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Feb 12th 2017

Visiting Kambuga Hospital in Western Uganda

Visiting Kambuga Hospital in Western Uganda

Last week I visited an emerging surgical program at Baraka Hospital in the Maasai Mara region of Kenya. I described a fundamentally impressive project, showing what potentially can be done in a resource limited country when clinical services are implemented with independent and reliable funding, administrative expertise and a measured and thoughtful plan.  What Baraka may evolve into as its clinical scope (and cost) significantly increases will be interesting to study. I suspect some further integration with the Kenyan public healthcare system will be necessary.   That will likely create some challenges.  This past week I spent some time in the Kanungu district in Uganda.  Situated in southwestern Uganda, in one of the most rural and remote parts of the country, the visit refocused for me the extreme challenges of delivering medical and surgical care within a public health system in a low income country. 

 

 

Kambuga hospital is a busy district hospital providing primary care services to about 250,000 people in this region of the country. Most live in a rural setting.  Many of the challenges that I witnessed in Malawi last year were further magnified here.  Obtaining a hemoglobin was easy enough but other simple biochemical tests such as creatinine, a measure of kidney function proved to be a bigger challenge. Ultrasound facilities (a basic tool for diagnosing urological and other issues) were not available on site. Electricity was not reliable, requiring someone to manually start the generator when needed and reliable running water remains a constant challenge.

 

 

 

  

 

 

 

I did spend some time seeing patients and performing surgery. The one thing that is clear when travelling to this part of the world is that despite the enormous challenges in place, the medical staff that I always encounter is supremely dedicated, very bright and committed to trying to learn and do the best that they can for their patients.  It is a reassuringly common trait shared by all healthcare providers around the world.   I met Dr. Hope Mulinga Kibansha.  She is a medical doctor, who after graduating from medical school in Uganda in 2008, worked in primary care for two years and then completed the three-year masters of medicine designation (MMED) in general surgery in 2014. She is now enrolled in a three-year program in the capital city of Kampala that eventually will give her urology certification within the College of Surgeons of East, Central and Southern Africa (COSECSA).   She currently splits her time between that formal training and running services at this hospital, effectively commuting on a bi-monthly cycle between a full time job here and her training in Kampala.  As the most senior doctor at Kambuga, Dr Hope also effectively serves as the hospital's lead administrator or CEO as well as chief of staff, overseeing the modest budget, quality control and managing the entire medical and nursing staff.  Of course she also functions as the only surgeon on site although she has trained the two medical primary care doctors to perform Cesarean Section.  She works incredibly hard in this challenging environment with a certain nobility and admirable grace.

 

  

 

In OR #1

The Kambuga Hospital Surgical Team                                          

                                                                                                                 

It was with her request to bring a urologist that I came along with the Medcan Naweza team for this second week.  Over the last four years, Naweza has successfully developed a chronic disease management and outreach program in two rural settings in Kenya.  I met Dr. Michael Hawkes, a brilliant paediatrician and infectious disease specialist from Edmonton who has worked extensively in Uganda for many years and has an existing research presence in Kambuga.   Building on its Kenyan experience, Naweza aimed to apply its learnings into another resource-poor setting, one that in this instance includes a public hospital.  A series of pieces on the Naweza experience over the years can be found here.

 

 

 The Medcan Naweza team February 2017

 

 

I worked in the operating room for two full days and did extensive ward rounds, preoperative urological assessment and teaching.  The latter focused on prostate care and once again the broader themes of surgical safety.  As you can see, the operating room is modest and in fact “OR #1” and “OR #2” are only separated by a divider. I did prostate surgery as well as some simple but much-needed paediatric urological surgery.  As my experience of working in these resource-challenged environments evolves, so does a realization that the greater opportunity is not just to perform surgical cases with the local doctors but to attempt to leave a sustainable, locally-driven program in place.  It is not easy.  Building surgical capacity requires a commitment to safe surgical practice, nursing and anaesthesia training as well as surgical expertise.    

 

 

 

Nevertheless, there are common themes that I have seen both in Malawi and Kenya that I focused on in Uganda. I think as much as anything, a greater support around providing guidance to develop commonly accepted surgical processes would prove invaluable. In North America we often complain about the extent of healthcare administration but in Uganda, Malawi and elsewhere the need for at least some solid, process driven, non-medical leadership is glaringly obvious.  My efforts to introduce surgical safety themes at the beginning of my visit, including appropriate preoperative assessment and the surgical checklist were received with great interest by the staff.  However, these systemic changes will need time and at least some administrative leadership to tie together.  Providing for a process around proper intraoperative instrument and sponge counts seems equally obvious, requiring little resource but is not readily performed. A left behind sponge from surgery should be a never-event.  Of course, safety is also compromised by the constant attempts to save and endure in an environment where basic supplies such as gloves, water, endotracheal (breathing) tubes and modest surgical equipment are very limited.  Governmental bureaucracy, limited in funding, poorly managed and prone to corruption, adds to the problem.   I found in the medical staff at Kambuga a tremendous desire and willingness to adopt these basic principles but limited by a fatigue in navigating the sheer magnitude of their day-to-day challenges. 

 

I left Uganda having had the opportunity to meet new colleagues and learn. Indeed, meeting a female surgeon in this part of the world, particularly someone who will eventually perform urology, is particularly inspiring. Dr. Hope and her colleagues embody a commitment to patient care that remains unwavering, even if the challenges are significant.   Watching her and others work in this environment is quite motivating and I think also helps to make me a better, more tolerant clinician.   Despite our own real and perceived healthcare system challenges, we are very fortunate to live and work in Canada.

 

With Michael Hawkes at the end of the visit.  Exhausted

 

Ultimately our role I think is to look for sustainable solutions to surgical care in the developing world.   Building on my experiences in Malawi and now both Kenya and Uganda I will be developing a plan that will focus on surgical and anaesthetic training, staff education and building capacity in a resource-limited country.   Please look for that over the next few months. 

 

Finally, the University of Toronto Department of Surgery is holding its second annual symposium on the challenges of global surgery on February 17.  I look forward to much thoughtful debate

 

 

 

 

Rajiv

 

 

 

 

 

Comments

Posted: February 12, 2017

By: Dr Mike Bentley-Taylor

Very proud of you Rajiv
The challenges of providing good medical care in most of the world is indeed difficult.
We in North America just don't appreciate how fortunate we are.
Mike

Posted: February 12, 2017

By: Yegappan Suppiah

It's really pleasing to see a wholistic approach being taken towards building a sustainable model of care!

Best of luck and I hope you are well!

Yegappan

Posted: February 12, 2017

By: Nick Leyland

I am proud to know you Rajiv and I support your efforts to improve global health!
All the best,
Nick

Posted: February 13, 2017

By: Tom Little

As busy as you are it is so important to give these African nations a helping hand to improve their abilities to do more for themselves. Well done and a great example for others to follow.

Posted: February 13, 2017

By: Mike Hayes

Congratulations yet again Rajiv. At a time when politicians in certain regions of the world seem to be working hard to avoid helping those in the greatest need...you an your team step in to show how the gift of giving back is very much alive and well. Thanks for sharing. Hope you can get some much needed rest.

Posted: February 13, 2017

By: Mark Nykoluk

A truly inspiring story Dr. Singal - thank you for all you've done for me and my family, and for what you are doing with others on this planet! Amazing!!!

Posted: February 14, 2017

By: Charlie Pielsticker

Really enjoyed your stories and can only imagine how much more there is behind these stories.

Many thanks for taking your time and expertise to others in remote parts of the world---Change is certainly required but unfortunately will take much time .


Look forward to more insights and stories.

Posted: February 15, 2017

By: Alan Magnacca

Thank you for putting me on your blog. No question what you saw and what you did is fantastic - congratulations. I see you refer to the Medcan team.
Is this something that Sean has initiated? Or ?
Your comment about need for process and admin is almost as important . I am thinking out loud as to how that may be tackled in someway.
Be back to you as I obviously need a lot more understanding of the issues etc.

Posted: February 19, 2017

By: Angela Tracogna

Hi Rajiv
Glad you are home.
I read your post, and always surprised to the degree that many parts of the world do not have consistent access to clean water, power etc. What a challenge for surgical health care providers there. You are correct, that though our healthcare system is not perfect, we should still be extremely grateful for all we have.
Get some rest. Talk soon.

Posted: February 19, 2017

By: Doug Farley

Hi RS, welcome back! Can appreciate that you're more than a little tired. Surprised not sick also when I reviewed those photo's. Great initiative and equally great work - sacrifice. I'm not sure what I know about medicine but I know a little more about finance, and Uganda's are dirt poor. Characteristic of sub Saharan Africa. Entire Federal gov't revenues appear to be $3B, which means it just over twice as large as Sickkids. And despite borrowing rates of 23%, the currency is extremely weak. So a tough environment to install Western medicine, and as you said, needs to be a locally trained solution. Parachute ones won't solve the issues. Thanks! Cheers and ciao Doug

Posted: March 26, 2017

By: Robert Eisenberg

Amazing program. Resembles Save a Child's Heart in many ways. Such a big bang for the buck, such great need, such great opportunity. Thanks for sharing and for your humanitarian efforts. How can we help?

Posted: July 13, 2017

By: Frank Ahimbisibwe

This is my home area. Growing up here in the 80's, Kambuga hospital was not only a place to visit when one was sick but even for leisure because it was an embodiment of first class infrastructure. Staff quarters, hospital rooms and beds, walkways, tarmac, compound, OPD, maternity and everything about it was just perfect. When I visited recently on my doctoral research (Public health) it was a shadow of the past. I dont know who to blame. On a good note, I had my SMC done there successfully by a visiting NGO team

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