Exploring Infectious Disease &

Tropical Medicine in Uganda

Austin J. Price, MS4, MPH

University of Kansas School of Medicine

Spring 2019

Learning Objectives

1. Compare/contrast the differences in how medicine is practiced

in the US vs. Uganda

2. Gain appreciation for the role that infectious diseases play in the

morbidity/mortality of patients in other areas of the world

3. Better understand how resource limitations affect patient care

and patient outcomes

4. Learn about how cultural differences affect healthcare in a new

setting (from both the prospective of the physician and patient)

Kampala, Uganda

Uganda’s capital/largest city

Located in South/Central Uganda,

near Lake Victoria

Population: ~1.65 million

Very urban area, but with poor

infrastructure

Largest hospital in the country (Mulago

National Referral Hospital) located

here but largely non-operational due to

ongoing remodel

Home to the country’s only medical

school at Makarere University

The Clinical Setting—Kiruddu Hospital

Suburban subsidiary of the larger Mulago Referral Hospital

Currently Mulago’s main campus is under renovations, so

much of patient care is outsourced to smaller hospitals like

Kiruddu

Large, 8 story building, 1 elevator bank, no air conditioning,

ED waiting room is outdoors

Care is provided free-of-charge, but services are drastically

limited due to costs

Infectious Disease Ward—separated into men’s/women’s

wards

Approximately 30 patients on mens ward

NO ISOLATION of any kind

No partitions between patient beds

Very little privacy

Not air-conditioned

Shared (primitive) ward bathroom

Why Infectious Disease

Ward?

Pursuing internal medicine residency beginning June 2019 in

San Francisco, CA

Plan for ID fellowship after residency

Very interested in ID and tropical medicine

Hold an MPH in infectious disease epidemiology from Johns

Hopkins

Was very curious to learn about the treatment of diseases that I

have largely only ever learned/read about

Typical Day on the Ward

Day begins at 0645 with ~1hr bus ride from Mulago main

campus (only a few kms but traffic is horrendous)

Arrive at Kiruddu ~0800, spend ~1hr reviewing labs/seeing

patients

Rounds begin 0900-0930

Attending physicians visit 2-3 days per week, otherwise

rounds are conducted by senior house staff and one intern

Approximately 15-20 Ugandan med students on service,

with 3-5 international students

Patient presentations are quite similar (H&P for new

patients, SOAP notes for follow-ups)

Rounds generally end 1200, break for lunch

1300 follow up on patient labs, write orders, speak with

family

1500 generally resident teaching to medical students

1600 bus departs back to Mulago main campus

Learning Objective #1

Practice in Uganda is largely based on clinical suspicion and physical exam—labs are

done sparingly

Many laboratory exams are unavailable, unless the patient can pay out-of-pocket

Imaging studies are rare apart form plain films

All radiology reports are handwritten

Nurses play a completely different role, largely removed from patient care

Patient loved ones serve as “attendants”

Attendants give medications, feed & bathe the patients, obtain laboratory and imaging

reports from various hospital locations, and assist with all aspects of the patient’s daily

needs

Learning Objective #2

Uganda’s population is vastly different than United States’

One of the planet’s youngest populations

Largely representative of the past and ongoing significance

of infectious diseases

HIV/AIDS is a huge problem—with half of my hospitalized

patients meeting AIDS criteria

Opportunistic infections abound

PML, CMV esophagitis/retinitis, cryptococcal meningitis,

disseminated mycoses, Kaposi’s sarcoma, PJP,

disseminated TB

Malaria is quite prevalent, especially in younger patients

TB is a major issue, especially in HIV/AIDS patients

Hepatitis B is prevalent, with many young adults with

chronic infection and HCC

Other ID cases of note: severe tetanus, filariasis,

schistosomiasis, Pott’s puffy tumor

Learning Objective #3

Resource limitations definitely affect how patients receive care

Labs/imaging are used very restrictively

Treatments are empiric and hinge largely on physical exam and clinical suspicion

All documentation is handwritten in paper charts housed under the bed mattresses, often the

documentation is hard/impossible to read or is lost altogether

Despite these limitations, the physicians are keen clinicians with excellent PE skills

Physicians know the common diseases of the population and how they present clinically extremely

well

Many patients do quite well and show marked clinical improvement despite limited resources

Certain conditions have extremely poor outcomes due to resource limitation (i.e. psychiatric illness,

renal failure (no HD), respiratory failure (no vent support)

Learning Objective #4

Cultural differences abound

Physicians are much less explanatory regarding

illness/prognosis

Patients are wholly trusting of physician input

Language barriers are quite common even between

Ugandans due to prevalence of tribal languages

Many patients possess superstitious beliefs (i.e. illness is a

result of wrongdoing, demonic possession, etc.)

Disease stigma is common, particularly regarding HIV

which is viewed largely as a moral failing

Religion is more integral in medical care

Med students pray each morning on the bus

Patients ask physicians to pray with them during rounds

Patient’s religious beliefs are discussed openly as part of

their medical care

Interview with Senior Resident

Dr. Frank—senior house staff—spent considerable time in Sweden during training

Largest obstacles:

resource limitations

patient adherence following discharge

largely dependent on patient factors (education, family support, living conditions, occupation,

proximity to healthcare facilities)

Health literacy remains a major concern

Resource limitations:

prevent over-reliance on labs/imaging for medical diagnosis

prevent medical waste

promote astute clinical decision making

Most Profound Clinical Experience

19yo male Sudanese refugee

CC: several week history of painful protuberance of the left

forehead

Presented with malaise, fever, and decreased appetite

Found to be in severe sepsis with large fluctuant mass

present over the left frontal bone

Started on empiric antibiotics, fluid resuscitation, I&D

performed (specimen subsequently lost)

Imaging (paid for by organization that supports refugees)

revealed destruction of the underlying bone, with frontal

lobe extension

Presumptive diagnosis: Pott’s Puffy Tumor (complication

of chronic frontal sinusitis)

Patient continued to deteriorate on therapy, neurosurgery

consulted for evaluation

I had to leave before the resolution of this case, but I fear

the prognosis was quite poor

Life Outside the Hospital

Tons of wonderful exploring

to be done

Jinja (source of the Nile)

whitewater rafting

Murchison Falls National

Park

Entebbe National Botanical

Gardens

And much more!

I would like to extend the most sincere gratitude to

the Halsey Scholarship Committee and benefactors

for providing me with the funding to make this

amazing experience possible. THANK YOU!!