Exploring Infectious Disease &
Tropical Medicine in Uganda
Austin J. Price, MS4, MPH
University of Kansas School of Medicine
Spring 2019
Learning Objectives
1. Compare/contrast the differences in how medicine is practiced
in the US vs. Uganda
2. Gain appreciation for the role that infectious diseases play in the
morbidity/mortality of patients in other areas of the world
3. Better understand how resource limitations affect patient care
and patient outcomes
4. Learn about how cultural differences affect healthcare in a new
setting (from both the prospective of the physician and patient)
Kampala, Uganda
Uganda’s capital/largest city
Located in South/Central Uganda,
near Lake Victoria
Population: ~1.65 million
Very urban area, but with poor
infrastructure
Largest hospital in the country (Mulago
National Referral Hospital) located
here but largely non-operational due to
ongoing remodel
Home to the country’s only medical
school at Makarere University
The Clinical Setting—Kiruddu Hospital
Suburban subsidiary of the larger Mulago Referral Hospital
Currently Mulago’s main campus is under renovations, so
much of patient care is outsourced to smaller hospitals like
Kiruddu
Large, 8 story building, 1 elevator bank, no air conditioning,
ED waiting room is outdoors
Care is provided free-of-charge, but services are drastically
limited due to costs
Infectious Disease Ward—separated into men’s/women’s
wards
Approximately 30 patients on mens ward
NO ISOLATION of any kind
No partitions between patient beds
Very little privacy
Not air-conditioned
Shared (primitive) ward bathroom
Why Infectious Disease
Ward?
Pursuing internal medicine residency beginning June 2019 in
San Francisco, CA
Plan for ID fellowship after residency
Very interested in ID and tropical medicine
Hold an MPH in infectious disease epidemiology from Johns
Hopkins
Was very curious to learn about the treatment of diseases that I
have largely only ever learned/read about
Typical Day on the Ward
Day begins at 0645 with ~1hr bus ride from Mulago main
campus (only a few kms but traffic is horrendous)
Arrive at Kiruddu ~0800, spend ~1hr reviewing labs/seeing
patients
Rounds begin 0900-0930
Attending physicians visit 2-3 days per week, otherwise
rounds are conducted by senior house staff and one intern
Approximately 15-20 Ugandan med students on service,
with 3-5 international students
Patient presentations are quite similar (H&P for new
patients, SOAP notes for follow-ups)
Rounds generally end 1200, break for lunch
1300 follow up on patient labs, write orders, speak with
family
1500 generally resident teaching to medical students
1600 bus departs back to Mulago main campus
Learning Objective #1
Practice in Uganda is largely based on clinical suspicion and physical exam—labs are
done sparingly
Many laboratory exams are unavailable, unless the patient can pay out-of-pocket
Imaging studies are rare apart form plain films
All radiology reports are handwritten
Nurses play a completely different role, largely removed from patient care
Patient loved ones serve as “attendants”
Attendants give medications, feed & bathe the patients, obtain laboratory and imaging
reports from various hospital locations, and assist with all aspects of the patient’s daily
needs
Learning Objective #2
Uganda’s population is vastly different than United States’
One of the planet’s youngest populations
Largely representative of the past and ongoing significance
of infectious diseases
HIV/AIDS is a huge problem—with half of my hospitalized
patients meeting AIDS criteria
Opportunistic infections abound
PML, CMV esophagitis/retinitis, cryptococcal meningitis,
disseminated mycoses, Kaposi’s sarcoma, PJP,
disseminated TB
Malaria is quite prevalent, especially in younger patients
TB is a major issue, especially in HIV/AIDS patients
Hepatitis B is prevalent, with many young adults with
chronic infection and HCC
Other ID cases of note: severe tetanus, filariasis,
schistosomiasis, Pott’s puffy tumor
Learning Objective #3
Resource limitations definitely affect how patients receive care
Labs/imaging are used very restrictively
Treatments are empiric and hinge largely on physical exam and clinical suspicion
All documentation is handwritten in paper charts housed under the bed mattresses, often the
documentation is hard/impossible to read or is lost altogether
Despite these limitations, the physicians are keen clinicians with excellent PE skills
Physicians know the common diseases of the population and how they present clinically extremely
well
Many patients do quite well and show marked clinical improvement despite limited resources
Certain conditions have extremely poor outcomes due to resource limitation (i.e. psychiatric illness,
renal failure (no HD), respiratory failure (no vent support)
Learning Objective #4
Cultural differences abound
Physicians are much less explanatory regarding
illness/prognosis
Patients are wholly trusting of physician input
Language barriers are quite common even between
Ugandans due to prevalence of tribal languages
Many patients possess superstitious beliefs (i.e. illness is a
result of wrongdoing, demonic possession, etc.)
Disease stigma is common, particularly regarding HIV
which is viewed largely as a moral failing
Religion is more integral in medical care
Med students pray each morning on the bus
Patients ask physicians to pray with them during rounds
Patient’s religious beliefs are discussed openly as part of
their medical care
Interview with Senior Resident
Dr. Frank—senior house staff—spent considerable time in Sweden during training
Largest obstacles:
resource limitations
patient adherence following discharge
largely dependent on patient factors (education, family support, living conditions, occupation,
proximity to healthcare facilities)
Health literacy remains a major concern
Resource limitations:
prevent over-reliance on labs/imaging for medical diagnosis
prevent medical waste
promote astute clinical decision making
Most Profound Clinical Experience
19yo male Sudanese refugee
CC: several week history of painful protuberance of the left
forehead
Presented with malaise, fever, and decreased appetite
Found to be in severe sepsis with large fluctuant mass
present over the left frontal bone
Started on empiric antibiotics, fluid resuscitation, I&D
performed (specimen subsequently lost)
Imaging (paid for by organization that supports refugees)
revealed destruction of the underlying bone, with frontal
lobe extension
Presumptive diagnosis: Pott’s Puffy Tumor (complication
of chronic frontal sinusitis)
Patient continued to deteriorate on therapy, neurosurgery
consulted for evaluation
I had to leave before the resolution of this case, but I fear
the prognosis was quite poor
Life Outside the Hospital
Tons of wonderful exploring
to be done
Jinja (source of the Nile)
whitewater rafting
Murchison Falls National
Park
Entebbe National Botanical
Gardens
And much more!
I would like to extend the most sincere gratitude to
the Halsey Scholarship Committee and benefactors
for providing me with the funding to make this
amazing experience possible. THANK YOU!!