four-­‐year residency program that combines world-­‐class medical training with international service in resource-­‐limited settings. Physicians and nurses from Mass General rotate regularly through the Bugoye Health Center and work side by side with our Ugandan colleagues from the Mbarara University of Science and Technology to deliver care to the surrounding communities.

At 9AM, one year-­‐old "Marie" arrived at the Bugoye Health Center, a community health clinic in rural southwestern Uganda serving about 50,000 scattered through the mountains of the beautiful Rwenzori range. Our Global Primary Care team was on-­‐hand at the clinic. Her mother brought her early to the first-­‐come-­‐first-­‐serve line; for a day, she had not been eating well, felt feverish, and was now barely interacting with her mother. It was immediately clear to us in the medical team that Marie was very sick: she had a high fever, was listless, and, most alarmingly, was breathing with distress over sixty times a minute.

We suspected that Marie had a serious pneumonia or abdominal infection and knew that the community health center did not have the medications and support needed to keep her alive. Through an interpreter, we explained to Marie's mother that she would have to take the baby to Kilembe, a mining town 45 minutes away by car where the district referral hospital was located. Marie's life was in danger. The mother understood and left the exam room to coordinate the trip with her family. We asked her not to stray far.

An hour passed, and she didn't return. We began inquiring in town as to her whereabouts, but no one could tell us. Another hour passed, and another. Four hours later, Marie and her mother had not returned to the clinic. We asked nurses, clinic administrators, and other patients if they knew where she might have gone, without any success. Regina, who worked at the clinic, brought us to town when we finished with the day's other patients. There, through the community's social connections, she was able to locate "Janet," a friend of Marie's family who offered to guide us to Marie's house. When we said we were determined to pick up the baby and drive her to Kilembe ourselves, Janet made the slightest cringe and said simply: "It is far."

Though tested by faulty tires and shoddy brakes, we worked our way up one of the larger mountains. We proceeded slowly, stopping first to pick up Janet's young son, who saw her and then ran after the car. We paused again and again to negotiate divots, rocks, and potholes in the dirt road. Villagers watched with curiosity as the four mzungus (foreigners) passed. "How close are we?" Janet: "It is still far."

Janet and her son share the front seat during the search for Marie

Over an hour after we started, we reached a second peak, the site of Marie's village. Workers drying coffee beans at the village's trading post pointed the way, a fifteen-­‐minute hike back down the mountain through lush forest and fields of matooke (plantain). Beginning to doubt that Marie's mother could have made this hike alone with an ailing child, we discovered our doubts were unfounded: Marie was fighting for breath, waiting with her father in their small single-­‐room mud hut. Her mother had gone to gather food and bedding for the trip to Kilembe. The whole group—our team from Mass General, Janet, her son, Marie, her father, and Marie's older brother—trekked back to the jeep. Janet held Marie in the front, the baby's father sat in the boot with his son, and we set out for Kilembe, the smell of burning rubber accompanying us as the jeep shuddered its way down the mountain. Janet's son cut the somber mood with enthusiastic exclamations to the passers-­‐by.

Hiking through the matooke plantations to reach Marie’s house

Word of our progress down the mountain preceded us, and villagers chipped in to help ensure that our journey would be successful. A knock sounded on the back of the car as Marie's uncle, forewarned of our passing, passed us a large sack of matooke for the family to eat during their hospital stay (patients in Ugandan hospitals are responsible for their own food).

The ride to Kilembe was tense, punctuated by sounds of horns, cattle, Marie's cries, and then ominously, Marie's silence. One hand on the steering wheel, another on the girl's pulse: Marie was breathing rapidly, but she was alive. Janet would smile, though tensely: "She is ok."

Kilembe was waiting for us. We hurried to the pediatrician, who quickly assessed her and pointed us to the pediatric ward. We jumped the registration line and hurriedly placed her on oxygen. Although the hospital had run out of the intravenous antibiotic Marie needed, a nearby pharmacy carried it. We bought the medicine for under $10 and instructed the clinical staff how to administer it. Marie quickly recovered and returned home in three days.

Like Marie, poor families around the world face immense barriers to basic health services. The lack of trained health personnel, basic diagnostic tests, and reliable supply of medicines and equipment limit a clinician's ability to treat even the most common illnesses. Equally important, the costs of travel or the lost income from spending time obtaining health care represent significant barriers to health care access. In the case of acute, life-­‐ threatening illnesses, the expenses required to reach and obtain care from higher-­‐level care facilities can become the difference between life and death.

Raquel, Janet and Marie, fully recovered

Marie's struggle to access medical care is replicated every day by millions of people in rural Africa. Unlike Marie's story, most do not have a happy ending. At the Global Primary Care Program, we are working closely with our partners in Uganda to improve access to medical care and recognize that investments in health systems are the only sustainable solution to these challenges.

The Center for Global Health targets the entire continuum of health care -­‐ from public health to public policy -­‐ to improve access to health care before it becomes an emergency. In addition to building the clinical skills of our residents, we and our partners in Uganda are developing cell phone technologies to communicate about medication use, providing bus tickets to help with transportation costs, and training community health workers to dispense medications to treat common but potentially fatal illnesses.

Ultimately, everyone deserves the same care and chance to recover from childhood illness, like Marie.

Learn more about the Global Primary Care Program