Done but not over

Dr. Ruby Dunlap’s Uganda Fulbright Blog
Elizabeth and Ruby.JPGI expected to feel relieved, elated even, to be leaving Uganda. The work had been hard, the frustrations many, and all of us, Dad, Bob, and I, missed family and friends back in the U.S. It had been nearly ten months and we were ready to go home. So why were my eyes so wet as the plane lifted off into the night and the lights of Entebbe faded behind us? Uganda and her people have a piece of my heart and it told.
The last paper was graded, the grades averaged, and the final report made. Goodbyes were said, hugs exchanged, promises of emailing regularly made. The most immediate and obvious reflection came easily. All nations have some glory and some shame; I had learned better to embrace both the glory and shame of being a U.S. citizen. I had learned better to put the U.S.’s glory to work and to seek to remedy or mitigate some of her shame. I learned that being a child in Africa and being an adult with much responsibility are very different things. In communication with Joseph, Florence, and Jannat from Mbarara University of Science and Technology (MUST) in western Uganda, I consented to take on some advising of master’s in nursing theses. My stay in Uganda was done, my Fulbright assignment completed, but my work for Uganda is not over.
Ugandan Child.JPGThere is still much to puzzle over in the analysis of my experiences in Uganda. I expect it will take a long time to reflect on and I will likely not ever come to the end of it. But let us take another look at one critical issue. The blog entry, “If you put it that way,” reflected on the different ways one could think of resource-rich and resource-poor healthcare environments. It is difficult to think about the topic of this entry in more than one way; the temptation is to think that more money will solve all the problems of the resource-poor. But it is not so simple; there is perplexity in the problems and the solutions in both rich and challenged environments. One only has to consider the recent healthcare reform efforts in the U.S. to appreciate the complexity in what is possibly the richest healthcare environment on the planet.

A few months ago, Uganda’s First Lady, Madame Janet Museveni, was the guest of honor at an event at Uganda Christian University featuring the accomplishments and remaining challenges around Uganda’s very high maternity mortality rate. For every 100,000 mothers giving birth in Uganda, the adjusted 2005 UNICEF/WHO statistic is that 550 of them die from maternity related causes. Kenya shares this statistic with an adjusted rate of 560 women dying from pregnancy related causes and, like Uganda, just over 40% of women delivering having any kind of skilled birth attendant at all. ( If the statistics have improved since then, they have not done so enough to challenge the fact that maternal mortality remains a serious public health problem for both countries.
Mother and Child.JPG By way of comparison, in the U.S., the Internet headlines lament the “shocking” increase in maternal mortality rates from below 10 to 13 per 100,000 women in 2007 with a preliminary association between this rate and the fact that almost a third of births in the U.S. are Caesarean sections. According to the CDC (, while Caesarean deliveries have increased for infants of all gestational ages and for mothers of all races and socioeconomic levels, the rates for surgical delivery between 1996 and 2006 for preterm infants were the highest.
Minorities, especially blacks, have higher rates of maternal (and infant) mortality rates in the U.S. than whites. Reasons for this have yet to be clearly identified. Lack of access to antenatal care or failure to access available antenatal care, health conditions such as obesity, diabetes, and hypertension, have been mentioned as possible contributors to the disparities overall but the increase in Caesareans across ethnic and economic lines should be one association with increased maternal mortality rates which deserves quick and aggressive inquiry.
Canadian obstetrician Jean Froes, the founder of a graduate program at UCU in public health leadership whose single mission is to reduce maternal mortality rates in Uganda, East Africa, and the world, told me that I mustn’t be too critical of North American obstetricians who may be quick to do Caesarean sections. If research data support the clinical decision that a Caesarean section is indicated for this or that condition, no OB is going to risk not doing a C-section if the situation even comes close to that condition. For OBs whose liability insurance is at or near the highest of all physicians, the legal risk would be too great. Research results, variable clinical situations, and legal risk all contribute to the complexity of rich as well as poor healthcare environments.
Now I would like my dear readers to pause and reflect on the preceding paragraphs for a few minutes. Resisting the urge to diagnosis and prescribe too quickly (“all Africans need is skilled birth attendants” and “all Americans need is equal access to healthcare”), how does one go about untangling what is surely a web of causality for both of these discouraging statistics?
Along with speeches from various important people, the event at UCU included a video about maternal mortality in Africa which told the story, among others, of a young woman who, around the delivery of her baby in a hospital (about 41% of women delivering have a skilled attendant in Uganda), had “fits” (i.e., seizures). “She is having fits,” said the MD in the video, “because there is no magnesium sulfate in this hospital and that is the treatment for her fits.” (She survived her “fits.”) Another young woman, hemorrhaging and with a dangerously low blood pressure, needed an urgent blood transfusion but there was no blood in the hospital. Her family had to rush out and find blood from somewhere; hours later, somehow, they managed this and her life, too, was spared for the time being with the administration of blood.
How did nurses figure in the events of this day? A skit by some elementary school children from Mukono (the Kampala suburb town where UCU is located) represented the only voice for nurses. A poor Ugandan woman showed up in labor at the rural clinic run by a nurse. The nurse did a skillful and sympathetic assessment? No, the nurse screamed at the patient to pay the clinic fee immediately. “I have 5000 shillings,” stammered the woman. “5000!” yelled the nurse angrily, “I want 500,000 and I want it now.” (At the current exchange rate, 5000 Uganda shillings are two dollars and fifty cents. 500,000 shillings are about 250 dollars.)
And that was the only reference to a nurse or midwife that I heard in the hours I was at this event focusing on maternal mortality. “I hope you teach your students heart,” said an expatriate who has lived and worked here for 13 years, “because Ugandan nurses have a reputation for being harsh.” The nurse in this skit certainly did nothing to challenge that perception.
Still, in their defense, nurses in Uganda often have to work under conditions which would eventually make even the most tender-hearted of us im-patient with our patients and colleagues. “The nurses at Gulu hospital haven’t been paid in three months,” said a Fulbright colleague doing research in Gulu. “There is absolutely no communication between nurses and doctors or pharmacists and doctors. They don’t want to communicate. They don’t trust each other at all.”
Sipi Falls Children 2.JPG Nurses routinely, especially in rural areas, have to work without reliable electricity, without medicines and supplies, and sometimes without clean water. A single registered nurse may be responsible for 25-50 patients and I have heard of as high as 80 patients for one nurse. “Five patients can go bad at the same time,” said a student of mine we visited in the far southwest corner of Uganda, “and some of them will die without care because you can’t attend to them.” Families have to provide food and linens for hospitalized family members and most of them do. They often have to provide medicines as well, and, as the video documented, had to find a blood transfusion for their critically ill young mother.
My students and I had more than one discussion about nurses yelling at patients. All of them thought it ought not be done; all had seen and heard it done fairly routinely. All of them could understand why nurses would lose their tempers with their patients and yell at them. They pointed to the atrocious working conditions, poor education, and poor professionalization. No, it shouldn’t be done. Yes, it is understandable.
We might have some preliminary guesses about why the U.S. maternal mortality rate has “skyrocketed” from less than 10 to 13 women per 100,000. There will certainly be a complex of reasons just as the reasons for Uganda’s rates are complex.
“We already know what reduces maternal mortality rates in the developing world,” the coordinator of a Bill Gates Foundation grant to Makerere University told me. “It is raising the educational status of women and girls. But that is about the only intervention that will do it.” But “educational status” is also a broad and complex concept.
Still, better educated women have fewer children. Better educated women insist on being attended by skilled birth professionals. Better educated women are more likely to have ante-natal care that approximates international standards. Better educated women are more likely to be in better health overall. A woman’s education is proxy for so many things including economic status, culture, and lifestyle.
But why was magnesium sulfate, a cheap, old, otherwise readily available drug, absent from that African hospital? One might expect the absence of expensive and difficult to acquire drugs but magnesium sulfate? Why did that young woman simply have to endure her “fits” until they went away on their own? The answers elude me. It is part of the open-ended and unfinished nature of my story. Something got done; much that needs done remains left to be done. Africa’s story continues and so does mine.