Mulago Moments

The wards at Mulago are colorful, public places. Here, smells are stronger and voices softer. Patients generally bring their own bed sheets and blankets, wear their own clothes, and eat their own food, while attendants doze on woven mats between the beds and mattresses. The wards are largely open to the environment, with the riotous noise and inescapable pollution of Kampala seeping in through the huge open windows. Hallways, too, are entirely open on one side and even the ward walls in some areas are constructed of open stone latticework so that the wind regularly blows papers out of place. Today, standing on the fourth floor just before rounds began, I realized that I was being gently soaked in a fine warm mist of rain and wind. While part of me appreciated the obvious logistical problem of having rain all over the hospital floor (best evidenced by the employee who eventually appeared wearing scrubs and gaitors, attempting to push puddles around the floor toward an open drain), a small part of me was oddly thrilled by the sensation. I paused for a second, raised my hands and enjoyed the moment, so far from the climate-controlled, infection-controlled, sealed-window, fluorescent world I’ve come to associate with “hospital.”

In a month at Mulago, I’ve seen exactly one patient challenge or question anything a doctor has said or done. On one of our first days here, a young farmer who spoke good English presented to the casualty (emergency) department complaining of long-standing back pain. During a quick exam, the attending pointed out small deliberate scars on the man’s back and without consulting the patient, explained to us, “he got these from a witch doctor.” To my surprise, the patient immediately protested, “no! no I didn’t!” The attending, secure in his years of clinical experience, rebuked him: “Yes you did--what are these marks?” The patient refused to answer but simply clenched his jaw and shook his head emphatically. The attending sighed, paused ever so briefly, and subtly rephrased his explanation to us: “they’re from a traditional healer.” To my amazement, the patient’s tense expression immediately relaxed into a small, satisfied smile, and he nodded once, proudly. I wanted to grin, to laugh out loud, to shake this patient’s hand and find out more about the strength within him that demanded cultural respect in this setting where patients have so little power.

It makes me happy to see the few patients who fight, who refuse to melt into the beds. One of my favorite patients is a woman with endomyocardial fibrosis (EMF) who has been on the cardiology service since I arrived in Uganda. I liked her initially because she started correcting my Luganda grammar on the first day I met her, using rapid-fire sentences and emphatic hand gestures to emphasize plural versus singular constructions. I liked her more when I discovered after about a week that she actually speaks some English but greatly prefers making me struggle in Luganda. She’s a little pushy (well, by Ugandan patient standards), demanding to know when I will come back again, securing a promise of a picture for herself in exchange for a clinical picture of her abdomen, and it makes me smile.

If I can find time, I visit her and other patients on my “social rounds” near the end of the day. To be honest, social rounds have very little to do with medical care (though I do, for example, put my stethoscope to any cardiology patient’s chest again, willing my ears each time to remember the swish of the those amazingly clear systolic murmurs). I glance at any available charts, but mostly I’m just checking in with long-term patients I’ve followed at different points, greeting their attendants and their neighbors in the open wards, enjoying the welcoming smiles and the laughter that comes at my expense whenever I successfully butcher a new Luganda phrase. The patients on my afternoon social rounds serve as a useful counterpoint to the desperately ill patients I see on regular morning infectious disease rounds, where laughter has little place and sickness and worry consume the personalities of both patients and attendants.

Many of the people on my informal social rounds, in fact, are not even patients, which is a tribute to the amazing welcome I’ve gotten from almost everyone at Mulago. I might check in quickly with a particularly friendly nurse or nursing student or stop in to say hello to the fantastic lab instructor. I love greeting the strong contingent of relatives that sits on the hallway floor outside ward 4C, sharing food and nursing babies and waving en masse every time I pass in or out of the ward. I’ve learned how to ask easy phrases like “Who are you visiting? How long have you been here? Do you sleep here?” and am finally getting better at understanding parts of the answers, aided by those who speak some English. I never know quite where these laughter-filled conversations on social rounds will take me--last week, one of the women in the hallway offered me a booklet in English entitled “The Adult’s Secret Book—By the Auntie, Episode 1.” It turned out to be sort of a sex advice book for girls getting married, with advice on positions and practices [e.g. “most women abandon sex during pregnancy saying that the stomach is too big but please where are you sending your husband in this world of AIDS?”]. Our whole apartment is hoping that I am offered Episode 2 on this week’s social rounds! Yes, despite all of the frustrations and sadness, I absolutely love my life here.