Tuesday, May 1, 2007
Gorillas
Most travelers visit Uganda for one reason – see gorillas. So, we figured we could not spend two months here without a visit to Bwindi Impenetrable National Park.
Bwindi Impenetrable Forest, is regarded to be one of the most biologically diverse forests in Africa. It is rainforest, the source of five major rivers, home to over 350 different bird species and home to over half the world’s mountain gorilla population. An estimated 320 mountain gorillas reside in the park.
A bit about gorillas… there are about 100,000 gorillas left in the world today, the majority in the Congo basin. These 100,000 consist of three species, the Western lowland gorilla in the Central Congo basin, the eastern lowland gorilla residing in lowland forests and the mountain gorillas, made famous by Diane Fossey and her famous writings, “Gorillas in the Mist”. Mountain gorillas are the most endangered and there are only about 500 left in the world. Like most gorillas, the mountain gorillas travel in groups with one dominant silverback as the leader with several “wives” and many babies. The hair turns silver when males go through puberty at about age 15. Shortly after, the boy will leave with a wife or two and start his own family.
Currently in Bwindi there are 4 gorilla groups available for tracking. Each gorilla group has between 10-25 members. There are other gorillas living in the park but have not yet been “habituated” to humans; it takes several years to habituate a gorilla group to humans. Initially they fear humans and will attack on instinct, so it takes several years of visiting daily at a distance and slowly getting closer to prepare them for tourism. Tracking is not cheap – permits cost $375 per person, and will soon increase to $500 per person as of June 1st. Eight people per group per day, so 32 visitors per day year round, and they almost always have tourists. We tried to inquire as to where the money goes in a country where thousands of children die daily from diarrhea – 20% to the local community, 20% to the politicians / government and the rest to the UWA (Uganda Wildlife Association) that pays guides, trackers, veterinarians, etc.
So, our day began at 8am, with registration and a briefing. No eating, no touching, etc. If you are sick you are not allowed to see gorillas and apparently the biggest health problem in these gorillas is scabies and measles, so nobody under age 15 is allowed to track!. We then divide up into our prospective groups (based on what your permit says) and start tracking. Early in the morning “gorilla trackers” start at where they were seen the day prior and follow their scents, tracks, etc. They do this daily and are very good. The trackers radio to our guides as to where to find them. The hike is not easy; and gorilla tracking is not for the weary. Sometimes you can find them after a 20-minute hike, other groups hiked for over 4 hours. (you can hire a porter to carry your things) There is no guarantee how long you will hike! We had about a 1 1/2 hour hike before meeting up with the trackers. Once we found the trackers we were instructed to leave our backpacks, food and walking sticks with them. We then walked three steps and saw the silverback. The whole pack was walking to find food. They were all around us, literally 5 feet from us. After about 20 minutes the group found a nice spot and all sat down to eat and play. The babies wrestled each other and the adults ate. It was incredible to be that close to them. They are so human like it is scary. Our group, Habanyero group, has 20 members including 2 silverbacks, one age 15, and then the leader. There were 4 babies including a 2 week old, which we saw nestled in mom’s breast. Tourists are allowed one hour with the gorillas and then we had to return.
It was truly an unbelievable experience, once-in-a-lifetime experience– well worth the cost. If you ever get to Uganda, Rwanda or Congo, go track gorillas and be sure to get permits well in advance.
Thursday, April 19, 2007
Cervical Cancer In Uganda - Stats and more - a glimpse into our project
Working in the Communities
This project has been quite challenging. In Rufumbira, the local language here in Kisoro, there is no word for cervix, and the word vagina is a shameful, dirty word, rarely uttered. Even doctors, MDs, refer to the vagina as “down there” and giggle as we discuss the female anatomy. We have compromised and now refer to the cervix as “the mouth of the uterus.” So trying to communicate about cervical cancer has had its extra difficulties…. women empowerment has not yet reached Uganda, so we have our work cut out for us.
(for more information on cervical cancer statistics in Uganda, see post entitled “cervical cancer in Uganda.”)
Beginning Monday we will trek out into the surrounding villages and go house to house interviewing women. In our survey, we plan to include lots of extra time for education, hoping that by educating a few women, the word will get out about the importance of cervical cancer screening.
My time on the wards had its highs and lows. I learned an unbelievable amount; in my physical exam skills, diagnostic capability and managing 15 patients at once. Internship should be a breeze after this. However we also suffered through terrible tragedies…. A 22-year old girl who died from cerebral malaria because the parents were awaiting transport for three days. But we also had great success stories and I think, overall, we made a small difference.
Saturday, April 14, 2007
Day Trips around Kisoro
Kisoro sits at the foot of Maghahinga National Park, famous for its family of mountain gorillas and beautiful volcanoes that make the border between Uganda, Rwanda and the Congo. Every morning on our walk to the hospital, we marvel at the three volcanic peaks that define the Kisoro skyline. On our first day off after two weeks in the hospital, we ventured into the national park. The family of gorillas had already crossed into Rwanda so the Uganda portion of the park was no longer offering gorilla trekking. We decided to defer climbing the tallest peak until we could adjust further to the altitude and tackled the smallest of the three. It was a great hike through bamboo forests and lush green forest with opportunities for bird watching and monkey spotting – neither of which were successful. But it was a great day overall.
Our next field trip was a trip to Lake Matonda, a beautiful lake about an hour walk from the hospital. We hired a local guide who took us through quaint villages to an exquisite lake. From there we boarded canoes to a little island in the middle, home to the most magnificent storks. These birds are indigenous to Uganda and are famous for their monogamous nature – Uganda uses them in their campaign for HIV prevention to encourage people to be faithful! We had a nice picnic on the lake and them headed home, first visiting a very local bar and trying the local brew – banana beer.
Sunday, March 25, 2007
Working in the Hospital
The women’s ward is usually busier than the male’s, so we have one resident and 3 medical students on the female ward, and one resident and 2 medical students on the male ward. Dr. Paccione oversees all wards.
We arrive at the hospital at 8am, and begin “rounding” individually on our patients. We each have about 10-15 patients and see them between 8-10am. At 10:30am, one of us goes to clinic (we go to clinic every other day), and then the others start admitting new patients, We admit on average about 15 patients a day. We take lunch from 1-2, and then have teaching rounds with Dr. Paccione from 2-4:30pm. Then from 4:30pm – about 7pm we admit more patients and finish all our work for our patients. Then, we go home, eat dinner, drink a few beers and go to bed. This weekend we worked both days! On Saturday, we finished early enough to finally check out the town. Everyone stares at us since we stand out like a sore thumb. As the only white people in town, its hard to blend in.
Since I work on the female ward, I have only female patients ranging from 15 – 75 years in age. Since I am going into OB, I get all the pregnant women. You only go to the labor ward when in labor, so all pregnant women who get sick, just go to the female ward. And, considering the average women in Uganda has 9 children, you can play the odds that the majority of women between 18-39 that come will be pregnant! For the medical people reading, the main things I have seen are malaria, malaria and malaria! Malaria is endemic to the region, so anybody with a fever ets started on malaria medicines. They do not do smears to officially diagnose malaria, so we never know if they get better from the malaria meds or they had a viral illness and improve due to time! Other ailments include UTI, pyelo, congestive heart failure (in young women from endocardial myofibrosis, thought to be due to parasitic eosinophilic process), endometritis, dysentery, peptic ulcer disease, arrythmias (paroxysmal SVT), TB, HIV, asthma, pneumonia, IUFD, miscarriages (missed AB), hookworm, migraines, and osteomyelitis. We see lots of pneumonia; the number one presentation of HIV is community acquired pneumonia in a young person. So we test all young people with pneumonia for HIV, and the majority turn out to be positive. HIV, regardless of its prevalence, is still very taboo to talk about. It has only been in the past few years that medicines have been made available in Uganda, so for the past 20 years a diagnosis of HIV was a death sentence. Its lack of a treatment deterred people from getting tested. Even now that there are medications available; there are only enough for 10% of the people who need it. So, diagnosing HIV is not all that easy, emotionally or socially, to do.
So far, the learning curve has been tremendous. You really get god at your physical exam skills when you have no technology or labs to help you. (lab services available are: CBC, ESR, UA, B-HCG, blood smear, AFB smear and HIV). Ironically, its quicker to get HIV results than CBC results here due to the strong funding for HIV.
So far it is exhausting and amazing!!! I will write more soon!
Our Group
Babak: 4th year medical student, originally in my class, but took a year off to study in Israel, he will be doing internal medicine next year at Montefiore.
Katrina: 4th year medical student from upstate NY specializing in pediatrics and will stay in the Bronx at Jacobi for Pediatrics.
Dan Bourque: 4th year medical student who was also in my class, but spent a year working in Peru doing research on Leptospirosis (an infectious disease). He will be doing internal medicine at UCSD.
Michael: 4th year medical student from NY; he will be doing emergency medicine at NYU. His wife is Anya, one of the third year residents.
Ania: 3rd year internal medicine resident at Montefiore (married to Michael) went to medical school at Mount Sinai.
Aaron Fox: 3rd year internal medicine resident at Montefiore and went to Einstein for medical school. I worked with him at the free clinic as a 1st year and 2nd year.
Dr. Gerald (Gerry) Paccione: An internal medicine attending from Montefiore. He works with Doctors for Global Health (DGH) and has been coming to Uganda now for 10 years.
We arrived!!!!
The house: The house is much better than Limon standards but still slightly roughing it. It is four bedrooms each with a single bed, so we each have our own room, with a single bed, gracefully draped with a mosquito net. There is a kitchen with a portable gas stove and fridge. There is an indoor toilet and bathroom, just no hot water. So far we have been taking bucket showers with heated water. I guess some habits die hard.
We will be staffing the “internal medicine” service. There is a men and women’s ward each with about 30 beds, with the women’s side usually being overcrowded.
Wednesday, March 14, 2007
A Little Bit About Kisoro
The district of Kisoro is located in the far south-western corner of Uganda, a few miles from both Rwanda to the south and the Congo to the east. It is a poor, remote and beautifully rugged land of sharp hills, towering volcanoes and serpentine lakes. It is accessible only after hours of winding dirt roads. The district is over-populated, meaning the land is over-farmed and the hospitals overcrowded.
The Kisoro District Hospital, where we will be working, is the only public hospital in the district. (There is a private catholic hospital nearby, better equipped, but costs money). The hospital is very underfunded, meaning few doctors, no specialists and very limited resources. Doctors earn less than $4000/ year with little potential for extra income. In the cities, doctors earn twice that amount, deterring physicians from staying in the rural areas of Africa where they are greatly needed. At last count, there were three physicans caring for 150 beds comprising Medicine, Surgery, Pediatrics, and Obstetrics/Gynecology wards plus the bustling HIV clinics. The nursing staff is at 60% capacity and there are 2 lab technicians. Needless to say, there will be plenty of work to go around for our team.
A few statistics about Uganda:
Population 28.8 million
38% of the population live below the national poverty line
87% of the population live in rural areas
Life expectancy: 49 years
Infant mortalilty rate: 80/1000 births (compared to 6.43/1000 births in the US)
23% of children are malnourished
6.8% of the population is infected with HIV