Dyani Loo, Anne C. Carter Global Health Fellow

 “I am here because I have been trying to have a baby since 2007 and I cannot.”  The 29 year old Ugandan woman sat on the clinic bed holding her hands in her lap gazing at us with worried eyes.  The translator and I were sitting on tall wooden stools in a dimly sunlit room, enclosed behind privacy bed sheets hung on ropes.  We tried to unravel more of what she meant.  She continued to repeat, “I am here because I want to have a baby.  I want to get pregnant.”  As we questioned her that afternoon through the translator we teased out more and more of her story, but each new detail seemed to raise more questions.  She had had a C-section, but why?  Her last baby had died, but how?  

  

After sitting with her and struggling through the blocks between us, we learned that the patient had had a series of pregnancies.  The last pregnancy she reported carrying to 12 months and she had ultimately needed a C-section for the fetal demise.  No one had told her that carrying a baby past term was dangerous.  Prior to this, she had conceived 3 healthy children.  So why could she now not get pregnant? 

 

She told us that her husband was HIV positive and was actively trying to conceive with her.  The patient was HIV negative and had been educated about the risks of transmission.  Thus, she had been using barrier protection, not understanding that using condoms also meant that she was preventing pregnancy.  We explained this to her in few different ways and the moment she understood what we were saying, her expression immediately changed.  She wanted to have a baby. 

 

“But I can take ARVs.”  “I have seen people get pregnant on ARVs.” 

The reaction and her strong desire to have another baby was because of a mix of cultural values—the patient expected to have a large family which is cultural norm, of fear—her husband had a second wife who was willing to conceive with him despite transmission, and of love—“Because I have so much to share I want to have more children so they can share all that I have too.” 

 

Although these stories seem to resonate with us—stories of people caught in difficult situations, turning to the clinic for answers—it was the attitude and transition of the patient between coming and going after interacting with the clinic staff and understanding what her problems were that impressed upon me the most.  Like many rural areas, the clinic population in Ddegeya in general faces a mixture of medical and psychosocial problems, cultural and financial barriers, but most strikingly, frequent gaps in healthcare understanding and the common spread of misinformation.  All of this combines to weigh down the shoulders of the men and women waiting on those clinic benches for their names to be called. 

 

I also saw many patients at Engeye who had come to the clinic for straightforward illnesses, but each time patients came in with problems or fears about both simple and complex conditions they left more reassured, more aware of what they could do and of what was happening to them. 

We may not always be the “mazungus” with the magic pill.  We can in both routine and difficult situations, however, give our patients the answers, options, education and empathy that seem too often to be lacking.  For the woman who came to us belly swollen as if pregnant, but from ascites with end stage hep B cirrhosis, we can give her the education about her condition that she never received but should have.  We can help them prepare for what lies ahead, help process what has already passed; help understand what is happening now, so they can be psychologically ready to face the decisions that they have to make.

 

 

 

 

This is how Engeye clinic serves as an anchor for the primary healthcare foundation in Ddegeya village.  By providing education, frontline care and outreach, and continuing to strive to improve and do it well, the clinic is able to work with the community to shape the village’s healthcare and understanding of illness and disease transmission.  In line with this philosophy, the Anne C. Carter Global Health Fellows are working with the clinic to help them with their goals of quality improvement, public health outreach, community self-sufficiency and expansion of care.  

From abroad and also during our service visit to Uganda, we have also been actively working on a grant to expand services and testing to promote women’s health.  As part of the sustainability and integration with the community, the clinic has been working with the village health team members (VHTs).  These individuals are selected local community members who meet monthly at the clinic for healthcare educational discussions who then go back to their village to serve as information conduits to the rest of their communities.

During the September monthly village health team meeting I presented the Carter Fellow presentation on pregnancy basics, prenatal/antenatal care and education about high risk pregnancy topics of malaria and HIV.  About 20 VHTs showed up asking questions and taking notes.  Since the VHTs are community members, not healthcare workers, many of these questions were related to basics such as understanding length of pregnancy and clarifying misconceptions.

In addition to regular clinic operations, the Engeye team also does monthly community outreach in neighboring village Kalububbu.  This village is about a half hour drive through the banana groves down some very potholed dirt roads.  During our outreach visit, we made housecalls on elderly patients who are unable to travel to Ddegeya to see the clinic in person. 

Prior to leaving the clinic, we packed an EMS bag with essentials– medication, malaria RDTs, glucometer, lancets.  Upon arrival, we were greeted by the community members, and set up on woven mats in a small room.  Patients heard we were there and filed in and we were able to talk with them about their problems, record their medication changes and H & P’s in their health logs (college blue books which they keep with them for clinic visits).  One of the major problems in this area is that many of the patients self prescribe.  They go to the pharmacy and buy medications for their symptoms without understanding why that could be harmful.  Again, the clinic’s outreach effort to improve the healthcare knowledge of the community is both important and appreciated here.  For the woman who had been taking daily steroids for a year for sciatica we were able to help her understand the dangers of both the side effects from taking steroids randomly and also the dangers of stopping abruptly.  Another woman had taken random small amounts of malaria medication based on feeling unwell and after talking with us understood a little more about the dangers of not taking doctor prescribed dosages and about malaria drug resistance.

During my stay I also started a malaria quality assurance project.  The clinic switched from using malaria RDTs to thick smear microscopy for their routine malaria diagnosis mainly due to cost restraints.  Since the transition, they have seen an increase in the number of diagnoses.  This may be due multiple reasons: to the fact that the older RDTs were more sensitive to falciparum than other species, the increased sensitivity of microscopy, or possible error due to non-ideal field conditions for slide and reagent preparation and storage.  By collecting, processing and sampling smears with external validation through the national referral laboratory—Central Public Health Laboratories in Kampala—the clinic can be sure whether or not the increase in positive reads is due to increased sensitivity or type 1 error and whether or not laboratory protocol needs to be altered. 

In addition to working in the fields and taking care of the children, the local women learn crafts from family and friends: sewing, jewelry making, basket and mat weaving.  By working with the clinic, the Carter Fellows are helping to develop a project to increase the economic development of the women in the village by providing buyers for their products, with the markup profit going toward the cost of running the clinic so it can be sustained. 

 The woman that was worried about why she could not conceive is only one story of the wonderful people that I met at Engeye.  For her and the others that come I have seen a big change in attitude, expression, and mood between waiting to be called and leaving with an understanding of what is happing to their health and what their options are for planning ahead.  The same is true of me.  I came to Engeye with plans of how to help and a basic understanding of the problems in the village and am leaving now with a more concrete understanding of community health, the people here, how the clinic runs and what it needs, and how we can now tie our projects to the faces and personalities of the amazing individuals that live in this village.  I feel honored to have had the opportunity to work alongside them and provide care.  Thank you Ddegeya!  Webale!