How different is paediatrics in Uganda compared to the UK?

How different is paediatrics in Uganda compared with the UK?  That question has a very obvious answer.....or does it? 

It’s a question we had asked ourselves prior to coming and one that is actually much more difficult to answer than we first thought.  The differences are obvious.  The lack of doctors (approximately 400 medical students qualify to be doctors each year in Uganda compared with 7,500 in the UK).  We could do something very similar with nursing numbers.  We can talk about the fact a child can receive a maximum of 5 litres of oxygen or that compatible blood isn’t always available.  We could point out that investigations here are a luxury, not a necessity. We could even mention that the incubators and warmed using light bulbs (often broken or in need of replacement) and a complex system of moist napkins are used to control humidity. 

These are a few of the many differences, but there are lots of similarities.  It may seem odd that we could then say that paediatrics in Uganda and the UK are similar, but let us explain.   The most important first: it’s paediatrics.  Yes it’s a statement of fact, but it is important to realise that no matter where in the world you are, when children become unwell they present in the same ways.  Newborn children in Uganda still most commonly have problems with breathing and infection when first born.   Is the treatment different?  No!  Not at all- give them support to help them to breathe and treat the infection.  Of course, the antibiotics you use may differ slightly, but the problems, assessment and treatment are almost identical. 

A view of the main hospital

Moving on from newborns, let’s talk about children.  What are the most common reasons that children present to hospital in the UK?  Gastroenteritis, breathing concerns and fevers.  In Africa?  That’s right- gastroenteritis, breathing concerns and fevers.  How do you manage these conditions – appropriate fluids, oxygen/antibiotics/support and treat the cause of fever (usually antibiotics/antimalarials).  The availability of support differs, but the patients themselves are more alike than they are different.  There are diseases specific to tropical regions, the most prevalent of these being Malaria, but in general the children present with similar symptoms.  The big differences are that the children often present later (distance to nearest health advice) and with co-morbidities, most commonly malnutrition.

So, we have mentioned a few of the similarities of UK and Ugandan paediatrics and it is these underlying principles of paediatrics that, with some adjustment, have allowed us to work in Uganda.  However, we have still had to go back to school and learn tropical medicine. We will talk more in the next blog about the challenges we have faced, from understanding the Ugandan culture to improvising when the equipment we would usually use is not available. 

Happy Easter everyone!

Colin and Jess

How time flies!

Jess and I enjoying a relaxing afternoon

We have already been here 4 weeks.  In that time we have become accustomed to cold showers, washing our clothes by hand and going to the market every other day for our fresh food.  Whilst initially it took a lot of getting used to and we could see a lot of the negatives, time has now allowed us to see the many positives.  It makes a massive difference having food which you know has been picked that day and the price is remarkable!  A weekly vegetable shop for £3- every little helps!  Having restaurants that cater for the western diet (pizza, burgers and chips) has also helped us to have a small taste of home. The extremely friendly attitude of our hosts and the pleasant house in which we are staying has also helped. 

Getting used to the hospital was a challenge. Whilst we were aware of the high childhood mortality, seeing it first hand is something very different. Since starting work properly in Jinja on Monday 4^th March we have worked for many, many days in a row!  At least we don’t have to work nights!  Working has allowed us to understand how the hospital works and how patients are seen and treated.  The special care baby unit is placed at the main hospital and all other paediatric services are at the Children’s Hospital 15 mins walk away. This means that there is limited access to paediatric staff for the special care unit, due to the geographical area the doctors cover.

 Whilst working, we have identified areas which we feel we could help to improve and, following a meeting with Dr Namasopo Sophie (Lead Paediatric Consultant in Jinja), we have agreed on 8 areas we will try to address during our placement.  This has given us a clear plan for the next six months encompassing developing guidelines for common conditions, staff training and audit work, firstly, targeting the Emergency Department and Special Care Unit.

We have also been lucky enough to meet with Sarah Nalule (Project Manager of Health Child) to discuss a possible role we could undertake within their organisation.  We hope to further develop this link, in the hope that we could take the training we are planning for staff at Jinja Regional Referral Hospital and tailor it to other health workers who are working in Community Health Centres in and around Uganda.

White water rafting in Jinja

We have met several people who are working in Uganda for PONT, a project also funded by THET (the same organisation that funds Global Links Scheme).  We hope to meet up to see the work they are doing in Mbale, in the hope it may help us to avoid common pit falls, sharing knowledge and give us inspiration.

All of this has led to us having a very busy first month in Jinja.  In order to relax following our hectic introduction to Uganda, we went rafting this weekend.  Jinja has some of the best white water rafting in the world and it certainly did not disappoint.  It was a full day activity on a beautiful day which left us exhilarated, exhausted and unfortunately a little bit sunburnt! 

We have enjoyed our first month in Uganda, although it hasn’t always been plain sailing.  We are now looking forward to continuing our learning and working toward the goals we have agreed with Dr Sophie...

And of course to discovering all the beauty Uganda has to offer!

The River Nile at night

Colin and Jess.

Trusting local transport

Today (27th February) we undertook our first long distance journey in Uganda.  We travelled from Kampala to Jinja.  It was a 2 1/2 hour journey which was as terrifying as it was beautiful.  Looking forward you saw on-coming traffic, swerving in only to avoid on rushing cars momentarily before swerving back and onto the wrong side of the road.  However turning your eyes 90 degrees you we transported into the most beautiful and lush green surrounding you will ever see.  The trip was beautiful and we arrived safely.

On arrival in Jinja, we had a tour around the hospital which showed us the triage area, emergency department, and wards which were all extremely busy and filled with children who were so sick, they would be receiving the highest possible level of care in the UK.  We were introduced to a friendly and helpful staff and look forward to meeting and working with many others in the next few months.

Colin and Jess

Finally, our OOPE begins...

Arrived at 0100 on 25th February after a flight that was slightly delayed.

We were met at the airport by Noella who works for the Ugandan Paediatric association.  It had been a long journey but finally we were here!

We were taken to our accommodation which was next to Mulago hospital, the national referral hospital of Uganda.

Views over Kampala

Waiting at the accommodation at 0200 was the housekeeper who gave us a very warm welcome and showed us to our room which was extremely clean and came with everything you need (bed, mosquito net, toilet).

The first days- a tour of Kampala.  

Noella was our tour guide and was joined by Juliet, both of who were fantastic guides and showed us some amazing sights and views as well as helping us to negotiate the local market.  We were shown the martyrs shrine and learnt about the history of Uganda and the background to one of Uganda’s public holidays.  Following this we travelled to the cathedrals of Uganda and enjoyed great views across the city.

On day 2 we were shown around Mulago national referral hospital.  The paediatric unit has 60 admissions per day.  It has 6 paediatric wards as well as a outpatients department, a cancer centre and HIV centre.

The acute care unit (ED) is responsible for triaging infants and children according to ETAT and then commencing the necessary immediate management.

At the time of being shown round 4 patients were being treated as emergencies - all of whom had a reduced GCS and were several dehydrated and malnourished, before even considering the diagnosis that had brought them to hospital - it was not expected that any of these children would be admitted to PICU.  ACU had a small lab able to estimate haemoglobin and test for malaria.  The test for malaria could be turned around in 2 minutes!

PICU is a 7 bedded unit situated next to the emergency department that allows intensive observation. No ventilation is available, but bubble CPAP can be used.

I could write for hours on each ward we visited, but I will mention only 2 more.  

Firstly, the malnutrition unit: looks after those children who are severely malnourished.  These children often had single or multiple co-morbidities and were at risk of many infections.  It takes children here 3 months before they are in a position to go home, due to the poor condition of their underlying health. The challenges in fluid management and feeding are huge and it is only with expert care and parental education that so many make a recovery.

Secondly, the respiratory and cardiology ward had children sharing 2 to a cot, with no room between to ensure all children can be close enough to the oxygen supply. Each oxygen cylinder is divided between 4 children, so it is unclear whether any/all are receiving much benefit, particularly because there is no SATs monitoring. Therefore, the need for oxygen is all down to clinical signs.

It was a truly eye opening day. There was a huge amount to see and try to understand that is done so differently. This is only the beginning. In order to ever become useful here, I have a huge amount to learn.

That is the challenge of accepting a placement abroad.

Colin with "tour guides" Noella and Juliet

Colin and Jess

RCPCH Global Links Course

Global Links Course

For all those of you considering working in a developing country but who aren’t sure how to approach getting involved or are not sure what to expect, be sure that the RCPCH global links team will answer your questions and if you do go on placement will provide with you support at every stage. 

This was epitomised by the 9 day course that was arranged for Global Links volunteers prior to going on placement.

The course comprised a day of introduction looking at issues volunteers may have as well as meeting volunteers and doctors from Africa who had come across to spend time in the UK.

Following this was a day looking at Audit and applying this in African countries. The course was well designed and allowed UK doctors to understand to what degree audit was undertaken in Uganda and also how to approach the topic when on placement.  The presence of doctors from Africa was hugely important in this, a theme which was present throughout the course.

On days 3-5 we undertook a ‘Child health in developing countries' course which looked at all aspects of healthcare and culture in developing areas.  The facilitators used various situations to help work through issues in low resource settings and with the help of the doctors from Africa we were able to gain an understanding of the services available and how to approach certain situations.

Days 7-9 concentrated on leadership, management, teaching and service provision.  These sessions looked at generic principles in each of these areas and concentrated on having different ways of teaching.  The service provision day looked at how we could make small changes in order to facilitate change.  Techniques learned from these sessions could be equally applicable in low or high resource settings.

Whilst on this course we also visited the Houses of Parliament to welcome the Minister for Health in Uganda to the UK as part of the Uganda-UK Health Alliance.

This 9 day course was in addition to a 3-day security course we had been sent on to ensure we were aware of our personal security and how to minimise risk to ourselves.

Following completing this we both felt so much more confident about travelling to Africa and also much more aware of potential pitfalls and problems. However, be aware that as much as you can try to prepare for a low-resource environment, each location offered by Global Links has individual challenges so be prepared to be flexible and spend time getting to know your placement hospital before trying to implement changes.

Colin and Jess