These past two days I have sat in on two of the three clinicians to observe how they operate with patients. The first day, Monday, I sat in with Angela and on the next day I sat in with Joyce. But first I must explain a few things. On Mondays, Wednesdays, and Fridays, St. Francis operates on what they call “non-clinic” days. This means that the clinic is open but it is mainly for single appointments or walk-ins. These days are usually less busy than others. So that leaves Tuesdays and Thursdays for “clinic days”. On these days they primarily focus on ART patients who need refills or consultations. In addition, they divide their clients into two groups: registered ART patients and outpatients (or OPDs). They can see either type of patient during the week. So I sat with Angela in one of the consultation rooms to observe. One thing to note is that they doesn’t seem to be any patient privacy laws in place because I freely sat in on most of them. Only one female patient asked for privacy due to an upper chest examination. A couple of women had no problems exposing their chests while I was present and one showed his penis to the clinician while I was there. The variety of cases was very interesting and I was amazed at the breadth of issues that each clinician had to deal with in a typical day. Just a highlight of a few cases I observed these past few days:
- Young baby was brought in by mother. Clinician referred to lab for blood samples. She explained that the first thing is to check for malaria since it is so prevalent in this area. Lab tests came back negative but prescribed multivitamin and requested return for check up in 3 days. The clinician also asked for the immunization card to prove that the baby had been receiving her immunizations. The clinician asked for husband to attend as well. She later mentioned that so few husbands get involved in learning about natal care with their spouses.
- Man complains of pain in sinuses. During interview it was discovered that he had seen a local “herbalist” who treated him by “surgically cutting” into his sinuses. He was referred to see an ear, nose, and throat specialist at the main hospital. The clinician explained that the specialist may not be there since they sometimes supplement their meager salary by working at private clinics.
- Young woman, 7-months pregnant, HIV+, and taking ART. She missed 5 days of treatment because of financial difficulty in getting to the clinic. The clinician mentioned that there are very few HIV drugs for pregnant women. The clinic only has one type. The clinician later explained there is also a stigma with drugs and family planning to rural people. They sometimes think it is “white man’s medicine”. The clinician prescribed 28 days worth of ART medication even though she requested the patient return in two weeks. She explained that this was in case the patient had more financial difficulty and could not return in two weeks. Note: I asked about what is considered the minimum CD4 level to begin ART for patients. The clinician explained that it is 250 but the Ugandan Ministry of Health is now mandating 350. However, drug availability has not caught up to the increased demand that has come from increasing the minimum level.
- Woman with husband arrived. She spoke very little Lugandan but mainly spoke Swahili and another tribal language. The clinician indicated that she showed signs of TB but tested negative to date. She previously had TB in 2003 but had completed all her medication back then supposedly. The clinician wanted to do a chest X-ray to verify but St. Francis does not have an X-ray machine. She had a sero test in December for HIV and came back negative. Note: I have seen several TB patients each day I have been at St. Francis. It is a chronic problem in Uganda – particularly among the rural poor. There is no isolation room and very rarely have I seen masks being used. The only mitigation step they seem to implement is to keep the windows open.
- An older man had come in on Tuesday from a long distance. He had a very noticeable limp and had trouble walking. His feet were swollen and his lower abdomen was distended. He also complained of penile sores. The clinician examined him and saw that he was not circumcised and he would need to be soon. He explained that he had gone to another clinic and had received an HIV test but the clinic would not release the results to him for some reason. The clinician tried to explain that some other clinics would withhold information or mislead patients in order to keep them coming back to make money. So the man was referred to the lab for blood sample testing. He later came back and his results showed that he was HIV+ and that he had very high glucose levels indicating he had severe diabetes. The clinician explained that the rule is to treat any ailments that the patient has first before beginning ART. If this is not done, severe complications could arise. The man was informed that he would need to stay in the area and get insulin treatment right away since he was in bad shape. Upon learning of the results, the old man just broke down and started sobbing in front of us. It was very emotional to see this old man crying. The clinician explained that she just realized that she had given him so many issues at once, and it was too much for him. I was concerned that he had no money for insulin. Fortunately he did have a little bit of money. Also he needed transport and there were no drivers at St. Francis available at the time. So the clinician gave some money to a nurse to get him a taxi.
- Just a rough sampling of other patients: A young student who complained a of gum bleeding and loss of appetite; a young Muslim girl who was there for her ART refill; an old woman with a baffling lesion that spread across her entire front of her chest and across her arms and part of her back – she was referred to a skin specialist at another hospital.