Public Health

This past week I have been shadowing the Public Health Nurse, Sister Marie Kigame. It provided me with an opportunity to spend time in the clinics and villages to see what some of the public health issues are in this community. Sister Marie is very passionate about public health and has many visions for the Kisoro District. Her interests are mostly with women and children and her number one goal is to strengthen and expand the Child Wellness Clinic at Kisoro District Hospital

To ensure mothers bring their babies into the clinic for regular check-ups and vaccinations, Sister Marie thinks that providing incentives for mothers would increase compliance. If the funding were available she would like to provide mosquito nets at birth, cups/bowels for 6 month old babies as a reminder to begin supplementing the baby’s nutrition with solids, and a toy at 9 months old. Although there is a high risk for contracting malaria, many people do not use mosquito nets because they do not think there is a risk or they simply can’t afford them. At 6 months old many babies become malnourished, because mothers are unaware that breast milk is not enough at this age. The toys would be used to evaluate whether a child is reaching their developmental milestones. There are only two toys at the Childhood Wellness Clinic that the nurses use. It is difficult for me to watch as the toys are passed from baby to baby, coming into contact with every draining orifice without being sterilized. The lack of resources forces issues like this to be ignored.

Sister Marie would also like to begin providing care specifically for the elders of the community. It was explained to me that in this community elders often feel that they are a burden because they can no longer work. Sister Marie thinks that if she first organized a time and place for seniors to gather for tea and socialization every month, it would create a great venue for health screenings. Screenings could include blood pressure checks, and assessments of each elder's capacity to perform normal activities of daily living. In addition, she would like to provide safe assistive devices such as canes and walkers that are more stable than the thin bamboo walking sticks that are normally used. As far as I know there are currently no services focusing on the elders in the community. The difficulty here is the lack of availability of health care workers to provide this type of care.

Another public health goal on Sister Maria's agenda includes outreach to the women in the local prison. Next week there is a focus group for the women at the prison. This will be an opportunity to assess the women for abuse and to see whether personal hygiene and other health needs are being met.

Finally, Sister Marie makes monthly visits to various secondary schools in the area giving health education. It is her idea that rather than just talking at the young people she would like to initiate a program where the youth form committees and give health education presentations themselves on topics such as HIV/AIDS, nutrition, malaria, drugs, alcohol, smoking, and any other issues that the youth might find relevant. In this way they are learning from their peers and getting more routine health education. All of Sister Marie’s visions are possible, but difficult to initiate, considering that she is the only public health nurse for the entire district.

I spent Monday with infants and their mothers at the Childhood Wellness Clinic. The clinic was packed. Here babies are weighed to ensure they are meeting their weight for age goals. It is quite a site to see the naked babies hanging from the rafters to be weighed, urinating at any given moment, with no one else noticing but me. Next, they are vaccinated by the very busy nursing assistants, Sarah and Panina, who are identifiable by their purple dresses. Finally, the babies are plopped down on a mat on the floor and are given a mini physical examination by me and Sister Marie. This includes measuring their head circumference to screen for hydrocephalus. Hydrocephalus is a common and often overlooked issue in infants, and if not treated a child will not survive.

The following day we went to a small village known as the Giseke Trading Center. Here we set up shop in a rustic little building with dirt floors, rickety wooden benches, and no running water. The women and babies poured in, and at one point I counted 20 babies waiting to get vaccinated. Interestingly, there was rarely a peep from each child, aside from a small yelp after an injection. All of the infants appeared well-nourished and well-developed. It was amazing to see how committed these very poor village women were at keeping their babies vaccinated. The final day of child wellness outreach involved going to the dusty town center that also serves as a library. I was able to get in on the action and give babies vaccinations and chart their growth pattern since it was only Sister Marie and I at the outreach. It pained me to give injections to the sweet little unsuspecting bundles of love, but of course all for a good cause.

Visiting the antenatal clinic was a particular highlight of the week. Depending on if it is market day, (market day is a very busy day in town) anywhere from 30-80 pregnant women are seen. Sister Jolly, the nurse in charge of expecting mothers, gave me hands on teaching of assessing a mother and her fetus. I learned to tell with my fingers how far along a mother is based on the height of the fundus, (her abdomen). Palpating the abdomen to find the baby's head and butt was fascinating, and listening to the fetal heart beat was done with a rudimentary listening device that worked quite well. After the expectant mother was assessed the mother would pop anti-malarial and de-worming pills. Pregnant mothers definitely have different concerns here in Uganda in comparison to the US, where the only pills women need to take are prenatal vitamins. The average woman we saw that day was in her early 30's getting ready to have her 5th or 6th child. According to Ugandan values I have a lot of catching up to do!

Friday was a big day where we visited a very rural health center to do a cervical cancer screening outreach. Apparently cervical cancer is a leading cause of death for women in Uganda. In the Kisoro District 10% of the women screened are HPV positive and a high risk for cervical cancer, and about 4% have advanced cancer.

It was an amazing turnout of at least 80 women. It was quite moving to witness this large group of Ugandan women lounging on the grass in their colorful wraps, as a nurse mid-wife gave a presentation on women’s health issues, and what to expect during the exam. There were three providers to conduct the pelvic exams which included a full female physical exam. Peggy and I worked together as a team conducting the female examinations. I won’t go into too many details, but I now know what to look for when examining a cervix. I learned a lot from taking health histories, such as a husband refusing to get treated for Syphilis and therefore re-infecting his wife. Also, many women had multiple oddly placed scars on their bodies, which I learned from one woman that it was a treatment for being bewitched. Basically, they make small cuts in the skin and then place herbs in the wound in an effort to heal an affliction. Overall it was a successful and eye-opening screening day.

The more time I spend in Uganda, it is glaringly obvious that I am from a VERY fast paced culture. The team for the cervical cancer outreach left 2.5 hours late due to “transportation issues,” and no one seemed the least bit phased as we sat around and waited. When we arrived to the health center and the waiting women, before we could begin our exams, we had to stop for tea and chapatti. Many women that day waited upwards of 5 hours to have a pelvic exam. I don't know a woman in the US who would do that. I guess we can all learn something from these women. Patience is a virtue I know I need to work on.

My weekend was quite lovely. I visited a popular holiday spot called Lake Bunyoni, which means “place of little birds.” I identified 7 new birds, my favorite being the colorful Malachite Kingfisher. Peggy and I only had to travel two hours north to get to this serene lakeside, which is one of the few safe freshwater places to swim here. The lake has 28 small islands, some with a unique history. After hiking up to watch the sunset over the lake, while enjoying a refreshing beer, I was told the story of Punishment Island.

In the 1930’s it was common to banish young woman who had become pregnant out of wedlock to this tiny island. Men who wanted many wives or men who could not afford the dowry for a wife would go to this island where the girls had no choice but to go with the men. Although there is a woman still alive in the village who was a victim of this mistreatment, it is no longer practiced today. What is still practiced, I have come to find out, is the high bride-price for a wife. I will explain more about this in a future blog entry.

The next entry will be about my first week on the female ward. Thank-you for taking the time to read about my experiences.