Photo Overview of Uganda

This selection of photos is from my whole time in Uganda:

https://picasaweb.google.com/sleely/UgandaTour?authuser=0&authkey=Gv1sRgCMS6nYnnqeK-Yg&feat=directlink

Shira & Mira in the field (photos at the end)

Patients slowly file along the dusty road, past the water pump, into the shade of a single huge tree in the middle of the health center. Rows of wooden benches are crowded into the tree’s shadow, and a scale for babies hangs from a branch. Some patients arrive riding unpainted bicycles or sitting on the padded, tassel-ringed passenger seats mounted over the rear wheels of bicycles or motorcycles, the women sitting side-saddle with infants in their arms or swathed to their backs. They are perhaps 90% women, most with a young child, wearing dresses that are a cacophony of mismatched color-swirled fabrics decorated with repeated patterns of teardrops, leaves, umbrellas. They sit tall and silent, packed so closely they are touching. Sometimes one hands her baby to the man or woman beside her for a few moments; I wonder if they've met before.

The shade-tree is the center of a compound housing a dozen buildings, each painted a pale, solid color with open windows and a concrete stoop. There are staff quarters and latrines for those who stay onsite, in-patient wards lined with twin beds for general patients, women, maternity and TB, a laboratory equipped with microscopes, freezers, and sometimes power, and clinics for out-patient treatment, ante-natal care, children, and HIV patients. The few staff who have arrived early sit in back offices preparing for the day’s work while the patient numbers slowly increase – five, fifteen, fifty.

Each patient carries a worn school-child’s exercise book, of various shapes and bindings. As they file in, each sets the exercise book on a table in front of the closest building, then takes a seat.  There is no clock, but the minutes tick by. No one asks questions or expresses impatience; there is no rush. One woman is lifted from the back of a motorcycle and laid on blankets on the ground; then everyone returns to their seats, quietly. A man shows his infant her own face in our car’s sideview mirror. A few set blankets in the shade of other buildings and trees, perhaps eating roasted corn wrapped in paper sold from the roadside just outside the health center. No one is drinking water, though the dusty heat is slowly increasing.

The scene is typical at 8am at remote health centers across the country. Around 9am volunteers and staff arrive at the tables and begin sifting through the notebooks is order, calling patients one by one to learn their purpose, take their weight, height and arm circumference, and send them to the appropriate clinician. Patients travel up to 30 or 40km to reach the clinic, leaving behind dependents, chores, and income generation for most of the day. These are government health facilities, and most services are free of charge, supported by international donations – for HIV, at least, primarily funded by the US.

Some of the sick patients are checked for HIV, using quick tests easily administered by a volunteer or nurse. In the US, anyone HIV-positive is treated with anti-retroviral therapy (ART), but in countries like Uganda the costs seem prohibitive. In the US, laboratories check the amount of virus in each patient’s blood, but again this is not feasible in Uganda. Patients are therefore tested to count a type of immune cell affected by the virus; if the count is below a threshold or if the patient is very ill, they are provided with ART; if the count is above the threshold they are given antibiotics to boost their immune system. Re-counts of immune cells are supposed to be repeated twice annually to monitor patient health and determine ART effectiveness.

Analyzers for checking immune cells (CD4) were traditionally designed for the first world – for research and organ transplants – and they require first-world infrastructure and skill. Blood has to be prepared and sometimes refrigerated; machines require uninterrupted power and temperature and humidity control. Lab technicians must be trained to prepare samples, as well as computer literate. In Uganda such infrastructure is available only in limited settings, and so patients or blood samples must be sent long distances to central laboratories for testing. Patients lack the means for distant transport, and so systems have developed whereby blood samples are collected on specified days from each health center, transported in cold storage on motorcycles to hospitals, and processed. Weeks or months later, result documentation reaches the health centers to be sorted into patient records, and on their next visit patients can then be provided with treatment if qualifying. In the meantime, though, some patients have returned to find no result available. Other patients have fallen ill or died. Some patients never return. Projects and policies have sprouted across the continent to address issues of blood collection and transport, testing, monitoring patients, tracking data, etc. One of my projects is development of a reliable national sample and results transport network.

Today, though, there is a rather new solution. One trend in diagnostic technology is toward portable battery-powered analyzers requiring no climate control and limited operating skill. Uganda is piloting such analyzers, and this is one of my projects. With this technology patients could potentially arrive one morning at the health center, discover they are HIV positive, be tested to determine whether they qualify for treatment, and receive counseling and medication before departing. Successful initiation of treatment is not only crucial to the health of one patient and the situation of their dependents, but recent studies have proven the long-held belief that appropriate ART treatment reduces virus transmission to others.

The new technology is so reliable and easy to use that the greatest challenges are with system integration – national policies, daily procedures, staffing levels and record-keeping have developed based on the limitations of conventional technology, but to take advantage of the benefits of the new technology trends, the system has to change. Traditionally HIV treatment was concentrated on specific weekdays to collect batches of samples to send for testing and to free staff for other tasks on other days. However, ill patients arrive daily and testing and treating them as they are discovered requires staff, records and facilities to be available to these patients every day. Results have to move from the analyzer operator to the clinician and patient within the facility, but this was previously not part of anyone’s job. These are small changes, but there are many of them, and they are crucial.

Designing and testing this system is my goal for the next few months, and a graduate student (Mira) has joined our team for the summer to focus on this project. Together we visited health centers to observe and understand their practices and culture, and now we are designing not only a system, but also the tools and training program to implement it nationally. Then we will try the system at a few centers, adapt our plans as we learn, and collect data to demonstrate that – hopefully – the system is effective. The intention is that this system is used at hundreds of sites across the nation – perhaps influencing system design in other nations – as increasing numbers of such technology are deployed across the developing world and more and more companies release competing products to the market.

Click here to see more photos at 2 health facilities