Shoulder to Shoulder

This past week I traveled to Concepción, Honduras. I lived there for a year after college and it’s the most rural, hard to get to spot I’ve ever lived. It’s at least three hours to the closest grocery store and that’s when it hasn’t rained and the dirt road is passable. When I came back this week not much had changed. A road paving project has been underway for three years now but still hasn’t made much progess except knock down a bridge and cut down a bunch of trees.

I worked for an organization called Shoulder to Shoulder which has a contract with the Honduran government to provide health care to most of the Department of Intibuca. The clinic in Concepcion is one of several run by this NGO. When I arrived at the clinic the place was practically abandoned. The town hadn’t had running water for over a week so the dentist, most of the doctors, and other staff were gone because they couldn’t clean instruments and provide many of the services they typically do. None the less, dedicated patients waited to see the one doctor on call. While this clinic is basic and a couple of hours away from the nearest hospital it is the site of urgent care for thousands of people living in the surrounding villages. This clinic sees up to ten births each month, care for dog bites and machete wounds, and regular treatment for more common ailments.

With me on this journey was a Nikon microscope. Surviving several flights and the bumpy road to Concepcion I was able to deliver it successfully to this clinic’s lab. A full-time lab technician, Freddy, runs the lab and can do basic blood and urine exams as well as X-rays. Tests such as cervical cancer screening are sent away to a lab in a larger town. This microscope will be used for a nutrition project called MANI 4. It will follow three previous nutrition projects named Improving the Nutrition of Children in Intibuca that provide nutritional supplements to the poorest children in the area and measures their growth and incidence of anemia. To learn more about this project check out their website: http://shouldertoshoulder.org/?page_id=653

Amy Schumer
University of Vermont COM, MS-1

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TME in Zimbabwe

Greetings from Zimbabwe! Adam and I have been in the city of Harare already for over a month. We thank you for your patience awaiting this first blog post!

We are stationed in Parirenyatwa Hospital, a sprawling complex with over 2000 beds that serves as a community hospital for Harare and a referral center for the entire country. There is hope that it would be a fantastic location for UVM students and residents to rotate in the future. As such, we have been doing our best to serve as forerunners and representatives.

Prior to our arrival, we had almost idea of what to expect. Not too long ago, Zimbabwe was one the more prosperous nations in Africa. However, the country’s many woes have been highly publicized in western media over the past decade. In 2008, Zimbabwe was the source of the world’s worst inflation, with prices doubling daily with currency eventually ballooning by a stunning 22 orders of magnitude. In the midst of the economic collapse and the HIV epidemic, Zimbabwe became the site of the world’s lowest life expectancy in a country not in wartime—37 years old in men and 34 in women. At one time, over a quarter of the country’s population was HIV positive (it is now estimated to be around 15%).

Without a reliable source to tell us how much things had improved, we expected the worse. The Zimbabwean immigration website informed us that visitors were required to bring in sufficient funds to survive the length of their stay—which we guessed meant no functioning ATMs. Visa requirements were Byzantine and Adam spent dozens of hours on the phone with the embassy, trying to get a straight answer. Tourist blogs warned that waving with an open palm—the sign of political opposition—was an imprisonable offence.

What we have found, however, is one of the friendliest and most pleasant countries we could imagine—and one that has made great strides forward from the chaos of the 2000’s. We have been welcomed with a smile everywhere we have gone, and never felt unsafe for a moment. In addition, although the country still has overwhelming medical needs, we’ve been surprised at the comprehensiveness of hospital services and robustness of the medical education system.

Adam is in the surgery department and I am in the pediatric department. For me, the experience has been a thought-provoking juxtaposition between familiar medicine alongside huge differences in pathology, culture, and resources.

For example, every morning our team—made of medical students, residents, and an attending pediatrician—go on patient rounds.  The bedside physical exams and teaching are usually superb. I feel right at home with about half of the pathology—bronchiolitis, neonatal sepsis workups, neonatal jaundice, asthma exacerbations, and diabetic ketoacidosis. We get labs and imaging when needed, and usually provide standard-of-care treatments.

Yet it is impossible to ignore the fact that somewhere around half the hospital’s patients are HIV infected. Malaria is on the differential for any febrile illness, and TB for basically any chronic illness. Less than ten years ago, this hospital was the epicenter of one of the largest cholera epidemics in recent history, one of the only nosocomial cholera epidemics ever recorded. Medication shortages, staff shortages, and bed shortages are the norm. And perhaps the only reason things function at all is that it is an up-front, pay-for-service hospital—those who are truly destitute are referred to far more crowded and under-resourced centers.

From my point of view, this mix of familiarity and along with high volume, acuity, and new pathology has served as an ideal transitional learning experience.

It is also an ideal place for additional resources to make an enormous difference. There is a fantastic infrastructure in place here, and the hospital is staffed with dedicated, talented, and experienced medical professionals. Any new medical resource here is immediately utilized to its absolute maximum capacity. For example, when Adam showed up on the surgery wards carrying a copy of a new edition of a surgical question bank he had brought, it attracted the attention of every member of his team. Adam soon decided he had little choice but to donate the text to the department, and within a week dozens of spiral-bound copies of the text had been distributed. One week later, some residents and physicians had already completed the entire book (and pearls from the book quickly were finding their way into clinical practice).

As such, we believe that the University of Zimbabwe and Parirenyatwa Hospital are perfect partner sites for The Microscope Exchange to support and collaborate with. And we are excited report that we have already been able to present a magnificent 5-headed teaching microscope to the University of Zimbabwe College of Health Sciences (UZCHS). We are confident it will get a remarkable new lease on life here that may last for many decades.

UZCHS is the only medical school in Zimbabwe and the source of nearly all of the country’s physicians and nurses—going on to serve a population of almost 15 million. Nearly 200 students matriculate each year at the medical school. The challenges these students undergo on the path to becoming health professionals can be shocking. Students will save every penny they have to purchase new textbook editions—paying sometimes twice the books cost in shipping—just stay abreast of standards of care. From the years of crisis, students tell stories of eating on the 0-0-1 plan (one meal per day), and having no water to wash their hands after dissecting in the anatomy lab. Their educational model is in the strictest British tradition—meaning that what we consider student abuse in the US counts as a complement here. Although we heard Zimbabwe was suffering from enormous brain-drain, we have found that the hospitals are full of residents and new attendings excited to improve their country and grow as physicians.

Most pertinently for our perspective, medical students at UZCHS learn histology and pathology on only a few dozen outdated microscopes. The professors in the UZCHS department are skilled pathologists and microbiologists, but lack the resources to provide the necessary training in diagnostics and pathology for students (even though doctors across the rural areas of the country are expected to perform most microscopy themselves).

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We presented the microscope to the Dean of the Medical School, and between all of the hospital’s clinical departments, he chose medical education as the greatest area of need. The microscope will be utilized by multiple departments around the clock. Most excitingly, its top-of-the-line scope mounted camera will allow projected microscopy for entire lecture halls, effectively creating the capabilities of nearly 200 microscopes.

 

We will be back with some final departing thoughts. We have been having an incredible experience, and want to thank those who have made this trip, and our microscope donation possible, including
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-Pete

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UCI Update

After some missed connections, I have received the news that the lab at UCI has received the 100x oil immersion objective for the 5- headed teaching scope we brought last summer and everything is working well.  Now onto the camera…

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A Microscope to Nepal!

The following post was written by Taylor Weston, a high school senior from Bridgewater, CT who brought a microscope with her to Chitwan, Nepal while participating in global health experience with Projects Abroad:

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Taylor presents the microscope to Binod to be donated to the Chitwan Medical College

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Proud owner of a new microscope!

 

 

 

 

 

 

 

I left for Nepal on December 7th out of JFK airport with the microscope in five pieces securely packed in my suitcase. I had a four-hour layover in Dubai then continued from there to land in Kathmandu on December 8th around 6pm. A member from the organization I was working with, Projects Abroad, met me at the airport and drove me back to the hotel in Kathmandu. We spent the night there and in the morning boarded two buses to start the 5 and a half hour drive to Bharatpur, a district of Chitwan, where were would be staying for the next week. Once there I realized how different Bharatpur was from the more touristy area of Kathmandu. The roads weren’t paved; mostly all dirt and the shops and houses were more shacks than buildings. All the signs were now in Nepali with hardly any in English. We stayed at the Hotel Global, which was placed in good distances from the hospitals we’d be working and shadowing at. All 19 of the volunteers were split into groups of 3 or 4 and then given a schedule showing when we’d be at which hospital. During my time there I was able to visit the Chitwan Community Hospital, the Chitwan Eye Hospital, the family planning clinic, and an outpost hospital located in a very rural part of Chitwan 45 minutes away from the hotel. On our first day we went to the Community Hospital. We shadowed the internal medicine doctor, who talked to us about his training in becoming a doctor and how they all need to be proficient in English because all of the medical books are in English. He then brought us around with him as he visited with patients, translating what they were saying and what he was doing. We then went into the labs to look around. This is where some culture shock hit me. There are no sanitation measures taken in these labs. Blood samples are strewn all over the counters, no gloves are used, and there is a pink hairdryer being used as a heat source. There was only one microscope in this lab, which looked like a lower grade than the one I had brought. When we went back to the hotel that night, I went and talked to Binod, a Nepali local who works hand in hand with Projects Abroad, if it would be beneficial if I donated my microscope to the community hospital. Binod later decided that I should instead donate it to the largest hospital in Chitwan, The Chitwan Medical College, instead. This was a problem though because I was leaving before the director of the hospital would return from a conference in Kathmandu. Binod told me that he’d be willing to take it over himself and let them know where and who donated it. As of now the microscope is being used in the labs at the Chitwan Medical College and I am still waiting of the pictures of it actually in the lab. This was a life changing experience and words cannot describe how grateful I was to be able to make sure a significant donation that will be able to improve the lives of many Nepalese people.

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Last Day!

IMG_0272 P1010226I’m writing on the afternoon of our final day here at the Uganda Cancer Institute.  As is often the case, the end really came up quickly.  It’s been a bit of a scramble over the past couple days to try to finish all the projects we had started, tie up various loose ends, and leave everything in order for the next batch of students in the fall.  But it’s beginning to look like we’re going to get everything squared away and we need to start facing up to the fact that we are actually going to be leaving tomorrow!

Some microscope updates: When Dr. Sadigh came last week, he was able to bring along two more microscopes that were donated by some of his colleagues in Connecticut.  Since we had already been working with the lab here at UCI, we decided to see if we could find any other places that would benefit from an added microscope to their lab.  I was connected to Mr. Ponsiano Ayiko, the superindendent of labs at Mulago Hospital, the main hospital for Kampala and most of Uganda.  After a couple of meetings we were able to locate a home for one of the scopes within Mulago’s main Hematology Lab.  They had been working with only one microscope to serve the hematology needs of entire six-story, 1,500 bed hospital.  In an area of the world with endemic malaria, a disease diagnosed by looking at a sample of blood under a microscope, that certainly qualifies as under-resourced.  The microscope is going to good use and the staff of the Hematology Lab were excited about the prospect of hosting UVM students in the future.

We also talked with Dr. Abraham here at UCI who is in charge of outreach programs to the UCI satellite offices in Arua and Mbarara.  Currently, all cancer cases in the country are referred to the UCI campus in Kampala.  In the next few years, however, UCI will be trying to build their satellite offices to provide more comprehensive cancer services throughout the country. The hope being that with more convenient locations, people will be more likely to seek and adhere to treatment.  At the moment, the office in Arua has a trained pathologist on staff but no lab equipment.  The microscope will be a huge step in the right direction.  Soon they will hopefully be able to diagnose and monitor cancers at their remote locations.  And again, Abraham had a lot enthusiasm for taking future UVM students on the 5 hour drive to across the country to Arua so they could learn how UCI is trying to provide services to those who would have no chance otherwise.

Other than that, it has been a lot of saying good bye.  We will definitely miss this place.  Absolutely everyone has been friendly and helpful and we have learned an incredible amount.  I hope we have been able to contribute a little in return and laid some groundwork for a long future collaboration between UCI, UVM and the Microscope Exchange.  I’m running out of time right now, but I will try to post a final wrap-up and reflection on our experience when I return to the US in couple days.

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Small Steps

We lost David this week as he returned to his practice in Connecticut. It’s been great to work with him and his excellent guidance left us confident as Karl and I presented our research at the UCI Research in Progress meeting Wednesday morning. Luckily in David’s place we gained Dr. Sadigh and his daughter Mitra. Dr. Sadigh has been an equally valuable resource on the wards and it’s been exciting to talk with him about the potential future of the collaboration between UVM and UCI.

We hit some snags setting up the camera on the 5-headed teaching scope. Sometime in the next couple days, I’ll need to venture into downtown Kampala in search of the cables necessary to connect the camera to the computer they have in the lab.  In the meantime, Karl discovered that we were able to connect the camera to a projector, which at least gave us a sense of the quality of images the camera can produce.  I proudly present below the first images transmitted from the teaching microscope camera at UCI!  It may be hard to tell from the photos but the images are quite crisp and I think it bodes well for being able to capture images of high enough quality to share between departments.

Also today we had the opportunity to tour the new Uganda Cancer Institute building set to open in the next one or two years.  It is a six story, 70-bed facility perched on a hill with views across old Kampala.  It has it’s own operating rooms, pathology labs, and various wards. I tired to take some pictures of the pathology lab and future home of the donated microscopes, but they are located in the basement and presently very dark.  It is exciting to get a glimpse into UCI’s future and to think about how TME is playing a critical role in that development.

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Presenting at Research in Progress meeting

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Visiting the new UCI building

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The first images from the teaching scope projected onto the wall!

 

 

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Connecting beyond UCI

A slow week for TME here at the Uganda Cancer Institute.  We are waiting on a couple parts that will hopefully enable the telepathology capabilities of the 5-headed teaching scope we provided to the UCI lab.  Our big project in the upcoming week will be to push to get that operational before we head back to Vermont.

On Monday, we were able to visit St. Stephen’s Hospital, a community health center just down the road from where we are staying in Mpererwe.  The hospital has 40 beds and serves about 80,000 people.  The building is divided into male, female, pediatric, and antenatal wards, 4 private patient rooms, an operating theater, a lab, and out patient facilities.  During our time we got to spend time in each as well as ride along with the ambulatory team as they made outreach visits to homes in the community.  It was a great way to gain some appreciation for the different levels of health care in Uganda.

I took advantage of the opportunity to talk to the lab techs at St. Stephen’s as they gave us a tutorial on microscopically diagnosing malaria.  Though they have a bench top microscope that suits their small space, we discussed other possible needs they may have as they try to build a more comprehensive diagnostic center.  Again this will be great site for students to get some experience at in the future and hopefully, we will be able to send future students with something to give back as well.

Other than that Karl and I have been rounding on patients, moving along with the data entry on our research project, and enjoying tea and meals with the Luboga’s.  Hard to believe our time is over halfway gone already!

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A day in the life at UCI

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Navigating the streets of Kampala
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Dinner with Eunice, Dr. Chia, Dr. Okuku, and Jennifer
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Karl breaking it down to the sound of the ndugu

After presenting the lab with the microscopes on Tuesday, things have slowed down a little on that front and Karl and I have been able to direct our energies towards other aspects of our rotation.  It’s been a week and a half since our arrival and we have started to get into the swing of our routine here.

On a typical day, Dr. Okuku comes by the Luboga residence around 7:30 to bring Karl, David, Eunice, and myself, to the Cancer Institute.  Our first order of business is to attend the daily morning meetings held by the UCI staff.  The purpose of the conference is different each day and so far we have attended three. Tuesday is the Tumor Board during which physicians from different departments are able to collaborate and develop treatment plans for the week’s difficult cases. Wednesday is Research in Progress during which a member of the UCI staff presents either an aspect of their own current research or a relevant recent publication.  And Friday is Morbidity and Mortality, in which the staff meets to review any deaths or difficult cases from the week and examines how care could be improved.  It looks like Karl and I will have an opportunity to present at a couple of these conferences in the next couple weeks.

After the morning conference, we work with Dr. Okuku and Dr. Chia as they round on patients in the Solid Tumor Clinic or meet with patients in the outpatient clinic.  These sessions are incredibly educational.  Both Dr. Okuku and Dr. Chia are eager to teach and have ample patience for the fact that Karl and I only have the knowledge and experience of one year of medical school to draw on.  Without the necessary resources or adequate access to health education or any form of primary care, many patients don’t arrive at UCI until their cancers have progressed well beyond anything you would typically see in the United States.  These patients and their supportive relatives fill the 24 beds of the Solid Tumor Clinic as the staff tries to best manage their treatment. There is little space or privacy between beds and traveling through the ward is a trip through a maze of cots, medical equipment, and people.  It is a place where the realities of mortality are never far away and at times can be difficult to face.  After being here a week, I have begun to appreciate the strength of the patients to be able to bear their diseases, especially in such a resource-limited setting, and the strength of the doctors and nurses who deal with the tough realities of disease and treatment every day.  This is my first experience on the wards as a medical student and it really feels like I have jumped into the deep end.

After lunch, we leave Dr. Okuku to continue meeting with patients and move to work on a couple of projects that will hopefully benefit UCI after our departure.  Under Dr. Chia’s guidance, we have begun to write treatment guidelines for the most common cancers seen in the Solid Tumor Clinic.  These guidelines will serve as quick references for the medical officers (junior clinicians) that manage treatment on the ward.  Also, this week, we have started data entry for a larger research project which will examine patterns the utilization of care and course of treatment for that presented to the STC in 2012.  For now it is just matter of extracting and organizing the necessary information from hundreds of charts, but hopefully once completed we will be able to use our data to answer such questions as who accesses medical care at UCI? How does the time course of diagnosis and treatment affect outcomes? And what treatments provide the best outcomes for different types of cancer?

By the evenings or weekends, we have been pretty beat, but we have managed to make it out to see some parts of the country beyond the hospital walls.  In the evenings when we don’t immediately return to the Luboga residence for a home-cooked meal, we have been able to explore the culinary options of Kampala (Indian, Japanese, and Ethiopian so far).  And we have been able to take advantage of some other attractions.  Last weekend, Karl got to face some of his deepest fears as Dr. Okuku and his wife brought us to a snake park where they kept over a dozen species of snake from around Uganda (along with a handful of turtles, chameleons, and small mammals).  On Wednesday, Karl and I made it to Ndere Cultural Center for a show of traditional Uganda dancing. And this weekend we are traveling to Murchison Falls National Park in Western Uganda to take in some of the country’s natural beauty.  Hopefully we will come back awed, rested and ready to start in on a new week at UCI!

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Microscoooopes, Assemble!

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All the bags reunited at last!

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Karl starts to unwrap the parts

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Lab Tech David looks on as Dr. Chia makes some adjustments

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Lab Tech John leads everyone through the first slide

Today was an exciting day! Yesterday, after enduring the same pair of socks for almost an entire week, Karl was finally able to track down and coordinate delivery of his missing bag.  Along with it came the remaining pieces of the 80lb, five-headed teaching microscope that consumed most of the space in our checked luggage.  Which meant, this morning, after the Tuesday morning tumor board, during which the oncologists of UCI assemble to discuss treatment of the week’s particularly difficult cases, we were able to wheel our suitcases of microscopy equipment over to the lab to assemble them in their new home at the Uganda Cancer Institute.

Housed in one of the more spacious buildings on the UCI campus, the diagnostic lab is already quite formidable.  They employ several full-time lab technicians and are able to perform basic blood tests, diagnose blood and fecal borne illnesses, as well as identify specific tumor markers that indicate the most effective courses of treatment.  But considering the size of the lab and the number of patients it serves, they are under-resourced with only one small benchtop microscope.  Hopefully, with the additional benchtop microscope and the five-headed teaching microscope we were able to bring along, they will have not only the necessary resources to meet demand, but also, with the teaching scope, a greater ability to educate and form consensus on microscopy findings, and, with its mounted camera, the ability to upload images from the scope and share them for second opinions from labs around the world.

It was clear from as soon as we got there that the microscopes have a great new home.  The lab technicians John, Fred, and David were eager to get involved with the new equipment. The teaching scope is fairly monstrous. On top of the main body sits the casing of the digital camera and from each side project two-foot long arms each ending in two pairs of additional eyepieces.  But with the lab techs’ help we were able to quickly get everything assembled.  When we realized that the power outlets in Uganda were designed to put out a voltage nearly twice what the microscopes could handle, Tadeo, the UCI biomedical engineer were able to track down the proper converter and everything was up and running within an hour.  It was great to get the first slide in focus and see a person at each of the five pairs of eyepieces exploring what the microscope could do.

The microscopes will hopefully become part of a brand new independent pathology lab at UCI.  They have recently hired a Ugandan pathologist who is working in Rwanda to come back to Kampala and start the new department.  It’s exciting to imagine a time in the very near future when the laboratory at UCI is able view a biopsy from a cancer patient in Kampala, make a diagnosis through a collaboration of the local team, then ask for a second opinion from a supporting pathologist at a hospital in the United States!

Still haven’t had a chance to try to upload pictures, but Karl took advantage of an opportunity to express his artistic side and took some great shots of everyone working together to assemble all the equipment and hopefully we can get those up soon after we get back.

For now, it’s the end of a long day and I have to get to bed.

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Travel and Introduction to UCI

After a full 24 hours of travel, Karl and I arrived yesterday at Entebbe International Airport outside Kampala, Uganda. All my luggage, including two full suitcases of microscope equipment arrived with the plane, but Karl continued his role as perennial wrench in the works, somehow managing to have one of his bags, which contained an arm of the teaching scope, left on the ground at JFK. Hopefully it will make the next connecting flight and all clothes and equipment will be here sometime tomorrow.

We were greeted by Edward and Gonza, friends of our host Professor Sam Lubogo, who graciously awaited our late flight and delivered us safely to our living quarters for the next four weeks. As soon as we left the airport, I began to encounter the signs that reminded me so strongly of my last time in East Africa. First, the smells–the smoke wafting from the enumerable cooking fires and settling sweetly on the calm and surprisingly cool Ugandan night air. Then, the sights–the red dirt roads; the people, commuting on foot, appearing in the headlights and disappearing back into darkness as we thundered past; the boda-boda motorcycles sputtering up hills and bullied to the roads margins by the lights and horns of passing traffic; and, as we neared Kampala, small streetside stands cooking late-nights meals for the masses of people finishing their day’s work at near midnight. Even in the dead of night, everything about this city exudes movement and energy and life.

As we are staying in extra rooms adjoining Professor Lubogo’s home, it is not surprising that our accommodations are amazingly homelike–comfortable beds, a desk with a vase of flowers, hot showers, and nightly family dinners–it is easy to forget we have traveled so far.

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Walking into the courtyard of UCI

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Outside the rooms at Dr. Luboga’s

Today we awoke to a hot breakfast and met our colleagues, Dr. David Chia and his wife Eunice from Connecticut, both staying at Prof. Luboga’s as well, and Dr. Fred Okuku, an oncologist at the Uganda Cancer Institute. We drove into Kampala and up the hillside upon which perches the sprawling compound of Mulago Hospital. Near the top of the hill, in the shadow of the unfinished concrete three-story future oncology ward, sits a collection of a dozen buildings that comprise the Uganda Cancer Institute.

Dr. Okuku quickly oriented us to the facilities. Patients and families that have traveled from as far away as Burundi and Southern Sudan occupy the yards of the UCI. They come on their assigned day to wait to be seen by a team of doctors as outpatients or are admitted into the 40-bed inpatient ward, which houses many cases of Burkitt’s lymphoma, a childhood malignancy rarely seen in the US. He showed us the lab space that will be the future home of the five-headed teaching and smaller benchtop microscope that we brought with us and briefly introduced us to the laboratory technicians. I look forward to spending more time with them in the next few days when we have a chance to assemble the microscopes and explore what the added capabilities will mean for diagnoses, treatment and education.

For the rest of the morning we were with Dr. Okuku and Dr. Chia as they met with patients back for their one-month or three-month check-ups. In addition to being a kind and exceedingly knowledgeable doctor, Dr. Okuku is the consummate educator and I look forward to working with him over the next few weeks. It is evident that anything we may have brought will be paid back at least a hundred-fold with the experience and knowledge of the doctors here.

The skies shine over Mulago and every doctor greeted us with an equally sunny disposition, but it is apparent that there is great need. The 40 beds and handful of doctors at UCI are responsible for much of the cancer burden of a region that extends beyond the borders of Uganda and a brief discussion with a Ugandan medical student led to an estimate that every year medical schools in Uganda graduate about 600 doctors who then join ranks to serve nearly 36,000,000 Ugandan citizens. And personnel shortages are just one strand of a much broader web.

I will try to post again as we begin to set up some of the microscopy equipment. Not sure if we will be able to upload pictures until our return to the US.

We are just at the beginning and are very much looking forward to the rest of our time here at the Uganda Cancer Institute. It’s already apparent that the people here will make for great partners for the Microscope Exchange and for the UVM College of Medicine. I only hope that we can contribute a fraction to them what they will undoubtedly contribute to us.

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