So here we are towards the end of October. I'm a bonafide med student, 10.5 weeks in, white-coated, stethoscoped, 3 exams survived (and passed!), 3 more exams looming a couple of weeks away, oodles of enzyme names floating in my brain...what happened to my promise to keep up the blog during medical, you ask? It's actually not that I've been too busy. (Busy? Yes. But too busy to spend a few minutes a week doing some reflective typing? No.)

The thing is, we got this talk the first day of school. The technology and digital footprint talk. It went something like this: you're medical students now, entering the medical profession--we have high professional standards of conduct, so don't let some online meandering thoughts reflect poorly on you. You have to get into residency a few years from now. They will scrounge up all the dirt they can find in your digital footprint...everything from the drunken parties captured in facebook photos to the disgruntled blog entry where you slammed a professor out of the need to vent. Oh, and then there's that thing called HIPAA, and we wouldn't want anyone intentionally or unintentionally violating HIPAA, revealing private patient information in an online forum. And, oh wait, what would you do if a patient requested your friendship on facebook? (See the required reading they gave us, from the New England Journal of Medicine on Practicing Medicine in the Age of Facebook

Take-home messages: Sweep away your digital dirt. Adjust your privacy settings on facebook. Untag yourself from irresponsible-looking pictures. And, think twice about blogging about medical school.

Hmmmmm...so I guess that's what I've been doing. Thinking twice about blogging about medical school. And I still haven't made up my mind. I do know that I miss blogging for that reflective pause it gives me. Time to reflect on what's happening, and assemble those thoughts and observations (in a hopefully semi-interesting way) in a blog entry. Go back two years later and see how you've changed, grown, stayed the same. But...are those all things I can accomplish in a private journal? Do I want future patients, residency admission committees, and classmates to scrutinize my journey, read about my weaknesses, joys, frustrations, strengths? But then, on the flip side, I think about some really fine medical school blogs I read in those intolerably exciting months leading up to medical school. They gave me an insider's view, and answered questions about what to expect, what it's actually like going through med school, the highs, the lows, the challenges, the joys, the milestones. I learned from them, laughed from them, sympathized with the authors, and they forced me to contemplate on the journey I was about to embark on. So, maybe these positives outweigh the negatives? One thing that concerns me, as I continue to mull over this, is that I realize that dozens of those golden first impressions are going unblogged, unjournaled, un-anythinged (aside from of course, discussions and correspondence with family and friends).

Yeah, so I'm still thinking. One thing I'm thinking about is creating a blog that's either less open to the general public (I have to invite you to read my blog), or a blog in which my true identity (Heatha like the Weatha) is concealed. Thoughts?

Posted by Heather at 1:53 AM | 3 comments    
Labels: blogging, medical school

My goodness how time has flown. Our departure date is staring us in the face--a mere 36 hours away. We are moving to a new home in a different continent. Med school starts in 12 days. Wow, life's gonna change quickly and dramatically. No time for long blog entry now...I'll probably update again once I'm on the other side of the Atlantic.

Posted by Heather at 11:09 AM | 1 comments    

I've written on here before how exciting it has been to witness Obama making history from an African perspective. I watched the election night results come in in the wee morning hours at a restaurant/bar in Kampala, I felt my first pangs of pride for being an American, I marveled as Ugandans embraced him as one of their own, I watched the inauguration from a tiny, overcrowded restaurant up-country in Mubende.

Yesterday was no exception. Obama made his first visit to sub-Saharan Africa, making a highly anticipated speech in Accra, Ghana. All of Africa was watching.

Many Ugandans feel that Obama is a Ugandan (at heart, by blood, by tribe). Obama's father was from the Luo tribe, which actually extends across the Kenyan border into Uganda. Therefore, Obama is Ugandan. But I think across sub-Saharan Africa, many Africans feel this raw connection to him and are overwhelmed by the hope, joy, and pride that that connection stirs.

The whole speech had me buzzing with excitement, and I know that this continent was buzzing with the same excitement. I don't know how important/followed/anticipated this speech was in America, but in Africa it was huge! I think one of the things that excited me was that this man has the power to re-cast Africa in the world's eye not as a dark, diseased continent, but the way I see it: a land of abundant opportunity, a land where hope prevails, a land set for exciting growth and change, a beautiful land with rich and diverse cultures, a land that does matter to the rest of the world, and a land that of course still has challenges--but challenges we can overcome.

Obama's speech yesterday (Kris and I caught it on BBC radio) was, I thought, very poignant. He essentially re-branded Africa as a land of hope and opportunity, while emphasizing shared responsibilities. He said that Africa's future is up to Africans, and focused on four key areas for the continent: democracy & good governance, creating opportunities, strengthening public health, and peaceful resolution of conflicts. He called upon young people in Africa to bring about change, with the words of encouragement: Yes, you can!

As a public health professional, I was thrilled to hear health--with a focus on systems strengthing, primary health care, and prevention--featured so centrally in his speech. I was glad he highlighted the US's comprehensive global health $63Billion commitment. I also liked the way he addressed good governance and corruption. I had to wonder if Ugandan president Museveni wriggled in his chair when he heard Obama say, "Now, make no mistake: History is on the side of these brave Africans, not with those who use coups or change constitutions to stay in power. Africa doesn't need strongmen, it needs strong institutions."

Oh, Obama, we love you. But of course, some Africans (including Ugandans) are winding down their Obama honeymoons. This has been evident in the local press. For example, I read an opinion article expressing the first pangs of discontent with Obama from more conservative and religious Kenyans who were disappointed with his reversal of the Mexico City Policy. I was a little disappointed with the sensationalistic coverage in the Ugandan Daily Monitor, where today's headline (post-Accra speech) exclaimed, "Obama attacks tribal politics; there is no cause for alarm - Kampala."

I'm going to miss experiencing Obama from Africa, but I'm also excited to live in the US under his presidency.

Posted by Heather at 10:40 AM | 1 comments    
Labels: Africa, corruption, Obama, politics, public health, Uganda

Well, it’s Day 6 of symptoms and the worst of malaria episode number 2 is behind me. I am feeling much, much better, but still left with a residual spinning headache and drained of energy. It’s hard to fathom that I could still be tired after all the sleeping I’ve done the past six days, but my poor body is still drained of energy.

Despite how much it sucks, the silver lining of getting malaria is that it’s a learning opportunity. I think I mentioned on my blog during my first (and far worse) battle with the ole’ malaria buggers, that if I had to pinpoint something good out of the whole experience, it was the perspective I gained as a patient regarding the lived experience of the disease. It really doesn’t compare to the type of textbook-learning I’ll be doing in medical school!

Anyways, I’ve been trying to supplement the experiential learning with some online reading, and wanted to share some insight on the life cycle of malaria parasites and what it does to your body. Let me preface this by saying that malaria and reading don’t jive together very well (hard to read or concentrate when your head is whirling)…but here’s what I gleaned...

The type of malaria that predominates in Uganda is from the parasite plasmodium falciparum. All it takes is one bite from an infected female anopheles mosquito. During the bite, it injects about 15-20 sporozoites into your blood, which make their way down to your liver. In the liver, the sporozoites divide quickly over the next few days, until the liver cells burst, releasing upwards of 600,000 merozoites into your blood.

The merozoites find their way to your red blood cells, thus becoming trophozoites. The trophozoites hang out silently over the next two days as they continue growing. Up until this point (7 days after the bite), the malaria sufferer will have felt no symptoms, and gone about their normal life. After the two days of growth, each trophozoite divides into 32 new baby merozoites, causing the red blood cells to burst as the next generation of merozoites is released into the blood. The 2nd generation merozoites find additional red blood cells to hang out in, become trophozoites and start over again.

Symptoms start when the red blood cells start bursting as this releases toxins into the blood. These toxins are what cause headache, fever, projectile vomiting, achy joints, and other classic symptoms of malaria. Often there's not enough parasites in your blood by Day 7 to feel any severe symptoms, but you may just feel fatigued. But by Day 9, (after the 2nd generation trophozoites have time to grow and burst the next set of red cells), that’s when most people start feeling stronger symptoms (headache, fatigue, stiff neck). By Day 11 (after the 3rd wave of red blood cells burst), you’ll feel pretty awful (fever, vomiting, headache). The generational bursting of red blood cells explains why malaria symptoms tend to come in waves, with peaks every two days. This also explains why it is absolutely crucial to get treatment early—every two days the parasite level increases tenfold or more, with symptoms escalating too. If you’ve failed to get treatment by Day 19 (post-bite), you risk multi-organ failure and cerebral malaria.

Based on this research, I’m pretty sure I got my malaria test and started treatment on Day 11, when the real ugly symptoms started to show their head, which means the culprit mosquito bite would have occurred the night of June 24th. Guess who happened to be visiting me in Ssembabule that night? That’s right, Kris. So we both must have been bitten by the same mosquito that night in our hotel room in Ssembabule.

Of course malaria can play out slightly differently in different individuals. Case in point, Kris and I had alternating waves of severe symptoms. On the day that I was sick as a dog, Kris thought he was getting better; the next day he took a turn for the worse, while I felt slightly improved; and on and on like that. If our red cell bursting had been in sync, we wouldn’t have been able to take care of each other as well! (We also had Kris’ bro Julius here with us all week, taking care of us, keeping us hydrated and fed.)

The process I described above is how malaria plays out in someone with little to no immunity to the disease. Apparently it takes 6 bouts of malaria within 12 months to build up any sort of immunity, so that rules out both Kris and myself as immune! In someone with immunity, their immune system puts up various lines of defense to destroy cells with parasites in them and clear away toxins from burst red cells. Someone with immunity built up may not even notice that he has malaria.

The interesting thing is, it’s the people with immunity to malaria who perpetuate the spread of the disease. When parasites encounter a tough defense from the immune system, instead of developing more trophozoites, they develop into male and female gametocytes. When the mosquito bites a malaria-naïve person (like me or Kris), she sucks up some trophozoites, which simply get digested. However, when she bites a semi-immune person, she sucks up the gametocytes, which hatch in the mosquito’s stomach, mate, and produce sporozoites. The mosquito then injects those sporozoites into its next victim.


There you go--some malaria enlightenment!

Posted by Heather at 10:54 AM | 0 comments    
Labels: malaria, Things I don't love about Uganda, Uganda

Currently suffering from my second bout of malaria. Woke up feeling fatigued/funny/naseous/headachey on Sunday; the feeling got worse as the day progressed, and I swung by the neighborhood clinic for a "B/S" (bloodsmear for malaria). The lab tech pricked my finger, did his thing, then came out with a slip of paper bearing my results. "Did you find malaria?" I asked, anxious to get the results. To which he replied "[raise eyebrows]". (In UG, raising your eyebrows means yes.) Had a brief consultation with the doctor, picked up my treatment, and swung by the supermarket to stock up on juice and sprite (staying uber-hydrated is a must for malaria sufferers).

Okay, the next sentence is going to get a little bit nasty, so reader discretion advised. About an hour and twenty minutes after swallowing my tabs (artemether), I could no longer fight the urge to vomit. And I started projectile-vomiting, including through my nose (which was, by the way, an extremely unpleasant experience). Repeat two times, and Kris decides to take me (armed with a kaveera (polythene bag) and taking the potholes and speed humps very slowly) to the AAR hospital downtown. The doctor there said an hour and twenty minutes was sufficient time for the first dose of malaria meds to start doing their job, so he just prescribed an anti-vomitting medication. Meanwhile, Kris had a headache that had worsened throughout the day, so he decided to get a B/S too. Ten minutes later, his results came back--he also had malaria.

We got back home at midnight Sunday night, and now it's 7:15pm Tuesday evening. Monday and Tuesday have been a complete blur of dizziness, achey-ness, nausea, drowsiness, and general rotten-ness and unpleasant-ness. Malaria just takes time get through; you have to give your body over for a good 2-4 days. I've been sleeping 20 out of 24 hours a day, and in a horizontal position for all but 15 minutes of the remaining four hours. Kris doesn't seem to have it quite as bad as me--probably a combination of having caught it very early and his residual immunity. My guess is we both must have gotten bit by the culprit mosquito while he came to visit me up-country in Ssembabule about a week and a half ago. The mosquitoes there were terrible.

The good thing is that I caught this relatively early (within 10 hours of symptom onset), and I should theoretically have some immunity built up from my first bout with malaria circa March 2009, so I'm hoping I'll turn a corner real soon.

Until then, ugggggghhhhh.

Posted by Heather at 7:06 PM | 0 comments    
Labels: malaria, Uganda

I predicted that June would fly by, and, indeed, it did. Most of June was consumed with the KPC (Knowledge, Practice and Coverage) survey that served as the mid-term evaluation of our community-based family planning project. It was a monster of an undertaking (at least compared with the level of activity and logistics we are set up to handle), and I was the one doing all the orchestrating. I had a lot of help from our Ssembabule and Mubende staff and the international volunteers placed here, but I still ended up working myself to the bone. For three weeks straight, I worked 16-18 hour days, including weekends. I was at the office every morning by 7am and didn’t leave until 10 or 11pm, only to go back to my hotel room and continue working for another hour or so. (The bright side of this? Hopefully med school will seem easy and relaxing after this job! I calculated and realized that for three weeks straight, I worked more hours than US medical residents are allowed to work per week!)

So, all this work, what did it involve? Week 1 was the planning week. Planning is generally not a forte for many Ugandans, including many of my staff. Something that could be planned relatively easily and straight-forwardly in the US becomes unimaginably complicated here. So just gearing up for all of the logistics for the following two weeks took a lot of time, energy, and careful spelling-out of tasks. Logistics we had to consider included vehicle and driver hire for the survey pilot and survey implementation, lunches and teabreaks for the training, packed lunches for the survey implementation week, fuel calculations, hiring chairs, how to make the photocopies, finalizing recruitment of interviewers/supervisors, preparing to pay allowances to staff and interviewers/supervisors. In addition to this, we had to adapt an existing KPC training for interviewers/supervisors, and decide upon and establish rules for survey protocols (e.g. household selection, respondent selection, etc.) Another time-consuming task was translating and back-translating the entire 30-page survey to Luganda.

Part of the training prep included coaching our American MPH-student volunteers how to speak slowly. When I’m in Uganda, I tend to slow down my rate of speech by 50% in general (mainly in Kampala), and by 200% when in the field. I watched them visibly struggle to slow down their pace of speech, only to receive feedback from our Ugandan staff that they still couldn’t understand a word they were saying. No matter how much the volunteers felt like they were slowing down their speech, it still wasn’t slow enough. The best advice I heard from one of our Ugandan staff was a stern request to “speak word per word!”

Week 2 was a five-day training of survey interviewers and supervisors, as well as a half-day sensitization meeting for District officials (DHO, CDO, LC3s from each sub-county). The selection of villages was done with the District officials present, so the random process we used was fully transparent. We divided sessions amongst the facilitation team, and each led different sessions. The fourth day of the training was a pilot, where we went out in teams to see how data collection went. We encountered a major hiccup when two of our interviewers dropped out the morning of the pilot, but luckily we were able to train two new ones over the weekend between Weeks 2 and 3.

Week 3 was the actual survey implementation. We had 6 teams, each consisting of a supervisor and two interviewers; when possible, teams were supervised by one of the training facilitators as well. Each team was responsible to conduct 10 surveys with women of reproductive age each of the five days of survey implementation. Supervisors made sure proper protocol was followed, especially in terms of random selection of the first household (using a household list prepared by the LC1 and a random number table), selection of subsequent households (visit every other house), and selection of the respondent within the household. Supervisors also did a field-level check of each survey to ensure no questions had been accidentally skipped, skip patterns were followed, and there were no inconsistencies within a survey. Each survey took between 30-75 minutes to complete (partly depending on skip patterns followed within the survey). Six teams times 10 interviewers a day times five days yielded 300 surveys at the end of the week, all of which needed to undergo a final pre-data entry check, then be double-entered onto two computers with EpiInfo.

Whew! My head is just spinning thinking about everything that this KPC survey entailed! I’m glad the bulk of the work is over, although we’re still finishing up the data entry and need to do some data cleaning as well.

I spent three days plus the pilot actually in the field supervising survey teams and have some interesting stories and photos to share…in a future blog entry.

I can’t believe it’s July 1st! July is also going to fly by. Kris and I have a vacation planned for the week of July 13th (he’s keeping the details secret in an effort to wow and surprise me!). I finish work towards the end of the month, then have just over a week in Uganda at the beginning of August before flying back to Wisconsin (with a two-day sightseeing stopover in Dubai along the way). Then life’s going to change dramatically and rapidly on August 17th (first day of med school)!

Posted by Heather at 8:28 AM | 0 comments    
Labels: family planning, Ssembabule, Uganda, work

Back in Kampala after a loooong three weeks in the field for an amazingly hectic but interesting KPC Survey to assess knowledge, practice and coverage of FP in Ssembabule District. I have some blog entry ideas whirling around in my head related to the KPC and my past few weeks in the field, and also lots of great pictures to share. My internet connection was so poor in Ssembabule that I was unable to post any blog entries.

The other inconvenience of poor internet connection was no source of news. It's hard to even find a newspaper in Ssembabule; any news on the radio is broadcast in Luganda (and I don't have a radio there anyways). The way I found out about Michael Jackson's death? I got a text message at 5:45AM from a former Makerere classmate from Tanzania saying simply: "Michael Jackson is dead!" This friend was a huge MJ fan and was devastated by the news. I wouldn't have known if it weren't for that text.

Got back to Kampala on Friday night and on Saturday Michael Jackson was on the cover of every single newspaper here, with a good 10 pages of each newspaper devoted to the late star. He was huge here. Huge everywhere, I guess.

Kampala always feels overwhelming after spending several consecutive weeks in the bush! The people, the buildings, the traffic, the commotion! All so very different than my base of Ssembabule, and the extraordinarily rural areas of the district I visited for the KPC.

Posted by Heather at 3:16 PM | 0 comments    
Labels: Kampala, Ssembabule, work

Oh, the joys of spending time with people who are **fresh** in Uganda. And I don’t say that sarcastically—there really are joys. It’s been so, so long when I was fresh here that I forget what it’s like, what’s strange, what’s exciting, what’s frustrating, what’s interesting. Everything just seems normal to me at this point. While there is always more to be learned, I very infrequently shocked by anything. My trip to West Nile gave me a taste of freshness. I felt like I had landed in a different country, where I didn’t know the language, the culture, the norms, the lay of the land.

But I’ve also been able to taste freshness through interactions with people who are fresh. May-August is tourist/volunteer/academic exchange “high season,” and I frequently meet with a friend of a friend, or a friend of a friend of a friend for coffee or drinks or a meal. I’ve had several of these meetings lately, in addition to a host of interns placed in my organization, and students and faculty from a number of universities that I’ve met in the past few weeks/months.

I genuinely enjoy hearing people’s first impressions of Uganda, and still laugh at their re-telling of the things that seem old and boring to me (e.g. “Have you noticed that a lot of Ugandans have really long handshakes, where they keep changing grips?”) I never tire of hearing of their enchantment with the beautiful, joyous, curious, friendly children they meet, or even listening to them describe what it’s like to eat matooke. It’s always interesting to hear what it’s been like to witness absolute poverty and severe inequities, and even more interesting when they share their impressions of people’s resiliency in the midst of all that.

Then I also watch them get frustrated (some more than others) when things don’t go as planned. (Essential ingredient for enjoying any experience in Uganda? Flexibility). I patiently explain that flexibility is a way of life here; nothing ever goes as planned. Some people really can’t wrap their brains around what that means; they’re the ones who often end up doing less well.

Interacting with those fresh to Uganda also reminds me of how far I’ve come, and how enriched my life has become in the journey between when I was fresh in Uganda and now. For instance, I’ve realized what a blessing it is to have learned to be totally, irrevocably flexible. This is a skill I’ve acquired in Uganda and something that will serve me throughout my life, in nearly any situation. Throw anything at me, and I can adapt, I can take it in stride, I can enjoy the challenge. What a joy to take life as it unfolds.

Posted by Heather at 7:54 PM | 0 comments    
Labels: culture, expats, Things I love about Uganda, Uganda