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.