Chronic Disease Care in Mbarara, Uganda

Henrietta Afari

Resident in Internal Medicine at MGH

PGY-3

Chronic Disease Care in Mbarara, Uganda 

A steadily growing problem in most healthcare settings in sub-Saharan Africa and similar socio-economic contexts globally is the high rates of chronic illnesses and associated complications. From a public health perspective, this makes sense: people are living longer-presumably due to gains made in communicable disease detection and treatment. I arrived at the Mbarara Regional Referral Hospital (MRRH) for a 4-week clinical elective in the internal medicine department eager to learn what this reality looked like for that part of southwestern Uganda.

At 9am every morning at MRRH, we would show up to the Accidents & Emergencies (A&E) unit for morning post-take rounds, where interns and residents present overnight and early AM admissions and transfers. Teams of about 10-20 comprising residents, medical students and sometimes, an attending physician, would review each admission in detail with daily plan made for each patient. There are on average 5-10 patients reviewed during daily post-take rounds. While I was struck by the rates of particularly HIV/AIDS in this population (to the point of routine inclusion of a patient’s HIV status in the one-liner), I was fairly surprised by the rates of chronic disease complications seen. On the very first day, we had patients with acute stroke, chest pain being ruled out for MI, acute decompensated heart failure, and acute decompensated cirrhosis. I found that the general principles of diagnosis and management were similar, in theory; in practice though, patients had fewer options due to limited resources. For many of these patients, though they had fairly advanced disease states on presentation, these admissions were often the first time they were diagnosed with or learned of these chronic conditions.

Following post-take rounds, we would proceed towards the medical wards, usually around 10am. I was assigned to the female ward where I would help scribe on rounds, take vitals, help review radiology and often give bedside teaching to the medical students. Not surprisingly, a sizeable number of the admitted patients also had some chronic disease complication, or were incidentally found to have high blood pressure or elevated blood sugars. One week, as many as 4 of the about 10 patients on that team were being managed for HHS/ DKA and one of the MRRH residents made a tongue-in-cheek remark about how this must be diabetes awareness week. Often after optimizing their acute illnesses, the patients would be referred to present to diabetes clinic or general outpatient clinic for further care. Many of these patients unfortunately travel from far to make it to MRRH, and appear understandably hesitant to make this fairly costly commute unless the discomfort associated with the illness becomes intolerant or debilitating, accounting for their often late presentations. It wasn't clear how many would be willing to make this commute just for routine clinic follow-up; I couldn’t find any data on referral completion rate but I suspect it may not have been high.

One of the local MRRH residents who has had an enduring interest in cardiology, noted during a conversation with one of our collaborative site-directors, Dan about how prevalent cardiovascular disease was at MRRH, and how much work needed to be done in this field. When asked his impressions on why such little work was being done in this area, he made a striking observation: “you’ll notice almost all the health-related billboards along the major link roads in Uganda are related to HIV/AIDS. Have you noticed any billboards addressing any cardiovascular or other non-infectious health disease?” (paraphrased). When Dan shared this conversation with me, I thought long and hard, as had he. We hadn’t seen any such billboards on our drives throughout southwestern Uganda. It appeared the resident was trying to make a point about how silent these conditions often go, in its early clinical phenotype, as in efforts dedicated to its management. My rotation in Mbarara, while initially designed to get a perspective of broad care delivery in a resource-limited setting like Mbarara, also reaffirmed to me my intent to further develop my interest in global non-communicable disease (NCD) care delivery.