Thursday, May 20, 2010

The Strength of Rose

Rose has read this post and has given me permission to share it, and to use the real names of her and her sister.

My primary reason for being in Uganda is to conduct research related to malaria and HIV in pregnancy. One of the studies I am involved in is a clinical trial trying to prevent malaria in HIV-infected pregnant women. Women enrolled in the study receive full antiretroviral therapy (ART).

Being enrolled in the study means the women will get much more intensive and individualized care than they would normally get in a government clinic or hospital. Rather than taking 1 or 2 antiretroviral medications (ARVs) to partially prevent transmission, they will receive full ART with 3 drugs, which will suppress the HIV, improve their CD4 counts, and nearly eliminate transmission. They will also have access to a large team of doctors with specialist support, personalized counseling from trained HIV counselors, and transport reimbursement for clinic visits. When they miss visits, we go and find them.

Because of all of these advantages, getting into our study could be lifesaving, and many of the women know it. Women have to fit certain enrollment criteria to be included in the study. Sometimes, the study coordinators have told me, women who have been excluded from the study leave our clinic crying. It is a big deal to be able to enroll.

One of our study nurses, Rose, is a midwife, and she is outstanding. She is a hard worker, very sympathetic, and also has training as an HIV counselor. She used to be a TDH midwife, so sometimes after her work at the clinic is finished, she goes to the TDH Labor Ward to visit and help them out when they are busy.

One day, Rose shows up with her own sister, wanting her to be enrolled. The sister, Safila, has HIV, and it is unclear what her gestational age is, but she appears to be in late second trimester. Rose had to practically drag her sister from the village to Tororo town to be screened for the study. Rose used the promise of the study to convince her sister to come stay with her in town, and knows that the requirements of clinic attendance involved in the study might just be enough to keep her sister there and save her life, and the baby’s.

As we do the ultrasound, Rose stays in the room and watches anxiously. When we announce that Safila is 26 weeks pregnant, Rose sighs with relief – patients can be enrolled up to 28 weeks. Safila is quite stoic, and it’s unclear whether she understands (she speaks some English but Rose often translates for her), but Rose looks like she is going to cry with happiness.

We send off some blood work to make sure all of her levels are ok for enrollment, and tell her to come back in a week. Three days later, the labs come back. Her platelets are extremely low – normal is 150 or greater, and they are 35. For enrollment, they must be 50 or greater. She cannot enroll. In addition, her CD4 count – a marker of the severity of her HIV disease – returns and is extremely low – it is 40. She has AIDS.

I worry about how Rose is going to take the news, but she immediately understands and accepts this. I assure her that, although Safila cannot not enroll in the study, I will continue to follow her personally with support from the specialists in Kampala and San Francisco.

Safila does qualify for ART because of her low CD4 count. Because of the platelets, we are reluctant to put her on the first-line medications, which would include AZT. Options are limited here, and many patients would get Stavudine, a drug that is no longer used in the US (for the most part) because of bad toxicities like permanent nerve damage. Through some serious legwork, I manage to discover that the hospital has a supply of Truvada, which is a newer combination regimen that we do use in the US, and is very good with few toxicities. I am taking the risk that they will run out of Truvada later, but I decide I will deal with that if/when it happens.

I start Safila on Truvada and get updates from Rose on how she is doing. We discuss the bouts of vomiting, and other complaints. We don’t find evidence of any underlying opportunistic infections in our workup. At first, I see Safila weekly to monitor her reaction to the ART. She seems to do well, so we space out the visits to every 2 weeks.

After some time, Rose mentions to me that recently Safila has been feeling worse. She has been vomiting daily for weeks now, and has bouts of diarrhea that come and go. It just so happens that G, an Infectious Disease fellow from UCSF, is visiting, and I take advantage of his presence to get help with management. I have support from my mentors in San Francisco, but it is nice to have someone who can lay hands on the patient.

He gets a more thorough history from Safila and from Rose. We discuss the possible causes of her symptoms. With limited diagnostic tools, we are unable to do a satisfactory evaluation the way we would at home (or even in Kampala). We decide to treat her for both a parasitic gastrointestinal infection and a bacterial one. We prescribe mebendazole and metronidazole.

It is at this visit that I look more closely at both Rose and Safila. They are sisters, but until now I didn’t realize how alike they look. They have the same full lips that appear pursed at rest. They have heart-shaped faces and prominent cheekbones. They have similar skin color, but Rose’s is shiny and healthy, while Safila’s is mottled and dull. Still, after a few weeks of therapy, Safila is starting to perk up. The most dramatic difference between Rose and Safila is that Safila is profoundly emaciated. Her skin clings to her bones, and emphasizes her cheekbones and the angle of her chin. If Safila were healthy, she would look a lot like Rose.

After taking the medications that G prescribed, Rose reports that Safila is feeling better. The vomiting still occurs but is less frequent, and the diarrhea has resolved. However, there is a new problem. Rose suspects that Safila is not taking her medications, at least not every day. Safila consistently refuses to be observed while taking them. She insists on taking tea or eating a specific food with her meds, something that will delay until after Rose needs to leave for work. Safila then ran out of one medication but not the other, and when Rose counted the ARV pills, the wrong number of pills was in the bottle – which could indicate “pill dumping” – when a patient doesn’t take her medicines but then dumps a bunch of pills at once to make it look like she has been taking them.

Rose has tried to discuss this with Safila multiple times, and is feeling worn down. Safila reacts badly to the subject, refusing to discuss it and becoming defensive and rude to Rose. I can sense Rose’s frustration, and also her fears for the baby. Safila’s viral load was quite high before starting ART; if she doesn’t take meds before delivery, she will have a high chance of transmitting to the infant. In addition, Safila’s own health is terrible, and these drugs could really save her life. Without them, she will die soon.

Rose and I strategize on how to talk to Safila. I offer to counsel her further, but Rose knows the language issue will get in the way of having a real, firm conversation about medication adherence. Rose brings Safila to talk with one of the TDH midwives, who gives her a serious talking to about the importance of ART and the consequences of non-adherence. It’s unclear if it helps, but it does improve Safila’s anger surrounding taking the meds.

I get a repeat viral load after 2 months on ART, and it has not decreased. That is not a good sign.

I arrive at work on a Monday morning and Rose tells me that over the weekend, her sister has become paralyzed. I am alarmed, and ask her to tell me what happened. On Saturday, Safila suddenly had severe weakness of her legs, and couldn’t move them at all. On Sunday, she regained a little movement but was still extremely weak and could only walk with 2 people supporting her. I ask Rose to bring her into the clinic.

I am feeling out of my league. I try to examine Safila thoroughly, doing a neurological examination that I remember from medical school. I ask about associated symptoms, test for sensation and strength, and try to work it out. I call two doctors in Kampala for help, and they advise me on additional examinations I can do. I email my mentors in San Francisco. I also contact a friend who is a neurologist for more help.

I get a lot of excellent advice. Unfortunately, most of it involves tests that I don’t have access too, and all of the possible diagnoses have terrible prognoses. The pattern of muscle weakness is very strange, and hard to categorize into one particular phenomenon. The basic labs I send off do not help. The weakness improves over a few days, to the point where Safila can walk supported by only 1 person. When the weakness improves, pain arrives, and Safila complains of a pins-and-needles sensation, especially when walking.

A few weeks later, I hear that Safila has gone into labor. She is preterm – only 34 weeks. I go to see her in the labor ward. Rose is there with her, in a private room on the ward. She is in early labor. Rose is very grateful for my presence; I couldn’t imagine not being there. We discuss the labor pattern and it sounds to me like the midwives are doing everything right. We confirm the timing of the ART and I reassure the midwives to continue with their plan. I also get some advice from San Francisco on what medications to give the baby, especially in light of the fact that the viral load is still high.

Safila will need someone to care for her overnight, but I also know that Rose needs to work. I ask Rose what she is going to do. She says she will sleep in the hospital caring for her sister all night, and then go to work in the morning. Amazing.

The next day, I hear that Safila is close to delivering. When I arrive on the labor ward, Safila is almost fully dilated. The labor pattern is good, and Safila seems to be tolerating labor fine. She is as stoic as ever. I notice that she is able to squat to urinate, which is a good sign of muscle strength improvement.

I know that Rose is going to deliver her sister’s baby, and I am worried that she is going to take risks to do it. The midwives do not have proper gear, and they are constantly exposed to HIV-infected blood. I encourage Rose and the other midwives to be careful, to protect themselves, and remember that their safety is the most important. I can tell that Rose is very concerned about her sister.

Soon, I hear that Safila has delivered, so I rush back to labor ward. Safila is doing ok, and the baby, a girl, is fine too. Very small (1.8 kilograms) but cute, and healthy. Rose looked relieved and thrilled. She tells me the story of the delivery. The baby was breech, and the delivery was very difficult. They had a hard time getting the head out, and nearly had to call me, but then Rose managed to get it out. The baby was tired and required immediate resuscitation, but perked up immediately and was crying well. Rose marveled over how beautiful and perfect the baby was. She is so relieved that the delivery turned out well. I can see the weight lifted from her shoulders.

We agree that Safila should not be discharged too soon, both for her and for the baby. We start the recommended medicines for the baby, and continue Safila’s ART. The next day, Rose approaches me with concern about breastfeeding. Safila’s milk has not come in, and Rose is concerned that it won’t because Safila is so severely malnourished and emaciated. It is a valid concern. In addition, Rose is concerned about HIV transmission through breastfeeding, but it is clear from the data that infants who are not breastfed (especially preterm, low birthweight infants) have a high risk of death. We agree to have Safila continue trying to feed, and I tell her I will look into alternatives, just in case.

The next day, Rose tells me that Safila’s milk still hasn’t come in, and Safila seems to show no interest in trying to breastfed. Rose has started buying cow’s milk and diluting it for the baby. There isn’t really any very good other option, so we stick with that. Once it is established that both mother and baby are doing well and have no signs of infection, I discharge them. I know they will be well cared-for by Rose.

On Monday, Rose stops me in the hallway. She tells me that the baby died over the weekend. I am stunned. I can tell she is upset, despite the Ugandan reserved stoicism. I pull her into a room and ask what happened.

She is clearly overwhelmed and still processing. She tells me that she suspects her sister killed the baby. She recounts the story for me, and I can see what she means. The baby died overnight. It is not clear what happened, but Safila’s response was completely inappropriate. Rose tells me that Safila insisted on sleeping with the baby for the first time, and Rose did not want to separate a child from her mother, so she gave Safila the baby. Safila did not wake Rose for any problems overnight, and in the morning did not say anything at first. After Rose had made tea, Safila told her “Your little thing is dead.”

Rose grabbed the infant and started resuscitation, but it was futile. The infant was long dead. Rose suspects that Safila smothered the baby. Rose tells me that she is not pleased with her own reaction. She became angry with her sister and accused her. As she recounts the story, I can tell that Rose is rethinking everything she did, blaming herself for not seeing it coming. She defends her decision to allow Safila to care for the baby that night – but who would separate an infant from its mother? Rose did nothing wrong – there was no way she could have anticipated this.

I try to consider all possibilities. I explain the phenomenon of SIDS (sudden infant death syndrome). This infant had several risk factors for SIDS – including being preterm and sharing a bed with her mother. In addition, malnutrition could have played a role (although the baby was still quite young to have starved just yet). I can see Rose’s point, that Safila’s behavior is suspicious.

Regardless of whether she killed the baby, her reaction is inappropriate. Not once in the days after the baby’s death did she express sorrow. We discuss this at length, and it is clear that Safila has been suffering from severe depression, probably for years. She seemed detached from the pregnancy all along, although we just assumed it was cultural stoicism. Whereas Rose had poured hope and love into that infant, Safila seemed to have viewed the baby as a burden. Safila had already buried 4 husbands, and seemed to have given up on life. Was this infant a sudden imposition of hope that she didn’t want to have? Was the baby an obstacle to Safila’s passive descent into death?

I try to comfort Rose, but there is only so much I can say. I would like to get Safila psychiatric treatment, and Rose agrees but doubts that Safila would be open to it. There is not much available in Tororo; there is a mental health clinic with nurses, but no real therapy or treatment available. At least we could try. (Later, Rose brings it up, and Safila swiftly declines to discuss the matter.)

In processing the situation, Rose tells me more about her sister’s behavior in the past. Rose admits that she has always thought that her sister was selfish and reckless, including how she cared for her two living children, often carelessly and needlessly exposing them to contracting her HIV. It is amazing to me that given this history, Rose still fought tooth and nail for Safila’s (and her baby’s) life. She dragged her from the village, got her HIV testing, found her treatment, moved her into Rose’s own house (with her family), fed her, cared for her, slept in the hospital with her, and delivered her baby. All of that extraordinary effort was validated when a healthy baby girl was born, and Rose loved that baby immediately.

A few days later, the DNA PCR (HIV test) results return from the baby at birth. The baby was negative for HIV - we had managed to prevent transmission. It is almost sadder to know it.

Every few days, I check in with Rose. She is still caring for her sister. Miraculously, the weakness and muscle pain resolve almost completely soon after the baby died. I am not sure what to make of that, but it is interesting. Rose also seems to have more success at getting Safila to take her meds observed. However, Rose is worried that her sister will return to the village, now that there is no longer motivation (ie. the pregnancy) to continue coming to the clinic.

I go on vacation, and when I return, Rose has news for me. She tells me that her sister died while I was away. Safila decided to go back to her village, despite Rose’s request for her to stay. In the village, Safila stopped taking all her meds, including Septrin, the daily antibiotic that prevents opportunistic infection. One evening, according to the neighbors, Safila seemed well, was talking normally and had taken food and water. That night, she died quietly. They had the funeral while I was still on vacation. I was very sorry to hear I had missed it.

Rose tells me that, despite her resistance, Safila recognized how much effort we had put into helping her. A woman who was with Safila in the village before she died told Rose that Safila had frequently expressed gratitude for the care. She had said, “My sister did everything to help me get better. She even got me a mzungu doctor!” Rose and I laugh about this appreciative comment, but at the same time we are saddened by a truth that we had told each other all along: you can’t save people from themselves.

The next day, there is a note posted on the clinic message board, and a copy of it on my desk. It is a sincere note from Rose thanking those of us who helped her to care for her sister. “This is to thank all the IDRC and TDH staff who stood with me at the time of my sister’s sickness, up to the time of death. May her soul rest in eternal peace. Special thanks go to Dr. Veronica and Dr. Julia for all the efforts they made in an attempt to save her life and to all the entire staff. God bless you indeed.”

It is hard to describe how moved I was by this letter, and by Rose herself. A compassionate woman who cares for people not only because it is her job, but because she truly cares. Although she is employed by the research clinic, she often goes to the Labor Ward after work to help out the Labor Ward midwives when they are overwhelmed. I have seen Rose’s selflessness in action many times. When I told her about a terrible rape case I had seen, she rushed over to console and counsel the young girl herself, and arranged for a social worker to come. When I told her that one of my surgical patients had unexpectedly tested positive for HIV, she accompanied me postoperatively to provide HIV counseling to the woman in the hospital. When the TDH midwives were arrested, Rose went and covered the labor ward for them so that the patients wouldn’t be unattended. Most movingly, she stood by her sister despite a history of bizarre behavior, despite great difficulty and resistance to Rose’s attempts to help her.

I know that Rose is grateful to me, but I am in awe of her: her strength, her selflessness, her loyalty and her resilience. She is an inspiration to me.

Wednesday, May 12, 2010

MVA Training

A manual vacuum aspirator is a wonderful thing.

It allows for uterine evacuation very easily. Without suction, a D&C requires a lot of scraping, which is slow and more dangerous (higher risk of uterine perforation)

An MVA looks like a giant plastic syringe with a long tube on the end of it. The long tube is called the curette. It is plastic, bendable and soft, which has a lower risk of perforation than a metal sharp curette. By pulling back on the syringe, a vacuum is created inside, and once the curette is inserted into the uterus, the vacuum creates enough suction to remove the uterine contents (aka products of conception).

It is remarkably easy to use, and is efficient and gentle enough that it can even be done without anesthesia in the right patient.

I thought that learning how to use an MVA would be great for the Labor Ward nurses. Normally, when a patient comes in with incomplete abortion, they need to call for a doctor who may never come. If she is bleeding and in pain, the best thing for her is to take care of the problem quickly. Since her cervix is already dilated, there is no need for painful manual dilation. In fact, once the pregnancy is removed, the patient feels better so quickly that the whole MVA process is essentially rapid pain relief.

So the other day I had a training with the TDH midwives to introduce them to MVAs.

I had heard that a papaya (or paw-paw, as it is called here) is a good replacement for a uterus because of the size and the texture inside. I bought 2 papayas at the market (for $1) and brought 2 MVAs to the Labor Ward yesterday.
Hence the papaya seeds inside the "products of conception."

The training was a great success. The midwives seemed apprehensive at first, but in the end, each one wanted her proper turn, and demanded to have her photo taken while suctioning the papaya!

Now that they have practiced using the MVA, I hope to teach them when real incomplete abortions come in, so that at least a few of them get comfortable with it. Instead of calling a doctor who won't come, or referring a bleeding patient to a place where she will be turned away for lack of money, they can quickly and safely evacuate the uterus and save the woman's life.

Sunday, May 9, 2010

Medico Legal

I went on vacation for a couple of weeks recently. When I returned, everyone on labor ward welcomed me back warmly.

“We missed you!” they said. “We had to refer SO many mothers!”

Sigh. Apparently, if I’m not around, no one does the cesareans, and they all get referred to St. Anthony, the private hospital.

As I was chatting with some of the midwives, I learned that while I was away, a woman died after delivery. I feel guilty. I know in my head that it is OK to go on vacation, but it seems terrible that a woman should die just because she had the bad luck to deliver when I was on holiday. It’s just as bad as a woman dying because she comes in after 5pm. It makes me wonder what is going to happen when I leave in 2 months. I guess this was the preview.

She died of hemorrhage. She was delivering her seventh child, and she came in and delivered very rapidly, and started hemorrhaging right away. When a woman gets postpartum hemorrhage, it can be a slow, insidious hemorrhage that just won’t stop, or it can be a rapid, frightening, unbelievable amount of blood. The uterus has a massive blood flow in pregnancy and if that’s not reduced after delivery, she can die within a matter of minutes.

This woman died in two hours. In that time, the midwives were unable to give oxytocin because the hospital had run out. They were unable to give ergometrine (methergine) because it had run out. They were unable to give Hemabate because it is too expensive and isn’t available in Uganda. They were unable to give misoprostol because the hospital has never had any – it was banned in Uganda until this past June because of fears that it would be used for illegal abortions.

The midwives here are quite good at infant and maternal rescusitation – they can do bimanual massage, hang fluids and give the right medicines if they are available. But they can’t do anything surgical. They called for help, but no one came.

The lack of oxytocin is a reflection of a larger problem. The hospital has not received its shipment of many supplies and medications because the payment to the National Medical Store, which is transferred directly from the Ministry of Finance, has not been made yet. The hospital usually operates at a bare minimum, and now they have reached far beyond the ridiculous. The hospital is out of metronidazole (a common antibiotic known as Flagyl, one of the few antibiotics they ever have), HIV testing kids, and syringes, to start. They have been out of skin cleanser for weeks, so instead of scrubbing the patient’s skin before surgery, we pour saline over it, which is pointless, but makes us feel better. Gloves are scarce. Patients (or their family members) are being sent to town to buy gloves and syringes so that medication can be given.

The midwife who tells me about the maternal mortality told me another story, equally disturbing in a different way.

A few days ago, three TDH midwives were arrested.


Yes: Arrested.

This is what happened, as it was recounted to me. A woman was admitted to Labor Ward with severe malaria. She was started on IV Quinine, and during her admission, she went into labor. Her labor course was normal, but when she reached around 6cm dilation, she started pushing. This was her first baby, and she was thrashing wildly and not listening to the midwives as they exhorted her to stop pushing.

Pushing against a cervix that is not fully dilated is not a good idea. It can cause the cervix to swell – which can impede dilation - and pushing against a cervix can hurt the baby if it is prolonged and forceful enough. This is one of the myriad benefits of pain management in labor – it reduces the urge to push before the body is ready – but that is not an option in Tororo.

Finally, the patient reached full dilation and managed to deliver. Upon delivery, the baby seemed very tired, as the midwives say. The stress of labor had caused the oxygen in the baby’s blood to decrease, and the acidity to increase. This is what is known as birth asphyxia, a frighteningly common outcome in poor resource settings.

Some infants who look hypoxic upon delivery are merely transiently depressed – they get resuscitation and perk up immediately. Resuscitation can include stimulation, oxygen, assisted ventilation, chest compressions, and administration of dextrose. In my experience, the midwives here are pretty good at resuscitation – they aren’t as structured or formal about it as we are in the US, but they do everything they can do. However, often oxygen is not available, and that is a key component.

Some infants are worse off– the ones who have been compromised for longer – and do not perk up with resuscitation. In order to predict the long-term outcome of the infant, we use the Apgar score at 1 minute after delivery, and 5 minutes after delivery. The first number tells you the almost immediate status of the infant, and the second number tells you how the infant did with resuscitation. If that second number is still low, it is not good.

In this case, the infant had Apgars of 3 and 6 (out of 10). So it did improve, although not completely at 5 minutes. Eventually, though, the infant looked well and was put under heating lamps, and later given to the mother.

The midwives decided to give the infant Gentamicin (not sure why, it is common here), and when it was time for the dose, they had to send the husband to town for syringes. When he returned, they went to give the IV Gentamicin, and found that the baby looked unwell and re-initiated resuscitation. The resuscitation failed and the baby died.

A few days later, the Tororo police came to arrest the midwives who were involved with the care of the mother and the infant. From what I hear, there was some confusion, and a lot of stalling for time. The police seemed perturbed to be arresting the midwives without being allowed to make a formal complaint.

The three midwives were taken down to the police station, and other midwives gave statements from the labor ward. The three arrested were charged. The midwife who delivered the baby was charged with assault (apparently the woman was charging that the midwife had beaten her and caused the baby to die). The midwife who performed the resuscitation was charged with child neglect. And a third midwife was charged, but I am not sure with what.

I heard the story from various people, and everyone had different pieces of information. It was confusing for that reason, and also because in the end, it made no sense. Why would a midwife beat a laboring woman so badly that it would cause the death of a full-term fetus? The woman would have to have some serious injuries for that to happen - did she? And there are usually many people in the labor ward – it could never happen without being witnessed (abetted, really) by other midwives, patients and family members. The idea of it is just preposterous.

In addition, the way the matter was handled was suspicious. If the patient and her family were unhappy with the care they received, why didn't they go to the hospital administration immediately, instead of waiting to be discharged and then going to the police? And why was the matter reported to the Kampala police when the incident occurred in Tororo? And on top of that, why were the Kampala police commanding the Tororo police to arrest without investigating? It was not consistent with proper procedure, and the Tororo police were not happy about it. There were suspicions that some family member of the patient had connections in Kampala with either the police or an important politician. It's all conjecture, but it is highly possible, given how strange everything was.

It sounds as if that baby had plenty of reason to do poorly. The woman went into labor while being treated for severe malaria – malaria in pregnancy is associated with both stillbirth and neonatal demise. An earlier episode of malaria might have weakened the fetus even before this episode. Pushing against a closed cervix for a long period of time can be dangerous for the fetus – the uterine forces combined with valsalva can be a lot of pressure on the fetus’ head, and if it is prolonged, can cause damage. It would make sense that the feuts had a localized swelling on its head where it was being pressed against the cervix. Lastly, this was the patient’s first delivery. Most likely her labor course and length of pushing was longer than multiparous women – more time for birth asphyxia to develop, especially in a previously compromised fetus.

I heard from one of the midwives that the family had taken the body to Mbale for an autopsy, and that the autopsy result was apparently absurd. The report, I was told, declared that the infant died of “poor resuscitation” and “neglect.” In case you are wondering, neither of these is a cause of death. A cause of death is something like “respiratory failure” or “trauma” or “hemorrhage.” Furthermore, the person who wrote the report could never have known if the resuscitation was “poor” and the child was “neglected” unless they had been there at the delivery. If this is really the autopsy report, there is suspicion that someone was paid off to make this report, or else the person who did it was non-medical.

The midwives, needless to say, were up in arms. If those three can be arrested (and I know all three – they are good, skilled, competent midwives), then any of them can be arrested. And for that matter, so can I. These midwives work for pennies, they always show up for work (unlike almost everyone else) and they work HARD. I am volunteering my time – I don’t need to be there at all, and yet I go there to work 7 days a week. None of us needs the threat of prosecution added to our concerns.

After being charged, the arrested midwives needed someone to stand for them to be released on bond. Each was able to have either her husband or a fellow midwife stand for her, and they were released and told to return on Tuesday.

The midwives clearly needed to vent, and they talked over each other to tell me the different parts of this crazy story. Finally I asked them what I could do to help them. (In some situations here, having a mzungu helps but in some, it hurts. If money is involved, you will always be charged more if you have a mzungu with you.) They asked me to go and speak with the hospital administration and ask for their support of the midwives.

It was Saturday when I first heard the story, and I stewed all the way until Monday, anxious to speak with the Senior Hospital Administrator. When I did meet with him, I first asked him what the situation was. He recounted the story for me from his perspective, which was similar to the midwives’ perspective. He was not here when the police came – which would explain why he was not able to go to the police station that day.

I then told him that the midwives were very upset and I was alarmed. He was quite sympathetic and concerned, and together we decided to call a meeting with the midwives to reassure them of the hospital administration’s support of them. We also agreed to have the Nurses and Midwives Council Representative contact the Council in case they needed further assistance, like legal representation.

By coincidence, we had scheduled the meeting for the exact same time that the midwives were scheduled to report to the police station, so we decided to delay the meeting. Several midwives were planning to accompany the accused midwives to show support. I asked them to decide whether it would be better or worse to have me there. They decided it would be very helpful, and so I dropped everything to go down there. In addition, the Operating Theatre staff also wanted to attend to show support.

We gathered in groups to walk to the police station, about a 15 minute walk. I walked with several of my favorite midwives. It was a great walk. We laughed, held hands, made mzungu-Ugandan jokes (“Mzungus talk funny!”) One midwife started singing a civil rights song, and then I started in with “We Shall Overcome.” One midwife started explaining to the others that mzungus bring so many things to Africa to help Africans, and that mzungus have taken on the burden of Africa. I tried to explain gently that it was a bit more complicated, that mzungu countries are not exactly innocent (in the past or now), but they didn’t really care. They were mostly trying to say they were grateful for the mzungus who come to help, so I didn’t push the discussion.

When we got to the police station, we waited. The three arrested midwives were sitting inside an office, and as a large group, we waited outside. Then I decided to take some photos since I had so many midwives in one place, and they were all dressed up beautifully. I tried to have a random man take a photo of us with me in it but he couldn’t handle framing the photo, holding the camera still, and pressing the button (which I’ll admit I have always taken for granted), so the picture is askew and cuts off several heads. Still, I got some good ones.

We waited and waited. We chatted about various things. More people arrived, including both anesthetists, some nurses from other wards, a clinical officer, and eventually the Senior Hospital Administrator. We were probably at least 20 people at that point. We kept expecting the police to finish their paperwork and then head down to court for the hearing, and all of us planned to follow.

Finally, after about 45 minutes, the police told the midwives that they were still not sure about this case, and they wanted to investigate further. They told the midwives to go back to work, and the police would call the midwives if/when they were needed.

I didn’t understand at first, but it turns out this is a very good outcome. It means the Tororo police (we think) are not happy about being forced to arrest without being allow to investigate, and are suspicious that the charges were made in Kampala and not Tororo. Hopefully, this will lead to a quick resolution for these falsely accused midwives.

Nonetheless, the episode has put everyone on edge. It is scary to think that this kind of thing could happen again (although admittedly it is rare). Working here with the bare minimum – and now even less than the bare minimum, without even syringes to give medication – bad outcomes are going to happen. We can do our best, but these are not the best circumstances. Babies are going to die, and sometimes mothers. The only way to prevent this is to improve the system, and that takes political will.


One of the midwives who walked with me to the police station asked me about the malpractice situation in the US. She was thinking about applying for a nursing job there, but was scared off by all the rumors she had heard about lawsuits. Thankfully, physicians, nurses and midwives in the US are not at much risk of being arrested, but the threat of litigation is indescribably stressful and has damaged the practice of medicine.

In Uganda, bad outcomes are assumed to be part of life – despite what we do, sometimes they happen. In the US, we have reduced the morbidity and mortality associated with birth to such a degree that we have forgotten what nature really does. We can control it – or so we think. When bad outcomes do happen, we are shocked because they are so rare, and we assume it must be someone’s fault. If the outcome is bad, there must be someone to sue. Babies don’t die being born, women don’t die in childbirth.

We tell ourselves that our litigation system provides the motivation for doctors and nurses to do the right thing. Working here, I doubt that theory more and more. These midwives are not in fear of litigation and make very little money, and yet they work extremely hard under frustratingly limited circumstances. Their work ethic rivals that of even the most hardworking health professionals in the US, and I think job satisfaction and camaraderie have a lot to do with that.

Because they are not blamed when bad outcomes happen, they can take risks that we can’t. They deliver breeches vaginally. They can wait for a protracted labor to take its course. When a cord prolapse happens (the cord comes out before the baby), they don’t run to a crash c-section; they know the baby is going to die. It means the c-section rate is lower, but it also means that infants die when they don’t have to. Is this good, or bad?

In the United States, we are schizophrenic. We blame obstetricans for over-medicalizing birth, and yet when bad outcomes happen, we want to sue them for not preventing it. We beat our chests over the high c-section rates, and yet birth asphyxia, stillbirth, neonatal death and maternal death are unacceptable outcomes. We allow the natural birth movement to make a lot of noise, but we can’t accept what nature actually does during birth. We want to have our own personal physicians care for us for nine months and then come in at the drop of a hat to catch our babies, but we don’t want to pay doctors enough to make that possible.

Where would I rather give birth? Hands down, I would rather be in the United States. I want safety, resources and an epidural.

Where would I rather work? I am not sure. I am tired of working long hours, skipping meals and giving up my personal life to care for patients in need, only to hear stories at parties and on TV and in the newspaper about how terrible, greedy, arrogant and selfish doctors are. I don’t mind working hard, but the constant haranguing is demoralizing.

I want to work in a place where I have the appropriate resources to help my patients, but I also want to work in a place where people appreciate what I am doing. But it seems that the more resources we have, the less we appreciate it.