Читать книгу The Patient - Olive Kobusingye - Страница 13
ОглавлениеDo not forget, through all the years
Those who have gone through the gates of Makerere
Give them the pride, Give them the joy
Oh! To remember, the gates of Makerere
The first weeks of medical school went by in a flash. Everything was new. While the students in other faculties carried on partying as was the custom at the beginning of every academic year, the medical students plunged into serious study. Every morning the medics walked from Makerere main campus across the valley to Mulago, mostly through Katanga valley. The cadaver room was the center of the new class. Small groups of five or six students were each assigned a cadaver. The introductory lecture in Anatomy was on the breast, but nobody called it that. Here in Anatomy it was the mammary gland. The arm, also called the upper limb, was more appropriately called the brachium. It was here that the seeds of complete language alteration were sowed, so that in future the doctors would think that pedal edema communicated better than swelling of the feet, and that epistaxis was clearer than nasal bleeding. It was here in the cadaver room that fears were overcome, and that lifelong relationships developed. There was something comforting about discovering that the smartest sounding guys did not necessarily have the steadiest hands at dissection, and that some unassuming students with thick rural accents had incredible capacity to memorize endless random facts about the human body. In a few weeks, everyone was comfortable in the company of the cadavers, which were slowly but surely being taken apart layer by chloroform infused layer. Prof. Sebuwufu said these were the students’ first patients, and they were to take good care of them. Dr. A. Galloway, the first head of the Department of Anatomy, would have been impressed.
Some organs were described as being pear or almond shaped although there was not one pear tree in all of Uganda, and God help the student who dared to liken them to an avocado, a fruit the students and their teachers saw and ate on a regular basis. The normal ovary was said to be almond shaped. The students had never seen an almond, and the ovaries in the cadavers were anything but normal, so their imagination of what an almond looked like would have to do. In the clinical years there would be other curiosities, such as the cobblestone appearance of a trachoma eye membrane. No student had seen real life cobblestones, and perhaps neither had some of their teachers, but cobblestone it would be. Then there was the classic anchovy sauce appearance of an amoebic liver abscess. For goodness’ sake, what was an anchovy? The descriptions tended to obscure rather than illuminate. The height of obscurity was perhaps the ‘café au lait’ spots, which would have been familiar had someone told the students that the exotic sounding phrase was French for milky coffee. Students that had not been within thousands of miles of any snow were taught how to recognize a diseased lung by a ‘snow storm’ appearance on the radiograph. The endless hours in the cadaver room, the physiology lab, and the wards that the students would graduate to after two years of basic sciences, ensured that their new language took firm root. Karungi, by nature generously endowed with a curiosity for words and languages, soaked up – or rather, imbibed – this new language like a sponge.
‘Science should speak the language of the common people’ Rudolf Karl Ludwig Virchow, nineteenth-century German physician (1821-1902).
***
The post-mortem room – PM room – was cooler than the rest of the hospital, being adjacent to the refrigerators that contained what the Pathology professor called the teachers. “The dead teach us many things. They make us wise if we take the time to study them. They come here carrying many secrets. Every dead body is a wealth of wisdom. So – open them up with respect. Look. Feel. Here in this room the dead speak. This is the House of Wisdom.” More often than not Prof. Wamukota said this while shaking the ash off the end of a cigarette. He probably used one matchstick a day, because he always lit the next cigarette off the butt of the one he was snuffing out. It did not matter that he saw many deaths from tobacco related diseases. He always said it was a pity for one to die with clean lungs. “Look! Clean as can be. This girl never smoked a cigarette, and very likely never cooked on a charcoal stove either. No trace of smoke. But what use are her lungs now?” Prof. Wamukota called every female a girl, no matter how old they were. “This girl of seventy five years came to the hospital with a cough, night fevers, and weight loss…” It always drew chuckles, but one had to be careful to not be seen laughing, because then one became the target for his caustic humor and ridicule. “Yes, you Nsereko. Come and tell us what you see here. Is that a normal liver?” A bony black forefinger tapped ash off the end of the almost finished cigarette, and brought it back to equally black lips, eyes barely open through the cloud of smoke, but clearly seeing enough to decipher the secrets hidden away in the dead woman’s liver. The PM sessions were optional, and they took place during lunch hour, but one missed them at one’s peril. They were introduced in the late 1940s by the first head of Pathology, Prof. Jack Davies, and had survived the many changes in location and management over the decades. The cold grey concrete slabs on which the bodies lay, the strong formaldehyde smell, the solid swing doors that separated this area from the rest of the hospital – this was probably the way things were when the mortuary was moved here in 1962.
Most of Prof. Wamukota’s exam questions came from his lunchtime sessions, so they were well attended. From here it was rumored that he would make his way to Katanga, an infamous slum sprawled between Makerere and Mulago hills where cheap alcohol and even cheaper women waited for university students and professors alike. There was a running joke that a student who frequented Katanga walked into an oral exam, and the professor looked him up and down before asking, “So – apart from the bar, have we ever met anywhere?” Needless to say, the student failed the exam. The vivas, or oral exams, were by far the most dreaded form of assessment. The student was supposed to be rattled, baited with ambiguous questions, and humiliated for being ignorant. The questions were sometimes about obscure conditions to elicit even more obscure answers. It was not uncommon for a student to be asked about a disease condition that they had never come across in their three years of diligent clinical rotations, and to emerge from the viva in tears. Even in this, the students kept their humor. The more vicious and mean examiners were said to be malignant. The more reasonable, and those that asked about conditions that the student was most likely to encounter in the treatment of everyday patients, were said to be benign. Malignant or benign though, those senior doctors were wholly committed to turning their students into doctors that they could be proud of, and they spared no effort in doing that.
***
Having left Makerere medical school for Rubaga Hospital, D’Arbela had a comfortable routine that rotated between time spent at Rubaga, and an upscale private clinic on Clement Hill Road in Nakasero. One afternoon he was in his office at the clinic when his head nurse burst in and told him to get out. “Leave now. They are looking for you.” D’Arbela had had the sense that he was under surveillance. It was rumored that he was supplying the NRA rebels with medicines using the cover of his clinic. He knew that many people did not get a second warning. He slipped out through the back while the security officers were at the reception asking about him. He had left his car in front of the clinic though, so he had to make the split second decision to either make a dash for it, or abandon it and find some other way to leave the area. He decided to get to his car.
D’Arbela was just pulling out when the soldiers came out the clinic. He hit the accelerator and sped away, but he knew the clock was now ticking for him. He was due for sabbatical at the Medical School, so kept his head low for a couple of days, bought a ticket, and left the country without ceremony. His first stop was London where he was no stranger, having trained at Hammersmith Hospital. He would later move to Saudi Arabia and make that his home for the next several years. Back home the exodus of health workers continued, each with their own unique story. It would be several years before he returned.
***
Dr. Bwogi Kanyerezi was head of the Department of Medicine when Dr. Obache, one of his colleagues, came to see him with a worrying story. Obache said he had been told by a close relative that some soldiers were planning to harm him. The relative was married to someone who worked as a secretary at the Army headquarters, and she had overheard some conversations. He had laughed it off the first time he heard about the threat, but the night before he had come home to find a strange car parked close to his gate. In the morning, he had noticed the same car at the end of the street as he drove out, and it had followed him to the hospital entrance. Although the car had civilian number plates he thought he saw some people in military uniform in his rear view mirror.
“Obache, if you feel threatened, get out. Do not wait. We can give you a leave of absence until things get better,” Kanyerezi urged.
The following day Obache returned with an update. “I have been offered military protection. I now have a tent full of soldiers in my compound. They are going to protect me.”
“You trust these people?” Kanyerezi was incredulous. “What are you doing here? How can you trust soldiers to protect you? You are not a soldier. Obache, just get away.”
“I think I am now okay. I have been assured that I will be safe.” Obache looked more relaxed than the day before, and the two doctors parted and went about their day’s business.
Three days later Obache was killed in his house in Kololo. The soldiers that were supposed to ensure his personal safety were nowhere in sight when the killers came. From what his colleagues and relatives could piece together, Obache was considered a traitor by his Langi kinsmen. He had stayed in the country and thrived during Amin’s time when all the Langi, particularly the elite, were being hunted down. His wife had worked as a secretary to the Minister of Finance under Amin.
Kanyerezi’s turn to flee came through bizarre circumstances only a few weeks later. The end of term exams in the Department of Medicine had concluded without incident. Results were displayed in the usual manner, and the students who had not passed were required to repeat the rotation. Four months later, someone reported that the Department of Medicine had “failed UPC students.” There was no way the lecturers could have arranged this even if they had wanted to, because they did not know which students had what political leanings. The accusation was initially dismissed, but an insider revived it and escalated it directly to Vice President Paulo Muwanga.
“Who is this Kanyerezi, to think he can just fail UPC students? We shall teach him a lesson,” Muwanga said. One of the people present when Muwanga was told about the UPC students’ examination results sought to alert Kanyerezi that he was now a marked man. The information eventually got to him the following day. He did not need much persuasion, remembering the fate of his colleague Obache. He drove home, prepared his family as best he could for such an abrupt departure, and around 7pm he drove out of his gate despite the nighttime curfew that was in effect. Because he did not have a better plan yet, he drove from his home in Rubaga to neighboring Lungujja and the whole family spent the night with friends. “A couple of hours after we left the house, a military truck full of soldiers drove up to the gate. Finding that there was nobody at home, they shot several rounds of ammunition in the air and left.”
Over the next three weeks, Kanyerezi either lay low or moved with great stealth. A friend took him to see a sympathetic Member of Parliament who was also a Major in the army, to find out just how grave the situation was. Major Angwa offered to get him military protection. “No thank you! I will take my chances without their help.” He reached out to the university Vice Chancellor, Prof. Asavia Wandira, explained his predicament, and let him know that the department was going to need a new head. He moved the family to a different location every few days to avoid being tracked down by the security agents. Through a network of friends, he secured help with escape plans. In the end, he left the country in a UNICEF vehicle that was destined for Kenya to pick up supplies. His wife followed soon after in the same manner.
Dr. Charles Olweny was already heading the Uganda Cancer Institute, now he took over as Head of Department of Medicine as well. Four and a half decades later, Olweny could still vividly remember how he became head of the Cancer Institute.
“In 1972 I was at the National Cancer Institute in the USA doing a Fellowship in Oncology. Six months to the end of the Fellowship a message came from Uganda. ‘You should return to Uganda immediately. If you delay your return there will be nothing to return to.’ Back home, Amin had expelled Asians, and many other expatriates had started to leave. All eight expatriate staff at the Uganda Cancer Institute were leaving. I wound up my stay prematurely and headed home. On arrival I reported to Kibukamusoke, who was Head of Medicine. He told me to go and talk to Prof. Kyalwazi. Kyalwazi was in Surgery, but had closer dealings with the Cancer Institute because of his research in liver cancer and Kaposi sarcoma. I went to see Kyalwazi, and told him that I could not head the Cancer Institute. ‘The Institute has just lost all its senior staff. I don’t think I can manage,’ I told him. Kyalwazi held my hand. ‘Son,’ he said, ‘you can do it. I will support you.’ Two expatriate colleagues were waiting to hand over the Institute. As soon as I showed up they effected the hand-over, wished me well, and left. To his word, every Wednesday without fail, Kyalwazi came to the Institute to do rounds with me, and to help me think through any issues I needed help with.”
Olweny lasted much longer than his predecessors in Medicine, but by 1983 when he left under the guise of a sabbatical, he was living like a fugitive, often having to spend nights in different locations to avoid ‘disappearing’ under the cover of darkness. These men were among the forerunners of the generation of Ugandan doctors that would go ahead to have illustrious medical careers while scattered in the diaspora. Despite the great odds, the Cancer Institute gave the world the first evidence that lymphomas (cancers of the lymphatic system) in all ages could be treated successfully with chemotherapy. Amidst scarcity, Olweny pioneered the concept of an essential drugs list, which concept was adopted by the World Health Organisation for use globally.
***
David Kisumba was the first Ugandan professor of orthopedics, attaining this status at a relatively young age. The reason few people know of him is that he died a truly untimely and premature death in a road traffic crash in Kololo, then a posh quiet neighborhood north of Kampala central business district. Nevertheless, he left an impression on his young nephew Mutyaba, who determined that he would be an orthopedic surgeon as well. The aspiration would have died the death of many such youthful dreams had his ambition not met with providence in the names of Professor Rodney Belcher, an American Navy flight surgeon who fell in love with Uganda. Belcher was no stranger to East Africa. He had started in Dar es Salaam as professor of surgery in the 1970s. In 1983, he came to Makerere as a Fulbright lecturer, but the country was in the throes of a full scale civil war, and he was forced to relocate to Nairobi. He was so committed to working in Uganda though, that as soon as the war ended in 1986 he started planning his return. Return he did, to a badly run down Mulago Hospital, where there were no orthopedic services to speak about, and where all surgical services were a major struggle.
Belcher realized that the care of the diseases of the bones and joints was always going to lag behind unless a department was created, where specialists could be trained. He was going to begin from the ground up. Mutyaba, who already had his general surgical training under his belt, was his first student. They needed a ward, an operating room, consulting rooms, classrooms … they needed a lot of infrastructure that did not exist in post-war Mulago in 1988. What did exist though, that came to their aid, was a dilapidated bungalow in Old Mulago that housed patients with disabilities, mainly from polio. Having identified the house as a potential base, Belcher had to find the money. For this he turned to his old friends from his Airforce days. One of them was now a Senator, and Belcher thought he might find a way to get his dream department funded. He went back home, asked around, and then decided that Mutyaba would be helpful in telling their story. Before long Mutyaba was on the plane to the US to work with Belcher on a proposal that would hopefully get funded through his Senate connections. Their hard work paid off. A War Victims Fund had just been established, and the Belcher-Mutyaba proposal talked of helping to treat the huge backlog of both veterans and civilians that had been injured during the five-year civil war in Uganda. With time, the money came, and the Department of Orthopedics was born.
***
Kweete had been on the antenatal ward for a week already. She had been admitted for observation, and to ensure that she would get specialist attention when she went into labour. So far, her pregnancy had not worsened her heart condition as had been feared. She did not know what to expect, this being her first pregnancy.
By 1986 Flavia Katende had been a tutor and midwife in Mulago for more than a decade. In that time, she had taught several generations of nurses and medical students to deliver babies safely. Yet every year there was some additional form of improvisation. She remembered that during her own training it would have been unacceptable for there to be only one health worker at a delivery. The doctor or midwife usually had a receiving nurse, so that once the baby was out, the receiving nurse took care of the baby while the midwife ensured that the placenta, or afterbirth, was delivered safely. They gave the mother ergometrine injection to reduce the bleeding, and gently rubbed the abdomen to encourage the uterus to contract, further reducing the bleeding from the placenta bed. The midwife or attending doctor did not leave the mother’s side until the bleeding had stopped, and the mother was clean and comfortable. Katende was aware that on some nights only one midwife was on duty in the maternity unit, assisted by inexperienced student nurses that were still terrified of the thought of cutting through skin and flesh. Delivery sets, the collection of instruments and supplies that one had to have in order to perform a safe delivery, had dwindled to a pair of rewashed gloves, old needle forceps, a blunt reusable needle, and loose cotton swabs. She had finally stopped giving her teaching on how to prepare for a normal delivery, because she could not bring herself to go through what were clearly fictitious lists. Students would never have seen the entire set anyway.
The evening of 25 January 1986 the maternity unit was unusually quiet. Lately the insecurity around Mulago had reached such levels that patients who did not come in before dark could not come in until the following morning. For some that would be too late. Katende would have gone home already but she was concerned about the teenager on the corner bed who was unlikely to have a normal delivery. She was the textbook high risk prime gravida, or first time pregnant: short frame, narrow pelvis, and baby’s head high above the pelvis despite the increasing contractions. Katende usually told young doctors to be aware of this ‘failure to progress’ in labor, and to plan intervention sooner rather than later, as a normal delivery was unlikely and unsafe. The doctors always took the decisions, but the more experienced midwives could tell which patients were not going to make it on their own. Katende knew the teenager was headed for a C-section, but there was no anesthetist in the theatre. There were no doctors either.
***
The war had been advancing from Luweero towards Kampala for a long time, and in many people’s minds this was how things were always going to be, but the last one month had been different. It was becoming clear that the guerrillas – ‘abayeekera’ – were going to enter the city, and that the government forces were not able to stop them. The day before the gunfire had been so close that the midwives joked that they did not need to deliver the babies – they were popping out at the sound of the shootings. But today was strangely quiet. The Senior House Officer and the interns should have been here. If they were not in the hospital by now, they were not coming. What was she to do with the young mother? Then there was the patient with heart disease as well. These two were going to need doctors.
***
Kweete went into labour in the night. The labour progressed without incident and at dawn she gave birth to a baby boy, assisted by two student midwives. Shortly after birth the baby started turning blue, a sign that he was not getting enough oxygen into his blood. The nurses took the baby to the nursery where newborn babies received more intensive care. A few hours later the tragic news came – despite the doctors’ best efforts, the baby had died. The doctors said there were serious defects in his heart and major blood vessels which were incompatible with life. Kweete was plunged into the depths of grief. She declined to have a post mortem done, and chose to bury her baby ‘without him being turned into a specimen’. As the country started to cautiously celebrate the victory of the NRA and the end of the bush war, Kweete mourned the death of the baby that had barely lived.
***
Professor Francis Omaswa was coming back to Mulago after a hiatus of more than 10 years. For three years, he had headed the Cardiothoracic Department at Kenyatta Hospital in Nairobi. He had just spent five years at Ngora Hospital in eastern Uganda, and he could hardly wait to get back into heart surgery at a big hospital. But Mulago had scars and wounds from years of abuse and neglect, and he was about to find out the hard way that fixing a hospital could be harder than fixing hearts. It felt great walking along familiar corridors, running specialist clinics, and deciding what patients to schedule for surgery. His first heart operation was a straight forward one, the surgery went well, and the patient was taken to the Intensive Care Unit on 3D as planned. At the end of the day, Omaswa went by to see how he was doing, and was pleased to find him stable. The hospital was quickly emptying out, and the evening shift was giving way to the night staff. The big hospital routines were all very familiar.
The following morning Omaswa went to the ICU to check on the patient before heading to the ward for a teaching round. An unpleasant surprise awaited him. His stable patient of the previous evening had passed away in the night. The night team was gone, and there were scanty notes to explain how a patient that had done well at table and for the following several hours suddenly made a turn for the worst. That was not a good start, but Omaswa was not so easily discouraged. A week later he had another patient scheduled, and it was another fairly routine heart procedure. This time he gave more elaborate instructions, and went over them with the nurses in ICU to be sure that nothing would be missed. Before he left the hospital in the evening he want by the ICU, and was happy with the patient’s condition. He lived just above Galloway House within Mulago, and he told the nurses to call him if there were any serious concerns. Decades later, Omaswa still recalled how things evolved.
“I was relieved that there were no calls in the night, as that meant that the patient had had a comfortable night. In the morning, I walked to 3D ICU to see the patient. As soon as I walked into the ward, I sensed that there was a problem. The procedure room was open and I could see there was a body behind a screen. As I turned to head towards the room where I had left the patient, the matron came out of the office. She did not waste any time. ‘Professor, I am sorry but your patient died.’ I stood still and felt a tightening in my chest. ‘How? When?’ I asked the questions, but somehow did not hear the answers. I knew it had to be the nursing care. There was nothing worrisome or highly complex about the procedures, I had done these same operations countless times before, and never had deaths. I turned and walked out of ICU without looking at the file. I walked down to the second floor, out into the parking, and I got into the car. A plan was quickly forming in my head, and the painful lumps in my chest and throat were not shifting. I knew I had to find a solution. A short while later I drove out of Mulago and headed straight to Nsambya Hospital. I walked into Dr. Duggan’s office and told her secretary that I had to talk to her, and that it was urgent. I got straight to the point. ‘I am looking for a hospital where to do heart surgery. I would do a weekly list.’ She must have heard the pain in my voice. Or maybe there were tears in my eyes. She was quiet for a while, then she simply said yes. I thanked her, and said I would be back to work out the details.
From Nsambya I drove to Nakasero, to Dr. Ruhakana Rugunda’s office. He was Minister of Health at the time. I still had the sense of urgency, and I told him I needed premises for a unit where we could treat patients with heart problems. I had walked around Mulago looking for space before, but that day I had an urgency like fire under my feet. I had to find a way to treat patients safely. That second death had rattled me pretty badly. I was angry and depressed all at once. Rugunda listened to me, and asked if I had suggestions. ‘Yes. There are some old buildings in Old Mulago that accommodated internally displaced people from Luwero during the war. I think those people have left.’ He said we could have the buildings. I walked out of there elated. In one morning I had a theatre in Nsambya where I could start work right away, and a couple of houses where I could set up a heart unit as a more permanent solution. The question was now how to find the money to get the unit together.”
Rotarian Robert Ssebunya had been in exile in Nairobi, and he had seen the work of the Kenya Heart Foundation. On returning home after the 1986 change in government, he set about creating the Uganda Heart Foundation fashioned after the Kenyan one. Omaswa had been a natural ally, and the two had had several meetings with a few other people to give direction to the Foundation. It was to this group that Omaswa now turned to find the resources to give life to his dream. Some wealthy Asian patients made contributions, but the grant that really set them firmly on their way was US$350,000 from Rotary International. They renovated the dilapidated buildings and turned them into wards, built and equipped the operating theatre, bought a top-of-the-range Echocardiogram, and recruited staff. The Uganda Heart Institute was born. The rest was paperwork.10
Prof. Paul D’Arbela, first Ugandan cardiologist.
Monitor Publications Limited.
Prof. Josephine Namboze (first Ugandan female medical graduate
1959). Makerere University School of Public Health 2019.
Dr. Rosemary Bagenda (second Ugandan female
medical graduate 1965) DS Archives
Prof. Charles Olweny, first Ugandan Head of
Uganda Cancer Institute. Prof. Olweny
***
Prof. Richard Bwogi Kanyerezi. Monitor Publications Limited.
Prof. Sebastian Kyalwazi, first Ugandan surgeon.
Prof. Ian McAdam. Albert Cook Library, College
of Health Sciences, Makerere University
On 20 December 1988, President Museveni visited Mulago Hospital. The staff of the hospital gathered in Davies Lecture Theatre to listen to him. The President was dapper in a stylish suit and tie and, if a little cocky in his speech, had an infectious optimism about him. This was the boardroom president; the bush guerrilla fighter was gone. He captivated the nurses and doctors with his plans, which reflected a passion for the rapid development of the country, after decades of mismanagement and neglect.
