Uganda Be Kidding Me: Iatrogenic Pediatric Orthopaedic Injuries in Kumi, Uganda Part 2

Kristin Alves

Resident in Harvard Combined Orthopaedic Surgery Program

PGY5

Uganda Be Kidding Me: Iatrogenic Pediatric Orthopaedic Injuries in Kumi, Uganda Part 2

In traveling and working in Kumi, Uganda, I have learned that to be able to really help we must not work in silos.  To explain why you would need to start with my initial hypothesis and what I thought I was going to have to address to help children with gluteal fibrosis and post-injection paralysis.  Now, weeks in, I realize that the problem is much bigger than two pediatric orthoapedic disabilities.  Solving these problems will take a collaboration between many parties including the ministry of health, the practitioners, surgeons, nurses, volunteers, etc.

To understand what I have discovered during my research, you need to understand the overall context of Uganda’s state of healthcare and economy and the political environment. The Idi Amin era in the seventies was characterized by corruption, human rights abuses, political repression, mass execution, and gross economic mismanagement.  While the country came to relative peace with President Museveni in 1986, there are unaddressed legacies of the conflict with great disparities in income, wealth, and health care seen in Uganda.  This has created vast disparities in social determinants of health with unequal development, inequitable access and distribution of power and resources.  In addition, the “president” has been in power for over 3 decades and has continued to focus on military development to ensure his continued power and has continued to decrease the health care budget despite an overwhelming need for financial support.  Understanding this history is essential to understanding the instability of the country and the disparities in care delivery that have developed. 

Uganda’s population is estimated at 28.25 million with 50% being children aged 0-14. 

Throughout the large pediatric population there is a high prevalence of disease and much effort has been put in the treatment, prevention and control of many of these diseases. One of the diseases that is endemic in this young population is malaria.  Commonly in East Africa infants and young children who develop high fevers are thought to be suffering from malaria. One of the medications that has been frequently used in recent years for malaria is Quinine. The overwhelming “story line” I’m hearing in my interviews is that quinine injections, especially inappropriately delivered quinine injections, are the cause of GF and PIP.  Quinine is a neurotoxic drug that can cause nerve injury and tissue necrosis and is not recommended to be given in WHO guidelines except in cases of severe resistant malaria; even then it is supposed to be IV not IM. 

These children receive injections every 8 hours usually for 3 days (9 injections total) and then if they are sick again with fever in a few weeks, they get the injections again for another presumed bout of malaria. 

After receiving these injections, some children develop post-injection paralysis – loss of motor and sensory function of the sciatic nerve distal to the injection if the injection needle hits the sciatic nerve or the drug gets too close to the nerve.  Other children develop a buttock abscess after injection which can then lead to muscle necrosis, fibrosis and gluteal contracture.  Compounding this tragedy is the fact that this neurotoxic agent is not recommended as a first line intervention for malaria. Oral or rectal treatment with another medication altogether is still the preferred primary approach. Even for severe malaria, notably cerebral malaria, intravenous medications are recommended, not intramuscular. 

However, the problem has another level altogether.  The inappropriately given intramuscular injections are attributed to untrained people in pop-up private clinics in rural Uganda.  Often these private clinics come about with a clinician with the correct documentation/credentials setting up a clinic then leaving it to be run by people who are not trained to make money.  The untrained workforce is cheaper and they can make money on a clinic set up using their credentials without having to be there. The reason people take their children to these clinics include issues with accessibility and education. They are not educated in knowing whether the “doctor” at the local private clinic is actually trained or not. In fact, they actually think these “quacks” are smarter because they don’t need tests to know what the diagnosis is and they charge money while the public real health clinics and hospitals are “free” and thus must be worse.  In addition, the time, distance, expense of going to actual public clinics isn’t worth it – there is too far to travel, too long of a wait, and often they get told once they’re finally seen that the drug they need is out of stock.  Compounding these issues, is the fact that the people think intramuscular injections work better and faster that tablets (much like US citizens think we need antibiotics for a cold).  It isn’t known why this belief has come about, but it is repeated over and over.  Thus, if your child is sick with fever, you believe they have malaria, you take them to the closest private clinic and ask for an injection. The untrained local practitioner then provides the injections without testing for malaria or counseling the child’s family on testing or on other more appropriate treatment options if the child indeed does have malaria. 

So how do these pop-up private clinics exist and why can’t we just put a stop to them easily? That my friends brings us full circle back to politics and economics.  The government has put minimal financial support into the health care system and thus the gaps in coverage, human resources, and ability to regulate are minimal.  In addition, the corruption at the highest levels of the government is mimicked in the rest of the governance with drug inspectors and district health officers relaying stories of trying to stop private clinics only to find that the law enforcement let the untrained local practitioners go after bribes.  Thus, it seems that while I am seeing a large problem with GF and PIP in the children of Uganda, what I am seeing is only a side effect of a much larger health systems and health care delivery problem. To be able to prevent these disabilities and others a much more comprehensive solution is needed, and I am hoping that during a dissemination meeting I am setting up with the Ministry of Health that I can help to begin to set the wheels in motion towards such a solution. While it seems like an impossible task, there is an African proverb that comes to mind as I move forward: “if you think you are too small to make a difference, you have never spent the night with a mosquito.”