Observations from Kampala

A note from my good friend, Dr. Honora Englander, who is currently on assignment in Uganda. Very well written, I think, with important observations about us as well as the local scene there. She welcomes your comments, too. (And please go back to these three posts to read about her previous Kenya experience.)

As many of you know, I have spent much of the last year thinking, learning about, and further developing work around humanism in medicine curriculum for African students. The basis for it came out of work that I started with Kenyan students to explore the personal challenges of providing care in a resource poor setting with high mortality from HIV/AIDS and other treatable diseases. "The Art of Medicine" in Kenya was based on a discussion series that we had while I was a resident at OHSU, where we discussed cases focusing on the personal aspects of providing care, instead of the typical clinical focus. The experience was meaningful and powerful for the Kenyan students, and many of them are eager to further pursue it. Seven of the Kenyan students have arranged to come to Kampala for an away rotation, in part to continue the conversation that we started a year ago. They arrive next week, and I am delighted to see them again. It is exciting, and as I return to East Africa I am reminded of the importance of these themes.

I hesitate a bit to write to you all about some of the things that are the hardest about being here. I have not yet sorted out my complex feelings about the dynamics and culture of care on the hospital wards, but I will share some of my early thoughts. My sense is that most, if not all, Westerners who work in a setting like this feel a certain frustration, and at times desperation, from the intensity of disease, limited resources, and the relatively slow pace to dealing with what they perceive as emergencies. There are critical labs that get drawn but not run, and life-saving treatments that get delayed until it is too late. Often in the afternoons and late evenings there are no doctors on the wards that are filled with ailing patients. I see many Westerners complaining, exasperated, and angry, about shortcomings of the system. And I hear repeated criticism about the "lack of accountability" and "professionalism" amongst local providers. I understand and see what people are talking about, but I feel that there is so much more to it all. And I worry about the effect that these critical voices from abroad have on an institution and a culture. These voices are hard to escape, and come with strong undercurrents of implicit assumptions and judgments made by visitors. And while I am grateful to be here, I do question the value and the harms of short-term visits by people from wealthy countries…. These questions are not new for me, but they are freshly revisited. I suppose they are what motivate my interest in promoting discussion amongst Africans around the art of practicing medicine, and also in encouraging a more thoughtful approach on the part of US collaborators and educators who send so many students and physicians overseas…