Otolaryngology in Mbarara, Uganda

Otolaryngology in Mbarara (1 of 3)

As travel goes, the trip to Mbarara, Uganda, had a bit of everything. There was delay in Kigali due to an airplane crash on the Entebbe runway, failure of my hotel shuttle to pick me up (with several taxi drivers unexpectedly unwilling to take me), and the theft of some of my medical equipment out of my checked luggage somewhere in-transit. But there was also the stunning 5-hour drive from Entebbe to Mbarara and conversations with the driver about traditional medicine in Uganda, the role of foreign mzungu doctors, and the Ugandan soccer team that barely lost a birth to the Africa Cup by 1 point to rival Kenya. The drive also gave me a chance to take in the warm, visibly tropical environment of southern Unganda as we crossed the equator and catch a glimpse of Zebras as we passed close to Lake Mburo National Park.

I've arrived in Mbarara as an otolaryngology resident given the opportunity to spend 2 weeks learning about ENT Surgery in Uganda and also with hopes of exploring possible future research and educational collaborations with Mbarara Univerisity of Sciences and Technology (MUST) and the affiliated Mbarara Regional Referral Hospital. Mbarara is home to approximately 150,000 residents with 500,000 people in the surrounding area. Mbarara Hospital serves as a major referral hospital for all of southern Uganda with an even larger catchment of unknown numbers that at times includes patients from northern Rwanda, Tanzania, and the Congo. As a hospital, it offers two operative theaters, two-four ICU beds, multiple over-crowded adult wards (by most accounts), and roughly 6000-7000 pediatric admissions to the pediatric ward each year. There are currently plans in place to build/open a new hospital that will reportedly offer 8 ORs and greatly improve the capacity to accommodate the large inpatient volume, expected to be completed next year.

By the numbers, otolaryngology in Mbarara is easily considered a needed specialty. Mbarara Hospital has 1 staff otolaryngologist, who has been a different cuban otolaryngologist every 2 years for some time now. This makes the ratio of ENT surgeons to population in Mbarara is very similar to that of the national average in Uganda of 0.06 ENT surgeons per 100,000 people (based on a 2009 study), which is remarkably lower than the 1:100,000 ration in the UK and the approximately 3:100,000 ration in the US.
Over the past several years, however, MUST has been trying to alter this deficit in ENT surgeons by starting a residency program with the goal of training and retaining otolaryngologists to serve southern Uganda. There is currently one resident in her post-graduate year three of four years with hope of bringing in a second resident soon.

Having arrived in Mbarara, with this background in mind, I am very excited about the days ahead.

Kyle Chambers, MD - PGY-2
Harvard Combined Program in Otolaryngology-Head & Neck Surgery

Read More

Ethiopia, the land of thirteen months of sunshine

Project: Surgical Capacity Assessment in Ethiopia
Partners: Harvard Humanitarian Initiative, MGH Department of Surgery, Harvard Program in Global Surgery and Social Change, Global Surgical Consortium


Ethiopia, the land of thirteen months of sunshine, is big.  Huge, in fact.  I spent this past October in  Ethiopia, crossing huge distances in planes, cars, and buses, visiting hospitals to administer a surgical capacity survey with the Harvard Humanitarian Initiative.

Visiting one of the hospitals in Debark with one of my co-researchers

After spending a couple days at the Ministry of Health and at Black Lion Hospital, working with the MoH Medical Director, Mr. Abebaw, and our local author, a pediatric surgeon named Dr. Miliard Derbew, we plotted out a rough idea of our country tour and then set about figuring out what combination of plane, bus, and car would get us where we needed to go.  It turns out that we needed to fly a LOT; I ended up taking eight domestic flights this month!  Fortunately, Ethiopian Airlines is quite good and, more importantly, inexpensive.

One of our many domestic flights required to reach hospitals around the country,
which is over one million square kilometers!

What we discovered through our travels is that hospitals in Ethiopia are distributed unevenly throughout the regions and city-states, with resultant disparities in physician:patient ratios in different areas.  Unfortunately, this limits the ability of many patients to access hospitals, particularly hospitals where surgery was available.  Though they frequently had access to primary care, the limited availability of surgical capacity translated into huge problems regarding obstetric care and trauma emergencies.  When patients are traveling by foot and camelback, the huge distances prove a problem.

Camelback is an acceptable alternative to an ambulance

While we also discovered infrastructure deficits, we were impressed by the creative workarounds that were developed.  Not only did we find the typical adaptations like electric generators and headlamps in areas without electricity, but we found air conditioners used to refrigerate medications, or living blood banks in areas without blood banking ability.  The ingenuity of the doctors and hospital administrators certainly was to be applauded.

Other than that, the country was a great pleasure to travel around.  We were able to experience a lot of wonderful things in Ethiopia, notably the wonderful coffee ceremonies.

Coffee ceremonies involve roasting green coffee beans, grinding them, and then cooking them over coals

Of course, no story would be complete without mentioning the incredible hospitality of the Ethiopian people we met, particularly the families, patients, and all the medical personnel we were able to meet with!

A gift from an Ethiopian family to keep warm; Ethiopia was surprisingly temperate!

Now that I'm back in Boston, I'll be taking some time to reflect on our experiences, but I will never forget this incredible month I spent in Ethiopia.

Tiffany E. Chao, MD, MPH
MGH Dept of Surgery PGY3

Read More

A central TB diagnostic lab

I spent the past two days on a computer at the National Health Laboratory Service�s TB lab in Cape Town, finding codes and dates needed to link sputum samples to clinical data for a cohort I�m studying of MDR TB patients from a nearby farming region.  The South African government somehow has decided to keep this NHLS facility occupying prime downtown real estate � next door is historic Somerset hospital, and over lunch, I walked a couple of blocks to the high-end waterfront shopping mall � but inside, it�s a giant sample-processing factory.  Assembly lines of slides and stains and culture bottles, overflowing boxes of discarded samples making room for a new day�s sputa, a room of Bactec machines, new machines for rapid drug sensitivity testing, all kept running from early morning to 11pm, with two shifts of workers each day.  I made the mistake of trying to look up a sample by date, not realizing that a new one is logged about every two minutes.  And repetition makes the work efficient; this may seem silly, but I was amazed by how quickly the woman working next to me could stack up a tabletop array of glass slides that were lying side by side (15 or 20 per second, maybe? I�m not exaggerating - it was impressive.)

The high volume and necessarily rapid turnover mean it�s impossible to go back and find mycobacterial samples of interest after the fact.  But fortunately, our collaborators at Stellenbosch University have set up a system where all multidrug resistant samples automatically get sent to them for cataloguing, storage, and further typing and molecular analysis.  I�m eager to link their molecular data with the clinical data we�ve collected these past few weeks and see what we find.  Also curious to see whether we can show any effect from the recent implementation of rapid PCR diagnostics: Shorter times to reporting MDR TB? Shorter times to getting patients on appropriate treatment? Or, a longer shot but the real interesting question, less transmission in the community?


Emily Kendall, MGH, PGY-2 Internal Medicine

Read More

MDR-TB in rural Western Cape, South Africa

I�m spending this month at Brewelskloof tuberculosis hospital in Worcester, a small town in South Africa�s Western Cape province.  It�s just a bit over an hour�s drive from Cape Town, but it�s a completely different world from that fairly cosmopolitan city.  It�s a farming town � lots of vineyards, some other fruit, a few livestock � and there�s not much else going on, although the setting is beautiful: grapes growing everywhere, ringed by mountains, spring wildflowers currently in bloom.  I�m gathering data on a cohort of patients with multidrug resistant tuberculosis (MDR TB), so I spend most of my time combing through paper hospital charts, doing my best to translate Afrikaans, and typing into a clunky Access database.  Not particularly exciting work, but the data is beginning to tell a few interesting stories. 

This population � at least the subset of people from these farming communities who get MDR-TB � is really disadvantaged.  Walking through expansive upscale shopping malls and trendy organic markets in the city (Cape Town, that is) on the weekends, it�s clear that there�s money in this country somewhere.  The hospital in Worcester is also immediately surrounded by lovely homes and estates.  The typical MDR-TB patient we read about, though, lives in a shack without water or electricity, has about a 6^th grade education, is trying to make ends meet through seasonal farm work, and binge drinks heavily on the weekends.  The tricky thing is that the same social factors that breed and spread MDR (poverty, crowding, and malnutrition that predispose to TB, and home and work instability and frequent intoxication that make it hard to take your TB drugs every day for six months) make it even hard to complete the two years of more-toxic treatment required to treat drug resistance.  

I�m also observing long delays before patients with MDR TB in their sputum got onto appropriate treatment.  Cultures take several weeks (and AFB smears, we�re told, tend to be reviewed hastily here and rarely come back positive), and then drug susceptibility testing take more time.  But besides waiting for lab results, there also must be other delay somewhere along the process of realizing a culture shows MDR, notifying the clinic, finding the patient, and getting them into treatment, because we are often seeing gaps of 3, 4, even 6 months between when a sputum is collected and when appropriate MDR treatment is started.  Plus, while waiting for the DST results, sometimes patients get a single drug added, or are started on treatment regimens with only 1 or 2 drugs that turn out to be active, which is exactly what you don�t want to see.  Starting first-line therapy after a positive smear or culture is automatic here, I�m told, even in patients with risk factors for drug resistance, but I�m curious to analyze whether these first-line regimens negatively impact either MDR outcomes or transmission of MDR within patient�s households and communities.

Finally, on a somewhat related note, all this reading of paper charts makes me appreciate electronic medical records.  But not everyone here views computers the same way.  We were talking today with South African collaborators about electronic records, about plans for expanding our electronic database to capture a broader slice of hospital�s data for research purposes, and even about the possibility of transitioning to a electronic medical record for clinical use.  The rural clinician in the group was puzzled about how this would work: the doctors would have to go back to their offices at the end of the day and type in everything they had done?  The idea of placing computers within the ward blew him away.  Another researcher mentioned that he�d been abroad and seen a clinical pharmacologist with an iPad, who was able to look up information about pharmacokinetics to show the team as they rounded; he�d been amazed.  But none of them really have a vision for what computers could add to their clinical or research work.  My American mentor/collaborator and I tried to convey the potential usefulness of an electronic record for prompting doctors to enter data that the hospital wants to collect, for keeping track of outcomes or adverse events in real time, or for retrospectively answering questions that no one has thought of yet, but I don�t think we got through.  I imagine that the push toward electronic charting isn�t so far away for a country like South Africa, but it will be a tough transition in isolated pockets like this one.  For one thing, they need to get internet; here in Worcester, I can�t connect long enough to find the CoE blog, so I�ll be posting this in a few days once I get to Cape Town for the weekend � where internet is still spotty, but slightly less so.  

Emily Kendall

PGY-2, Internal Medicine

Read More

Hurry Up and... Teach?

Mark Siedner

August 31, 2011

Mbarara, Uganda

It was with a rolling boil of enthusiasm that I landed in Uganda three weeks ago. In the four years since I returned from my last prolonged international trip, my pager and chiefs afforded me only the briefest glimpses of foreign shores. On June 30^th, like for thousands of other residents and fellows, those days (and nights) of regimented educational servitude ended. Abruptly. As soon as my funders and wife allowed, I shoe-horned my life into two suitcases and arrived here in Mbarara with a polished study protocol, approved ethical reviews, and just enough grant funding to just maybe execute my project: a study of the acceptability and feasibility of using cell phones to communicate critical laboratory results to patients in resource limited settings.

Then, like so many of those first days of medical internship when we realize that no textbook can prepare us for unbridled sickness, I was overrun with humility. As the sheen on my proposal faded, the finality of ethics review waned, and the tensile strength of my budget unwound, I became increasingly befuddled and was oft sighted wandering the sand-blown alleys behind papaya stalls and chapatti wallahs mumbling things like, �Sub-contracts cannot be cost reimbursable,� �You forgot to charge indirects on your fringe,� and �Did you really you think you could pay for an IRB fee with a bill printed before 2005?� I would be remiss to bore you with the list of missteps, oversights, undersights, and unmet expectations I have experienced since my arrival. But I would also be shirking the chance to build invaluable empathy with my peers and possibly even prepare the incoming international study-minded residents and fellows by keeping quiet. So forgive me as I attempt to list a handful of the preparatory hiccups I choked on in the past few weeks:

a)    Grants afford me the chance to bid on a ticket. They do not get me on the plane and certainly don�t get me within a hemisphere of my destination. When working (and spending money) at a foreign site, the grant will first need to be agreed upon and signed by your home institution and funding organization. This requires finalization of budgets (likely before you are sure of your costs), IRB approval (for funds to be paid), and a whole lot of time spent hurling epithets on a system called InfoED (for you MGH folks) where all this information is entirely non-intuitively entered. I would say the whole thing is a bit like learning a new language, but that would only be true if that language was neither written, spoken, or heard by anyone aside from (I�m convinced) a pernicious little computer programmer who has made his or her life�s mission to avenge the rage at failing a quantum mechanics class in college on grantees and administrators like us. Once this process is completed, a sub-contract between your home institution and foreign site needs to be arranged. Given that the foreign site is likely in a resource poor setting and cannot pay up front and be reimbursed, a quarterly payment schedule will need to be arranged. Once these are completed (in my case, I am told to expect about two months, and am still in the beginning stages), a judicious waiting period to hire any needed research staff and procure materials should be expected. In short � congratulations on winning a grant. Now hurry up and do something else for a while.

b)   I would be in a more serene place now if I was more flexible with my initial budget projections (perhaps a motto for academic research?). As it stands, I have all the serenity of a hot rod without a muffler. My cost projections were a bit like those of a toddler just beginning to grasp the nebulous concept of worth. As I would then alternatively think a cheeseburger was worth either 16 cents or twelve million nickels, I�ve been caught budgeting translation fees as both 25 and 2,000 dollars on the same budget. As if not knowing that printing a piece of paper here cost a dollar but photocopying one runs you 4 cents was not enough, predicting the volatile exchange rate has forced me into fits of pseudo-seizures. A $600 wire transfer for IRB fees last month converted into local currency is worth exactly $502 today, the day the fees are to be paid. In hindsight, my advice to myself would be the following: Have patience, wait as long as possible to finalize your budgets (preferably once you are in country), and whatever you do, do not buy cell phones in the US or computers in Uganda.

c)    Administrators are like the brown sugar in chocolate chip cookies. At first I took them a bit for granted � bypassing their names in my email inbox for Groupons. But that day you�re asked to do it yourself, you�ll suddenly appreciate how there is no sweetness in life without them. There is no money, no approval, no study, no publication. There is only dry, tasteless dough. Buy them flowers and scotch. Get them out of jury duty. Babysit. Just make them happy. For Pete�s sake open their emails first! If I remember nothing else from this experience � I hope I remember this key ingredient to the research recipe.

So what have the last three weeks brought me aside from a new diagnosis of hypertension? Incredible opportunities. I�ve spent three weeks working in the HIV clinic, seeing over fifty patients and more with cyrptococcus, tuberculosis, and unidentifiable skin conditions that I did in my entire clinical fellowship year. I�ve had the incredible opportunity to teach medical students, yearning like sea sponges for every last bit of medical knowledge in this over-constrained education setting at rounds each week. I have organized a journal club and connected the faculty to a web-based monthly international HIV clinical conference. I am mentoring a small group of residents and staff on development of research projects, all locally grown. We are developing new protocols for infection control precautions and in the exploratory phases of designing a hospital antibiogram. This is of course, I remind myself daily, why I came here. Because the need is so great and though I am not the best person for any of these jobs, I am also all we�ve got! And I am so incredibly honored to have the privilege to work where the challenges are so great, but the interactions with patients, colleagues, and local mentors are so incredibly rewarding. I�ve gotten nothing I wanted to done. And so much more.

Mark Siedner MD MPH

Infectious Disease Fellow

MGH/BWH

Read More

�Combating Chronic Diseases in India using Community Health Workers�, Blog 1

�Combating Chronic Diseases in India using Community Health Workers�

Bangalore, Karnataka, India

St. John's Research Institute 

Tanvir Hussain, MD, MSc

Blog 1: Project Background

On May 3, I returned to St. John�s Research Institute in Bangalore to continue working on the SPREAD Project.  The SPREAD project (Secondary Prevention of coronary Events After Discharge from hospital) is a randomized controlled trial in secondary prevention of acute coronary syndrome developed to serve the urban slums and rural village populations.  The design is an open trial comparing post-discharge interventions delivered by community health workers to standard care in 10 secondary and tertiary care hospitals. The objectives at the outset were to assess feasibility, estimate rates of adherence to pharmacotherapy, assess adherence to lifestyle modification, and obtain an estimate of the event rates in an Indian setting. 

SPREAD is an example of the response to changing disease burden globally.  As developing countries undergo epidemiologic transition and disease burden shifts from communicable disease towards chronic illnesses, current health delivery systems are being recognized as inadequate to manage CAD, DM, COPD, and cancer in low and middle income countries.  In 2009, the NIH provided funding to medical institutions in developing countries to implement innovative strategies in chronic disease care.  In India, where CVD is the leading cause of mortality in the urban and rural population, St. John's Institute of Bangalore is pioneering a community health worker (CHW) based secondary prevention model for CAD, the "SPREAD" project.

My role in the SPREAD project began during my six week global health elective funded by BWH Internal Medicine department during October through November 2010.  During this time, I enjoyed participating in the conceptualization of the intervention.  My role included working with experienced CHWs in producing a first draft of the CHW educational training materials.  I also produced a first draft of the patient encounter protocol for CHWs�that is, I developed a step-by-step tool CHWs could use during patient encounters to document and counsel patients during home visits, accessible to CHWs with primary school training. 

After I had left the project in the Fall of 2010, the team had taken several significant steps: identification of 14 potential study sites across India and a CHW at each site; translation of patient and CHW education materials into seven different languages (see pictures with Blog 1); training of the CHWs; evaluation of the CHWs; training of study sites for a non-�clinical� trial.  Conducting this process in several languages across fourteens sites was incredibly challenging.  And I was impressed by the team�s perseverance and accomplishments.  

Now that I had returned approximately eight months later, I was anxious to hear about the creative solutions created for the challenges faced by the team, the anecdotes and experiences bourn from the CHW trainings, the anticipations for the future, and more.  Part of my role on the project on this second visit would be to provide an assessment of the CHW training process to ensure the CHWs were adequately prepared to undertake the challenges of counseling and caring for post-MI patients from discharge to one year after their event, both at home and in the hospital.

In my next blog, I reflect on the unique challenges of employing a CHW model in chronic disease management, learnt from our project.

Read More