Touchy Feely Nirvana

Finally after 20 years of searching I’m working somewhere that begins each day with a group singsong and some gentle stretches. Mbuya Reachout was the inspitation of the Italian catholic parish priest Father Joseph and a doctor Margrethe Juncker in 2001. Since then it has grown into a massive enterprise based entirely within the poor Kampala parish of Mbuya. It now employs 234 and looks after 2300 people living with HIV / AIDs and their families.
The remarkable thing about it is its community focus. Counsellors and support workers are recruited from the local area (and are often HIV positive themselves) and work on education programmes in local schools and community centres to encourage testing and to break down the stigma around HIV. Each worker provides moral and practical support to his / her HIV infected neighbours. Within the project there is a literacy programme, a school fees programme, a food programme, a tailoring workshop providing much needed work and income and a loan scheme for small business start ups. The medical programme is supplementary to all this and works on the premise that without food, financial support and hope, medical care alone is insufficient. The clinics are run by specialist nurses and nurses attached to Mbuya on a 6 month HIV training course. I will be one of 4 medical officers supporting the nursing team in the clinics (there are 3 clinics in the parish) and am already learning loads!!
M

Laura

We never knew Laura. Angela came into our lives on Sunday picked up from the road side by some of our friends. Her friend Laura was one of 4 passengers killed instantly when their bus was hit by a lorry on the way back to Kampala from seeing the gorillas in Bwindi. Both were medical students from UCH spending their electives at the mission hospital in Kisizi. These devastating accidents are everyday news here. Potholed roads, poorly serviced vehicles and dangerous driving contribute to a disproportionately high death toll on the roads.
We were glad to meet and get to know Angela and her mum Brida. They returned to the UK today. We hope Angela gets through the next few difficult months OK. Our thoughts are with Laura’s parents and friends.

VSO CONFERENCE

We have just had a very successful Uganda VSO conference weekend in the luxury of the Jinja Nile resort. It was a good opportunity to air all our whinges about VSO (poor VSO I do love them really!).

The local volunteer committee will continue to pressure for:

1. A protocol at VSO Uganda office for how to deal promptly with volunteer allegations of fraud in their placement organisation.

2. A protocol to act promptly and sensitively when a volunteer complains that their placement isn't working out (whether thats because of the volunteer or because its a crap placement cos there are many of those!).

3. Better communication and information systems within VSO to enhance volunteer support and experience.

We had delegates present who had attended conferences 1,2 and 7 years ago who said the same angry complaints are made every year and no progress made!!....

WE HAVE MOVED

Home now is this comfortable bungalow in a small compound of 4. It’s a little muzungu enclave so we’re surrounded by friendly young brits working in schools or with aid organisations. The compound is in a dirt road suburb in the south of the city a walk from Jan’s health centre and a car commute from mine. For comparison with previous accommodation (score out of 5)
Disco induced building shaking sleep disturbance Kampala 0 Ishaka 4 Mbarara 2
Truck noise sleep disturbance Kla 0 Ishaka 1 Mbarara 5
Howling dog sleep disturbance Kla 3. Ishaka 4 Mbarara 5 (there aint no escape from this one!)
Though we did have a bed shaking earthquake in the early hours of this morning….

Recommendations for development at Ishaka Hospital

Feedback to Ishaka Adventist Hospital

The hospital is a friendly and welcoming place to work. We have enjoyed our short time here enormously, have learned a great deal and are sad to be leaving. We hope this feedback will be useful.

Facilities
The hospital facilities are adequate and will improve when the new outpatient department opens. The wards are clean and tidy. Access to diagnostic tests and medicines is adequate.
Staffing levels with the exception of the female and paediatric ward also seem adequate. The calibre of staff is good.
The nurse training school and laboratory technicians school are a positive presence within the Hospital.

Vocational commitment and Morning Prayers
The principles of the Adventist Mission underpin a positive approach to healthcare work. Morning Prayers are an upbeat start to the day and provide a forum for announcements. They encourage punctuality and should run to time finishing at 8.30 prompt.

Clinical Officers
The clinical officers are bright, reliable and conscientious. The hospital suffers for lack of a generalist physician to provide leadership and guidance for them in the outpatient department and on the wards. Without that guidance their practice will become increasingly idiosyncratic.
The Clinical Officers do not adhere closely enough to the sound and sensible advice of the Uganda Clinical Guidelines. They perform many unnecessary investigations. They over-prescribe medication causing unnecessary cost to the patients and exposing them to unnecessary and potentially dangerous adverse drug reactions. They are not used to working to protocols and tend to ignore them even when they are present and very clear. They should be frequently reminded of and urged to follow protocols and the Uganda Clinical Guidelines.

The Clinical Officers should meet every week with one of the Medical Officers for Continuing Medical Education (CME) and to discuss best practice for common conditions. The Clinical Officers should be encouraged to write brief, relevant and legible notes. Patient care would be best served if one clinical officer was attached to the wards for a week at a time.
We are actively seeking a replacement for us and would suggest to the hospital that they make this a financial priority.

Wards
The wards are clean, and not overcrowded. The semi-private ward is the much less busy of the two wards, yet they seem to have similar staffing levels. The women’s and children’s ward is in reality two wards and is dangerously understaffed. Through no fault of the staff this results in children dying needlessly. This needs to be addressed as a priority.
The staff do a handover between shifts and there is a ward book in which decisions and orders from the ward round are written. However, these decisions are not always acted upon. This system needs to be reviewed and improved if possible.
There are no protocols in place. We suggest protocols are introduced and adhered to in at least the following areas
Routine weighing and measuring of children under 5 on accurate scales
Routine voluntary HIV counselling and testing on all admissions
The management of unconscious patients
The management of shock
Fluid balance charts, orders for BP checks
The management of anaphylaxis and transfusion reactions
Blood transfusion chart
Removal of cannulae after IV drugs administration has stopped
Nasogastric tube positioning needs to be checked on each occasion by listening for air in the stomach. At present the ward has no stethoscope to do this.
Although already very busy, we believe matron should prioritise participation in the rounds at least once a week.
There should be access to clean drinking water on the wards for patients. Mosquito nets should be provided, at least on all the children’s beds.

Outpatients
Outpatients runs efficiently and waiting times are reasonable. We have introduced some simple protocols for management of common conditions. These should be kept up to date and added to over time.
The scales are inaccurate and need to be replaced. The department needs scales for weighing children less than 10kg. There are height measures but they are broken and need to be repaired or replaced.
It is unavoidable that people are sometimes waiting for hours, for investigation results for example. There should be access to clean drinking water in the department.
The staff in outpatients need customer care training; they should see patients attending as valued customers who they want to encourage to return.

Laboratory
There are an unacceptably large number of problems with lost specimens, inaccurate labelling and samples being collected in the wrong containers. This causes friction between the wards and the laboratory and teamwork between the lab and the wards is poor. Turn round of the tests and communication of the results to the ward is slow, and this has resulted in at least one death whilst we have been here. There is no system in place for monitoring or ordering of stock, so the lab runs out of reagents and cannot offer testing. Whilst we have been here the lab has run out of reagents for TPHA, FBC, HIV testing (first determine and then unigold) and CD4.
Stock control and ordering procedures are clearly inadequate and need to be improved as a matter of priority. We are often without blood for at least 24 hours before the stock is refreshed. The protocol for blood transfusion does not adhere to the Uganda Clinical Guidelines and this may contribute to the problem of running out of blood.
The laboratory continues to perform tests which are outdated and clinically unhelpful, despite the knowledge that the test is pointless. An example is the Widal Test. The senior staff are aware that the test has no merit, yet continue to order and perform the test, leading to inaccurate diagnosis and treatment of typhoid. They should participate in the CME sessions and pass on their knowledge, to alter clinical practice.
We suggest that the lab staff attend the wards on a daily basis and draw the bloods for testing or train the ward staff on a regular basis. This will ensure correct labelling and container use and we believe will improve communication between these departments.
In our opinion Sunday should be a normal working day. The laboratory staff are reluctant to perform tests on Sundays.

HIV service
The HIV service is relatively new and has great potential. However, the standard of service currently being provided is unacceptably low. HIV testing is rarely available on Fridays and not at all on Saturdays and Sundays. This means that for nearly half the week there is no testing at all. On other days there have been no counsellors and out-stocking of testing kits has been a continual problem. We estimate that testing has actually been available for less than 25% of the time in the 6 weeks we have spent here. All permanent lab staff should perform HIV testing and CD4 counts. It is a mistake for this to remain the preserve of only Duncan and occasionally Vicent. The consequence of a delayed diagnosis of HIV is often fatal when many patients are reluctant to come back to test.
Duncan’s performance as the in charge of HIV testing needs to improve dramatically otherwise the job should be given to someone else. The CD4 machine is capable of giving CD4 percentages, vital in the management of children, but the machine has not been calibrated and the staff member responsible has not arranged for this to happen despite requests.
The service should be redesigned, with a system introduced for timely ordering of test kits and CD4 reagents. Different and more reliable staff should be allocated to this vital area if necessary and sensitisation work undertaken with all staff members and students.
The clinical department suffers for lack of protocols. Starting people on ARVs is often unnecessarily delayed. Liaison with the wards and monitoring of inpatients with HIV/AIDS does not happen, and inpatients are only rarely started on ARV’s.
There remains some uneasiness and stigma amongst ward and outpatient staff about talking to patients about HIV and testing. There is a need for some training for the entire staff here and the HIV department should take the lead on this.

Drugs
Drugs and supplies are generally available, and easily on hand. The pharmacy is efficient and works well. Outstocking should not be tolerated and can be avoided by the introduction of a weekly stock check and never allowing stock on any item to fall below one months maximum usage before reordering. A simple Excel spreadsheet would make this task straightforward. We have placed an example on the computer in the records office which you are welcome to amend and use. The drug stock list needs to be updated to include;
W1050 Salbutamol inhalers
T0014 Aciclovir tablets 200mg
I0138 Cloxacillin 500mg IV vials
W0078 Aqueous cream
R1497 Soft paraffin
W0281 Clotrimazole pessaries
Something for prostatic hypertrophy (doxazosin, prazosin)
W1080 Silver nitrate cautery sticks
W0940 Podophylline solution
T1260 Spironolactone 25mg tabs
W0775 Oramorph solution
R0677 Gentian violet 25g
W0848 Paracetamol 250mg suppositories

Charges
Staff and patients are unaware of the charges in operation in the hospital. The clinical officers need to know the cost of items they prescribe, and charges for supplies and other items. Patients are often anxious about the size of their bills and this affects their decisions to discharge, sometimes earlier than we would recommend. We suggest price lists are displayed prominently on wards and in outpatients and given to clinical officers. Over prescription of intravenous fluids and intravenous drugs can dramatically increase costs.
For as long as the hospital service is so dependent on user charges for income the poorest and sickest members of the community will be discriminated against. Witness the lack of a feeding programme for malnourished children.
The hospital must look elsewhere for income if it is to discharge its obligations to the most needy members of the community.

Continuing education
The presence of the nursing school and laboratory training school is a great asset for the hospital. There is a clear desire to learn from nearly all staff, both those in training and qualified staff members. Regular evening weekly training sessions which are open to all should be introduced and we believe would be popular.

Income generation and investment
The hospital should work closely with VSO and other organisations to explore creative ways to generate income. Presently the hospital operates financially on a hand to mouth basis. There is an atmosphere of continual crisis within management. The service to patients suffers through an unacceptable toleration of out-stocking and no flexibility with charging to the poorest and sickest patients (e.g. malnourished babies).
The danger of underinvestment is worsening of patient services and falling staff morale and commitment. This will threaten the viability of IAH when KIU Hospital is fully operational.
Serious attempts should be made to generate income. The local health insurance plan needs to be reviewed. The cost and quality of private care offered should be increased (whilst maintaining a cheap and efficient service to the majority). Vehicles and facilities should be hired out. More attention should be paid to fundraising in the local and wider community.
The hospital needs a full time fundraiser skilled at negotiating for funds with the District, NGOs and international charities. Such a person should be able to generate an additional income of $50,000 pa. VSO may be able to help with such an appointment.
The hospital and church should use its land holdings to build houses for rent in the booming local market. This would provide long term income.
The hospital could advertise more extensively for medical student and other health professionals to visit from affluent countries and impose higher charges for use of the guest house and transport from and to Entebbe.

Priority areas of review
Increase staffing level on the female and paediatric ward.
Explore innovative fundraising possibilities to create more financial security.
Canvas VSO and other organisations to provide key personnel to develop the clinical service and generate funds for investment in the service.
Provide some staff training on high quality customer care. IAH will need to provide an excellent service if it is to compete with KIU.
Overhaul the HIV service to guarantee good service on 6 days of every week.
Protocols and guidelines to be established and adhered to for all common conditions
Weekly staff education sessions
Stock checking and ordering system put in place to ensure that there are no stockouts of essential items. Outstocking should be regarded as a disciplinary offence.


Jan Power, Mark Russell
February 2007

Ishaka project for feeding malnourished babies

Jan has worked hard on this proposal and we are aiming to fund the programme for its first 6 months. (Thanks to those friends and family who have already pledged support!) We want the hospital to apply for grant funding to continue with it from then on. All contributions are gratefully received. Email us and we will send the account details for deposits.

Nutrition Programme at Ishaka Adventist Hospital

The programme will be run by Sister Grace and Clinical Officer Festus.
The programme will cover any child under the age of 5 admitted with a weight to height ratio of 70% or less.
The standard protocol sheet must be used and adhered to for a child to qualify for the programme.
The cost of the admission will be covered by the programme up to a maximum of 30,000Ush per child and 600,00Ush per month.
If the child is HIV positive, the usual discounts on medication will apply, and will be taken into account in the preparation of the bill.
If the total bill is less than 30,000Ush the business office will prepare a receipt for Sister Grace or Festus. The patient will not be charged, and will be allowed to leave. On the next working day, Sister Grace or Festus will arrange with the treasurer for the exact amount to be transferred.
If the total bill exceeds 30,000Ush, the business office will prepare two bills. One for 30,000Ush which will be dealt with as previously. The balance bill will be met by the attendant prior to discharge in the usual way.
Sister Grace or Festus will authorise payment on each occasion by writing NUTRITION PROGRAMME on the charges chart in red, and signing this notation.
High Energy Milk is part of the programme, and will be costed at 300 Ush per litre. This represents the cost of the cows’ milk.
Sister Grace is authorised to purchase sugar, oil, kerosene and other materials necessary to the programme using programme funds.
Sister Grace will arrange for a nurse assistant to prepare the High Energy Milk each morning between 6 and 7 am. She will also advise the mothers on the quantity and frequency of administration of the HEM. This will be done outside normal working hours. The nurse assistant responsible for this task will receive 20,000Ush per month from the programme funds.
A standing order will be set up, transferring 650,000Ush per month into the hospital account. This is made up of;
600,000Ush to meet patients’ bills
30,000Ush to purchase sugar, oil and kerosene
20,000Ush to pay the nurse assistant.
The treasurer will notify Sister Grace if the 600,000Ush has been used in any one month period.
Any moneys left over at the end of the month can be carried forward to the next month.
The programme will run for 6 months. At the end of that period the hospital will make a report outlining the successes and problems with the programme.
The hospital should seek continuing funding for the nutrition programme as a matter of urgency. Organisations such as UNICEF, SCF and Oxfam are likely sources of such funding.

jan.power@rosmellyn.cornwall.nhs.uk

Dr Janet Power and Dr Mark Russell

Bushenyi Prison screening day report

BUSHEYNI PRISON HEALTH SCREENING AND TREATMENT DAY 9TH FEB 2007

INTRODUCTION
Busheyni is a small town in southwest Uganda and is the site of the district administrative headquarters and the district prison. There is a brisk turnover of prisoners since many are on remand.
Ishaka Adventist Hospital (IAH) has a pre-existing relationship with the prison. Some of the hospital staff undertake pastoral work in the prison, which includes an element of health promotion. PEPFAR funding has been applied for to begin HIV outreach work in the prison. The prisoners are brought to the hospital for medical treatment though attendance is limited by the lack of fuel for transport.
A large proportion of presentations to IAH outpatient department were for sexually transmitted infections (STIs). With the support of the prison officer in charge it was decided to screen and treat all the prisoners on a single day. Prison staff were also invited to take part in the screening.
Prior to the visit the main identified health problems were scabies, diarrhoeal illnesses, malaria, STIs (including HIV) and malnutrition. Poor funding results in very limited access to clean water, nutritious food, fuel for cooking and healthcare.

SENSITISATION
The prison was visited on 4 occasions before the testing and treatment date. The first visit was in mid January to establish the approximate numbers involved and that the project was feasible. The second visit was 10 days before the date, to check facts and confirm feasibility. The third visit was 6 days before the date, to undertake sensitisation amongst the prisoners. The final visit was the day before the test date to set up the site.
On the afternoon of 8th February, a meeting was held with all members of the screening team. At this meeting everybody was familiarised with the screening process(Appendix A), questionnaire(Appendix B) and treatment protocol(Appendix C).

PERSONNEL
The members of the screening team were as follows;
2 Medical Officers
3 Clinical Officers
4 Enrolled Nurses
2 Nurse Assistants
14 2nd year Student Nurses
4 HIV Counsellors (3 from Bushenyi Medical Centre)
1 Volunteer Counsellor
2 Laboratory Technicians
12 Laboratory Students
Bushenyi Medical Centre also supplied a centrifuge and some of the HIV determine rapidtests.

SCREENING PROGRAMME
After group counselling sessions all prisoners and staff were invited to opt into the screening programme. We used two rapid tests supplied free by Qualpro Diagnostics of India. The first, ‘retrocheck’ is a sensitive screening test for HIV antibodies in blood and serum samples. The second test, ‘syphicheck’ is a sensitive screening test for antibodies to Treponema Pallidum and indicates a previous or current syphilis infection. All who volunteered to be screened were also subjected to a sexual health questionnaire and a consultation with a clinical or medical officer.
All the prisoners were de-wormed with mebendazole.
All prisoners with symptomatic scabies were treated with benzyl benzoate.
All who tested positive for syphilis were treated with benzathine penicillin.
Genital ulcer disease, urethral/ vaginal discharge and lower abdominal pain in women were treated syndromically according to a pre-agreed protocol.
Those symptomatic for malaria were treated with co-artem (artemether and lumefantrine).
Some prisoners had bloody diarrhoea and were treated with ciprofloxacin and oral rehydration solution (ORS).
All those who tested positive for HIV received post test counselling(Appendix D) and were offered co-trimoxazole prophylaxis, multivitamins and a 2 week follow up for CD4 count.

RESULTS
On the day of testing, there were 407 inmates. Of the 21 female prisoners, 17 (81%) agreed to test. Of the 386 male prisoners, 320 (82.9%).
A total of 390 people were seen for testing and treatment. This comprised 17 female prisoners (4.36%), 12 female staff (3.1%), 18 staff children (4.62%), 1 prisoner child (0.26%), 320 male prisoners (82.06%) and 22 male staff (5.64%)

HIV
A total of 55 are HIV positive. Of these, five already knew they had HIV, two female and three male prisoners. Of the 50 new cases, 1 was a female staff member, 47 were male prisoners and 2 were male staff.
One prisoner was taken to court and released after testing but before the results were available (he tested positive for syphilis as well as HIV). One staff member requested syphilis testing only. His blood was tested for HIV in error, he was positive, but declined when informed of the mistake and offered the result.
Of the 17 female prisoners, 2 are positive (11.76%)
Of the 320 male prisoners, 47 are positive (14.69%)
Of the 12 female staff, 1 is positive (8.33%)
Of the 22 male staff, 2 are positive (9.09%)
Two male prisoners’ results were indeterminate. They tested positive with retrocheck, and were negative with HIV ‘determine’ and HIV ‘statpack’ (confirmatory tests). They were told their result was negative and were advised to retest after 3 months.
Syphilis
There were 108 positive syphilis tests.
Of the 17 female prisoners, 4 (23.53%) were positive.
Of the 320 male prisoners104 (32.5%) were positive.
No staff members tested positive for syphilis.
Sexually Transmitted Infections
There were 10 cases of Genital Ulcer Disease (GUD).
There were 37 cases of Urethral or Vaginal Discharge Syndrome (U/VDS)
There were 5 women with Pelvic Inflammatory Disease (PID)
Scabies
There were 239 people with scabies.
Of the 17 female prisoners, 4 (23.53%) had scabies.
Of the 12 female staff, 2 (16.7%) had scabies.
Of the 18 staff children, 1 (5.6%) had scabies.
Of the 1 prisoner child, 1 (100%) had scabies.
Of the 320 male prisoners, 231 (72.2%) had scabies.
Of the 22 male staff, none had scabies.
Malaria
23 prisoners were treated for malaria
Gastroenteritis
12 prisoners were treated for gastroenteritis

DISPENSING
A dispensary was set up and drugs were dispensed according to the protocol. Where possible single dosages were used, and prisoners were observed taking medication. Any prisoner who had received IM penicillin was observed for 30 minutes in case of anaphylaxis.
An estimate had been made of the incidence of HIV, syphilis, STI’s and scabies. Sufficient mebendazole was taken to treat everyone. Supplies ran out of doxycycline, erythromicin, benzyl benzoate and benzathine penicillin, and we restocked from the hospital pharmacy and local drug shops.

Total cost (rapid tests and labour provided free) 1,012,937 Ugandan Sh

This works out at 2600Ush ($1.45 USD) per test and treatment unit.

DISCUSSION
Sensitisation
Sensitisation at the prison worked well. The prison in-charge and staff were well briefed and cooperated very well on the day. The high take up rate amongst prisoners and staff indicates that the sensitisation was successful.
The briefing of health personnel was less successful. It was conducted in English, with no translation into Runyankore. On reflection, this was an error. Many of the forms were incorrectly filled, although this did not present a major problem on the day. The two visiting English Medical Officers had introduced protocols into the wards and outpatient departments at IAH, and had conducted weekly teaching sessions. It was intended that the week of the prison visit a session on STI’s was given, concentrating on syndromic management and discussing the protocol at length. This session was cancelled at short notice by the Clinical Officers. As a result, they were not as familiar with the protocol as they should have been. Some of their prescribing was not correct. This resulted in two prisoners being inadequately treated for syphilis (doxycycline 100mg bd for 7 days only), and several prisoners being over treated (doxycycline in addition to benzathine penicillin). This over treatment contributed to the shortage of some drugs later in the day.
Testing
We opted to use a TPHA based test kit. The weakness in this decision was the inability to differentiate between previous and current infection. We were aware of this at the outset, and made a pragmatic decision to treat with a single dose of benzathine penicillin alone.
We were very surprised at the low incidence of genital ulcer disease, and conclude that many of these positive tests reflect previous rather than current infection. It has been our impression from our work at IAH that syphilis is over diagnosed and genital herpes under diagnosed.
Dispensing
We decided to treat prisoners with symptomatic scabies only. This was a mistake. On reflection we should have treated all prisoners with benzyl benzoate as well as mebendazole.

RECOMMENDATIONS
We make the following recommendations;
IAH and Bushenyi Medical Centre to liaise about follow up of all HIV positive prisoners on the 22nd February.
The weekly health promotion talk by IAH staff should reinforce preventative methods of transmission of scabies and diarrhoea
The practice of using a single razor to shave the heads of several prisoners should stop immediately
All new admissions to the prison should receive testing and treatment for HIV and syphilis
All new admissions are treated with mebendazole and benzyl benzoate
Any cases of scabies are treated promptly to avoid spread of infection, the prison nurse will need a supply of benzyl benzoate
The prison nurse has ORS available to her for treatment of diarrhoea
The prison nurse stops dispensing chloroquine for malaria and has a supply of coartem instead
HIV positive prisoners who have indicated a willingness to disclose to the prison in charge and attend for follow up should be seen monthly and receive co-trimoxazole, multivitamins and antiretroviral drugs, if indicated. Any HIV positive prisoner should be seen promptly by a medical or clinical officer if they become unwell.
IAH should start the prison outreach as soon as possible.
Clinical officers at IAH should participate in training in the management of STI’s as soon as is practicable.

Jan.power@rosmellyn.cornwall.nhs.uk

Mark.russell@ciospct.cornwall.nhs.uk

Bushenyi Prison screening day

Bushenyi prison, 6km up the road from us is currently home to 406 men and women who have commited a range of offences from underage sex (under 18 in Uganda), to assault, robbery and murder.

If you remember Midnight Express the physical conditions are similar though the staff are friendly and were supportive of the health intervention. The water supply is intermittent. Food is scarce, firewood fuel to cook it is not reliably available and the yellow pyjama’d prisoners are often to be seen at hard labour in the neighbourhood. Inmates for longer than 12 months are clearly malnourished so much so that we mistakenly assumed many more than actually were, to be HIV positive.

We had marshalled a small football crowd of 45 from Ishaka Hospital, 15 trained staff and 30 students. The prisoners were counselled in groups of 50 and offered the health intervention which included testing for syphilis and HIV. 337 of 406 (83%) opted in (as well as 58 staff and their families). All were dewormed. Those who were symptomatic were treated syndromically for sexually transmitted infections (STIs), scabies and malaria. This day came about because both Jan and I had seen large numbers of prisoners in the out patient clinic with florid STIs.

Of the 337 prisoners we saw, more than 300 had obvious scabies, 20 had acute diarrhoea and 10 were hot and fluey with malaria (probably).

105 (26%) had at some time suffered from syphilis (testing positive with syphicheck) and 14.5% were HIV positive (retrocheck confirmed by HIV determine). Two were indeterminate (retrocheck positive, determine negative, statpak negative).

The testkits were donated free of charge by Qualpro Diagnostics from Goa India (huge thanks to them!) The labour was free and the final cost of testing and treating the 395 was on average 75p per person. All those who were HIV positive were given septrin and vitamins and will be followed up with a CD4 count in 2 weeks time.

It was a manic day but every body worked hard in the most wonderfully production line approach to healthcare I’ve been involved with since fluvacc days at home. Even the hour and a half of torrential downpour and the late lunch didn’t seem to dampen spirits. There are some great characters here and we shall miss them when we move on. Sam in particular is a whirlwind of energy, and went backwards and forwards to the hospital and drug shops on urgent restocking expeditions with extraordinary good humour. Molly was fantastic in charge of the pharmacy and Duncan and Vicent did all 790 rapid tests between the two of them.
The bottom picture shows a patient queue of prisoners waiting for their scabies treatment (we were temporarily out of stock!)

The Blame Game

Today at 2.45pm Brian died. He was 3 years old, had suffered once too often from malaria, and died for want of a pint of blood. He was in reasonable nick apart from his haemoglobin of 3.5g/dl. Just one of the 30,000 annual malaria casualties in Uganda.
Who is to blame for this catastrophe?
Museveni for being a time expired and corrupt autocrat in charge of failing public institutions?
His ex health minister Muhwezi for appropriating money from the global health fund and effectively denying all Ugandans the benefit of the fund for the next 3 years?
The IMF and World Bank for convincing Museveni that spending on health and education is the route to economic ruin (unlike having a sick or dead or uneducated population)?
The Adventist Church for not having enough money to send the car to Mbarara to collect blood for Brian this morning?
His parents for being too poor to buy a £3 mosquito net?
All of us for continuing to vote for governments that prioritise arms spending and oil security over peace and health.
Or me for shrugging off his death and carrying on with the rest of my day?

Infectious Diseases 101

We are coming towards the end of our 6 week placement here at Ishaka Adventist Hospital and are feeling sad at the prospect of moving on. We have been made very welcome, have a comfortable home with a view to die for and have learnt lots of practical medicine. For the first time in 20 year medical careers we have looked after people with malnutrition, measles, malaria, TB, HIV, typhoid and rheumatic fever.
Most are rewarding conditions to treat. We have now had 3 small children unconscious and fitting with cerebral malaria for more than 48 hours who wake up, start eating and 2 days later are smiling, well, and soon on their way home. The wailing, miserable, scrawny malnourished babies usually take at least a week to make their first smile but they do. Except one baby which died this weekend. Even conditions like TB and HIV respond to treatment and patients become active and well again – though drug side effects of the regimes we use here are still an issue.
There remains much stigma and ignorance around HIV and so late presentations with full blown AIDS are an everyday occurrence. Cryptococcal meningitis, strange neurological syndromes and severe TB make the prognosis poor.
We’ve seen a few older people with GI cancers we can do little for. Probably the condition we are most shocked and surprised by is rheumatic heart disease. A benign streptococcal sore throat or skin infection damages the heart valves of young children who then present several years later with heart failure. Everyday in clinic we see children as young as 9 in heart failure, though most are teenagers or older. We can control their rapid heart rate with digoxin, their failure with frusemide (and have even chucked around some captopril and atenolol,) but they need new heart valves. You can have this done as a medical tourist in India for $4000 or in South Africa for $6000, not much help when 50% of the population live on less than $1 per day. It is a classic disease of poverty, worsened by overcrowding and poor nutrition. It is unheard of in the post-war generation in the UK. Interestingly enough after my last blog (moaning about the tendency to over-prescribe) the incidence of rheumatic fever fell dramatically after the zealous prescribing of penicillin to all children with purulent pharyngitis in Costa Rica.

Medicines madness

Our little hospital has an attached nursing school and lab technician’s school. There is a private university a mile down the road with another lab technician’s school, clinical officer students and medical students. These students are an interesting barometer of attitudes to health care and consumption. It’s not unusual to see a 20 year old who has had a tickle in his throat for an hour and would like to be given a course of antimalarials and a week of broad spectrum antibiotics. This request is regarded as normal and acceptable. I will spend 10 minutes carefully explaining the difference between a minor infection with a cold virus and a life threatening infectious disease and the dangers of taking unnecessary medications (with gory descriptions of the worst allergic reactions I have ever seen). The student will leave much wiser but empty handed. Taking pity on him the obliging clinic nurse will shunt him off to see a clinical officer who will give him what he asked for and throw in some omeprazole, magnesium trisilicate and deworming tablets for good measure.
Typhoid fever or rather people who think they might have typhoid fever is another bete noir. When people are slightly unwell and think that on balance this time it isn’t malaria they are convinced it’s either typhoid fever or syphilis. They can be completely well with no convincing symptoms or signs of either illness but they want the tests. The typhoid test, at 75p is a days average wage here and is notoriously unreliable. We persist in doing it even though the way we do it is probably about as good as tossing a coin for all its scientific reliability. I patiently educate, counselling the patient to not waste their money, the nurse and clinical officer do their bit again, and an hour and a half later a fit 23 year old is led back in to seem me, cheerfully clutching a scrap of paper confirming his entitlement to 10 days of noxious (and unnecessary) antibiotic treatment.
The problem is that these illnesses are still common, often enough fatal and easily cured (in their early stages) by the use of appropriate drugs. When 30,000 (mainly young children) of a population of 27 million in Uganda are dying from malaria every year it’s a bit foolhardy to ignore the non-specific illness that is early malaria or early typhoid fever. Of course mothers are encouraged to present their children early for treatment and many village and small town health centres lack even a stethoscope or a thermometer let alone a laboratory for more sophisticated tests.
The management of diseases with antibiotics according to symptom complexes suggesting malaria or pneumonia or typhoid saves many thousands of young lives every year. But the consequence is a spiral of inappropriate drug consumption among older and much less sick people, serious drug side effects, the emergence of resistant organisms and unnecessary expense for an impoverished population.
Where does the balance lie? Better and cheaper diagnostic tests would help as would appropriate public health measures. The use of mosquito nets by children under 5 would almost halve the number of malaria deaths in this age group. Access to clean water and a good pit latrine would prevent most typhoid illness. Listening to radio 4 the other day I heard someone suggest that a 10% climate change tax on fuels would comfortably provide the funds to meet the millenium development goals necessary to eradicate the diseases of poverty. Why are we so reluctant…..