The art of ART in Kampala, the city of seven hills

The mighty Murchison Falls (our first week was spent traveling!)

Rolling tapestries of green give way to dense forests, but with the light at just the right angle, the blue waters of the Nile peek out from behind the trees.  We race past villages, fruit stands, and goat-herders seemingly as swift as the white-water gushes down Murchison Falls.  The car slows as we near the seven hills that make up Kampala, and purrs to a stop as we enter the ranks of cars arranged haphazardly in bumper-to-bumper traffic that never seems to let up.

View of the Nile from the top of Murchison

The stillness of the engine allows us the time to examine the scene around us – mothers rushing home in the impending dark with a lesso wrapping young ones to their backs, men jostling and taunting a wobbling, drunk teenager.  A boy, hardly four years old, laces fearlessly in and out of the traffic and weaves between the crowds, gleefully intent on his game of the day – chasing a simple plastic bag with a stick.  We watch him for 5 minutes, then 10, then fifteen, and he doesn’t tire.  The hustle and bustle hides some of the uglier truths of these streets – the pervading hunger, endless cycle of poverty, an endless list of diseases.

Working and observing in a hospital that specializes in providing compassionate, personalized care to those affected by HIV/AIDS, we see some of the worst stories of these streets.  In this hospital, hard realities are faced as a matter of business each day.  Raped walking home in the dark. Raped walking home from church.  Innocent children present to clinic for refills on their medications – all were infected with the notorious virus on their exit from the womb.  Still, many things are encouraging.  Youth at the Kisakye Youth Center who have mastered the art of ART (antiretroviral therapy) work to empower their peers to do the same.  Women, yearning to be the best mothers they can be, show up faithfully to clinic visits to prevent their unborn children from infection.

*Note: photos aren't allowed at Mildmay, but know that it's beautiful, and no words could do it justice!

While 1.5 million people are newly infected with HIV/AIDS in sub-Saharan Africa each year, this represents a 33% decline since 2005 (Kharsany and Karim, 2016).  It is facilities like Mildmay Uganda that are trailblazing the way to an AIDS-free generation.  In 2016, Mildmay had zero incidents of mother-to-child HIV transmission during pregnancy, delivery, and breastfeeding.  The word “patient” isn’t used in this facility – each client here takes an active role in his or her care and the dignity that comes along with it.  With 89,889 clients receiving anti-retroviral therapy to overwhelmingly positive results and 22,354 girls and young women in rural districts engaged in empowerment programs to reduce HIV risk, Mildmay reports that 8,170 new HIV infections were averted in 2016 (Mildmay Uganda Annual Report 2016).  What’s more, the vast majority of their services are provided at no cost to clients.  That’s a lot of lives positively affected by a tremendous collaboration between clients, physicians, nurses, educators, administrators, and even the CDC for funding so central to the hospital’s mission.

What’s a typical day at Mildmay like?  The first clients trickle in by 6 a.m., when the world is still dark.  It’s impossible to know what time they left their homes to beat the Kampala traffic and make it to clinic at this time.  By 7 a.m., a sizeable crowd lines every bench and free space in the waiting room.  At precisely 8 a.m., the light is switched on at the reception desk, amid bursts of applause from the waiting room.  Most days, about 400 clients are seen in the order that they arrived and picked a number before the healthcare team has a chance to rest their feet.

It might not be the most timely and organized system in the world, but it’s hard to argue that it’s not efficient.  It’s a far cry from the other outpatient hospitals that we’ve visited in our four weeks here so far.  At many of these facilities, thousands of patients seem to be spilling out from waiting rooms, on benches, cracked plastic chairs, and squatting on the red earth.  They are waiting for pre-natal visits, medications, maybe even minor surgeries from a staff that consists of one trained physician, a few clinical officers, and a handful of overworked nurses.  Their dour expressions speak to the many hours that they’ve already waited, but also the determination with which they will strive for medical care.  If they are able to be seen that they, they are extremely gracious to the physician.  And, if they are turned away that day, still many will find a way to return the next day.  Mildmay Uganda, as the staff will proudly tell you, is a center of excellence where clients count their blessings to be receiving care.

Every aspect of care is carefully coordinated.  New clients are identified at HIV testing and counseling services, and with words of encouragement and support, enroll in clinic and start their first dose of ARTs that very day.  The youngest clients arrive still attached to their mothers’ breasts, and mothers beam when they are congratulated on suppressing their viral load and protecting their infants from harm.   Realistic conversations about family planning happen alongside point-of-care cervical cancer screenings and breast exams.  Vials of blood are drawn and sent to the state-of-the-art lab that crests the Mildmay hill.  If you visit Mildmay, the vastness of the compound will amaze you as you climb the steep brick incline, and realize that an entire additional hospital system accompanies the clinics in the lower half of the hospital.  Some of the buildings on the top include the private Bethany clinic, two inpatient pediatric wards, the youth center, and the building that will host 300 medical students this coming September.

My role at Mildmay is still being defined.  We are enrolling clients in a study that will analyze the effects of computer-based cognitive trainings to slow the progression of dementia and cognitive deficits in older adults with HIV.  Still, enrollment is slow because our team is battling with red-tape placed by the Ugandan equivalent of the IRB (Institutional Review Board) – #ThisIsAfrica, after all.  I welcome clients in my broken Luganda sentences, help them to get breakfast and lunch, and take some vital signs.  As our study moved forward this past week, I was able to do their clinical assessments under the not-so-watchful eye of a physician.  The East African language I do know – Kiswahili – is helpful in some parts of Uganda, but not used in the slightest in bustling Kampala.  It’s frustrating not to be able to help with the tedious consent process, or initial assessments, but the few Luganda words I have picked up at least bring smiles to all.  The responsibilities given to myself and my three industrious, Type-A medical student colleagues are not quite enough to keep us busy, and we all find ourselves with ample time for side projects.  We were able to get in a day and a half of clinic observations in which I may have learned more than my entire first year of medical school – before we were asked by hospital administration to pay hefty fees to observe in clinic, and flatly refused.  Still, I have found that working in this part of the world requires infinite ounces of patience, and a willingness to accept that nothing will ever go quite as planned.  I take joy in the priceless experiences along the way - writing this on a Sunday after a joyful worship service filled with jumping, dancing, and jubilant screams.

The people closest to me know that one day, I hope to practice medicine in the developing world in some capacity.  I don’t know what my career, or my life, will look like in 10 years, but experiences like these continue to help me distill the world around me, and realize how much more I have to learn.  Thanks for reading and sharing in this exciting journey!

My classmates and I on a recent trip white-water rafting down the Nile
...with our sweet nurse friend we've attached ourselves to!

L-R: Gina, Brianna, myself, Emily, LaVana

References

Kharsany, Ayesha B.M., and Quarraisha A. Karim. "HIV Infection and AIDS in Sub-Saharan Africa: Current Status, Challenges and Opportunities." The Open AIDS Journal 10.1 (2016): 34-48. Web.

Mildmay Uganda Annual Report 2016. Rep. Kampala: 2016. Print.

Waiting on the Sunny Spells

One final exam squeezed unceremoniously between a late Friday lunch downtown and a class bar crawl– my first year of medical school came to a rather abrupt end.  Since the late July day in which my classmates and I were first draped with our white coats – a day of intermittent sunny spells mixed with rainstorms – my year had likewise been filled with brighter days and grayer days.

Here are a few themes that pervaded my year, for better or for worse:

Futility

On many days, long hours at the library often turned fruitless for me, as I would find my attention drifting away from the scores of Powerpoint slides in front of me, and to the people moving on the streets below.  I had entered medical school from two years of what I saw as immense personal growth.  I felt that, during my service, while I was constantly challenged in new ways by longstanding traditions, by difficult situations, and by the natural elements, that I was using my time and talents to serve those around me, and to better myself.  I remember being resilient and positive when faced with the impossible.  However, during medical school, I found myself thinking increasingly negatively about myself and the world around me.  I longed to feel like a contributing member of society again.  I found myself feeling increasingly distant from my coursework and my classmates – partly because I craved much more than the cycle of cramming for the weekly exams and hitting the bars afterward that many of my classmates were wedded to.  On some days, I dreamed about my days coaching sports on the field under the African sun and holding Chemistry review under the shadow of Mount Kilimanjaro – and how heavily this reality contrasted with the stark white hallways of the hospital.  I was not sure that a career in an academic institution was one that would bring me fulfillment.  Honestly, I am still not sure, but know that I will continue to think about this as I progress through my career.

Fulfillment

At the same time that my time in the library felt futile, rare moments brought me back to the reason I chose this profession in the first place.  A patient in the student-run free clinic who left me with a tight, long hug after her appointment said that she could tell I was “all in,” and it was the best moment of my week.  Our interview that day led us through her medical concerns and deep into her psychological needs, and a nursing student and I were able to get her the help she needed.  Moments like these sustained me on days when I spent dawn to dusk at the med school.     

 Anxiety

At multiple points during the year, anxiety rocked me to my core.  I remember during my very first exam, my heart began beating like a bass drum as I opened the exam, the words blurring in and out of focus on hazy yellow pastel background until I pressed the “Submit” button and surprised myself with a respectable grade.  Often, my stomach turned would turn to knots on the day of an exam, and I had to slip outside to walk off breaths that had become shallow and labored inside the tightly thermoregulated air of our library. 

In March, one exam that I had dreaded for a full month, solely because of the dozens of students before me who had failed it, pushed me to what I felt was my breaking point.  Anxiety hit me in full force, and I couldn’t rid myself of it.  I had obtained permission to take the exam up to two days later as I worked through this stressful episode, but as the exam day drew closer, I found little breathing room.  Prayer, yoga, running – all of these helped for a while – but as soon as I sat down again at my desk to study, the anxiety returned.  I began to see the rest of medical school as merely a series of increasingly stressful exams, and became convinced that I was not cut out to deal with the stress that lay ahead.  Every time I sat at a computer and tried to study, I would instead find myself searching online for “ jobs with Peace Corps” or “NGO openings in Detroit.”  It seemed like I welcomed any escape from my current reality.  My school counselor – bless her – got to know me far too well during this week, and offered words of encouragement and understanding that helped me through the process.  It became clear to me that I needed a break from school – and luckily, one refreshing night of going home and spending a relaxing night with my parents was enough to give me the courage to go back to school and take my exam – and ended up passing the sequence, to my immense relief.  Anxiety is a very real part of medical school that I will continue to work through.

Fear of Failure

Those who knew me before medical school might have trouble believing how pervasive the fear of failure became for me.  Before medical school, I’ll admit that most things in life came easier to me than they did to others.  I was blessed with a lot of talent, and I found that a little bit of hard work could place me at the top of anything I set my mind to.  Medical school was different.  For the first time in my life, I did not excel.  Sometimes, fear of imminent failure paralyzed me with fear such that I was unable to study – like in the episode I had in March.  One recent moment of growth when I was finally able to leave behind my fear of failure.  I went in to a difficult exam sure of impending failure, and was ready to calmly accept a failing grade if it was my rate.  I had not studied at my best that week, yet surprised myself with the knowledge that I had absorbed, with a grade that I was happy with.  At the tail end of the year, this became a lesson to leave fear of failure behind, to trust in myself, and above all to trust in God.

Mentorship

As I watched the gray hairs multiply on my head, I held onto one thing that kept me young – mentoring youth.  Through the Doctors of Tomorrow program, I met and mentored young people from the famous Cass Tech High School in Detroit.  I had my feet in all arms of the program – the ninth-graders working through their adjustment to high school, upperclassmen nervous for their SATs, and even college students at U of M!  One of my favorite parts of this program was guiding young people to grow and become independent thinkers.  My ninth-grade capstone group, who constantly kept me laughing by eagerly doing my silly  “Mama Jamila”  cheer, ran into a few roadblocks in their project with a Detroit shelter and outreach center for women.  At one meeting, just a month before we were supposed to have the final results of our outreach project, I delivered the news to them that their “cute clothes drive” wouldn’t be possible.  They were dismayed only for a minute, and then we rolled up our sleeves and brainstormed.  “What unique challenges do girls face?”  In just a few minutes, they brainstormed an intervention to raise awareness about menstruation, and collect menstrual products for the shelter.  They mobilized their resources, divided tasks, and one month later had filled five large boxes with pads, tampons, and new underwear, and had collected over $350 in donations!  Thinking about these students, and the courage with which the faced challenges in their lives, helped me to deal with a year that challenged me in so many unexpected ways.

Strained Relationships

During my first year of medical school, I missed every single important family event, being unable to travel across the country for graduations, birthdays, and anniversaries of my extended family.  I felt out of my element without this strong connection to family, and felt less-than-adequate about my ability to devote time to my family.  With my parents, I was able to talk to them frequently enough, but felt unable to explain everything that I was going through.  With friends, I felt that there were few with whom I could share my true feelings, so I placed most of my relationships on the back burner.  A few close friends remained on my speed dial, and we were part of each others’ lives on walks home and in hushed tones at night.  My rapid transition from Peace Corps to medical school didn’t leave me with enough time to catch up with all of my old friends.  I didn’t know how to go about re-forming connections when it had been more than two years since our last encounter – how could I say it all in a text message?  It would take hours and hours to catch up with a phone call or Facetime – how could I afford that?  Pondering these silly questions took days, which turned to weeks, and then months.  Where do I pick up from here? (Actual question)

Love

My family, who had gotten used to evolving relationships throughout my service and my return back to the U.S., were not able to completely understand my feelings – but were well used to this feeling.  However, their overwhelming love and support strengthened me in my weakest moments.

I got into a new relationship beginning in October of my M1 year.  Dating someone who shares my Indian heritage and Christian faith has been a first for me – and has made things easy and familiar from the start.  He is good to my parents and has helped me to grow in faith in my weak moments.  He gives me tough love when I need to stop complaining and tells me bluntly to grind my teeth until I finish my work.  He will drive a two-hour round trip to Ann Arbor to have a weekday picnic lunch in between classes.  While he is wonderful to me in every way, I found myself getting frustrated with petty issues, and realized in horror that I was turning into the crazy girlfriend that I promised I would never be.  Maybe it's an artifact of being in a relationship during a time that is metamorphosing me.  Since my realization, I've tried to leave the crazy behind (really!) with communication and understanding.  Working to speak the same love language has taken time and patience, but this process has taught me much about love during my M1 year. 

This year was a year of exploring parts of myself that I never knew of.  At times, I knew that I wasn’t being my “best self.”  I was hard on myself for it, but learned that I needed the little things – morning runs in the cool mist off the Huron river, the smell of onions and garlic simmering on my stove, or 10 minutes of prayer at night – to stay sane.  Luckily, after ever gray day this year came a sunny spell.  Ahead of me is a summer of travel, new experiences, and time to rest, reflect, and gear up for the year ahead.