BY HILARY ROGERS.
Photography by Hilary Rogers.
This year’s Global Health Leadership Institute’s annual conference was held during the first week of June 2013. GHLI invited four teams from Brazil, Ghana, Trinidad & Tobago, and Uganda, each team made up of health and government professionals. The teams came to Yale with a particular health issue that they wanted to work on in their country. The week was packed with lectures by Yale faculty on strategic thinking and team building, and breakout sessions within the country teams to develop strategies to bring back to their countries.
My tasks as the “student fellow” during the week of the conference were to conduct background research, help with presentations, take notes, and aid in moderating discussion. My most important task, however, was getting to know the Ugandans, as they would be the only people I would know a week later when I arrived in Uganda. I think this is one of the more subtle qualities of a Yale partnership that does not get discussed as often as others. My feeling of “fitting in” early on was due to the established relationships between Yale School of Medicine faculty and some of the Ugandans, which allowed me to be a respected and valued team member from the start. I had to be proactive to maintain this perception, but the inclusiveness at the beginning allowed me to feel comfortable and therefore demonstrate my abilities.
The Ugandans – Professor Harriet Mayanja-Kizza, Dr. Doreen Birabwa-Male, Professor Moses Kamya, Dr. Charles Mondo, and Dr. Gerald Mutungi – were doctors, public health and medicine professors, and government officials. They work in Kampala, the capital city, in the Makerere University College of Health Sciences, Mulago National Referral Hospital, and the Ministry of Health. Most of them had worked together in some aspect in the past, and a few of them were even “OGs” or “OBs” (Old Girls/Boys: friends from university).
The Ugandans brought to the conference the issue of rising non-communicable diseases in Uganda. The World Health Organization (WHO) classifies non-communicable diseases (NCDs) as chronic non-infectious diseases, such as the most common worldwide problems of cardiovascular disease, cancer, respiratory disease, and diabetes. Low and middle-income countries account for 80% of non-communicable disease-related deaths worldwide.[i] The WHO has predicted that Africa will have the greatest regional increase in NCD-related death over the next decade.[ii]
Rates of non-communicable disease in Uganda are low compared to those of high-income countries like the United States, but they are rising at a rapid rate, and the economic and healthcare infrastructures of the country are not prepared. Ridden by internal conflict and infectious disease, Uganda does not yet have the policies, resources, or specialists to effectively prevent and manage these diseases. Furthermore, NCDs lead to huge economic burdens on individuals, families, and the healthcare system. The World Economic Forum considers NCDs to be one of the top threats to global economic development.[iii]
Currently, NCDs account for 25% of deaths in Uganda.[iv] Two of the most common NCDs are diabetes and hypertension. The overall prevalence of diabetes is relatively low, estimated at 2.9%,[v] but there are regions with considerably high proportions. For example, the prevalence of Type 2 diabetes in the districts of Kampala and Mukono is 8.1%. Of this population, nearly 80% of women are overweight and an association among overweight, hypertension, and diabetes in women is observed.[vi] The prevalence of hypertension in the southwest regions of the country ranges from 20-30%. The Uganda NCD Alliance, an organization that promotes advocacy and outreach to advance action on NCDs, recently conducted a WHO STEPS survey on NCD risk factors in Kasese, a rural district in western Uganda. The results show the prevalence of hypertension to be 22%, diabetes 9%, and high levels of risk factors, such as physical inactivity, overweight, and heavy tobacco smoking (51%, 15.6%, and 9.6%, respectively).[vii]
In one of my informal discussions with Professor Harriet Mayanja, a conference delegate and the Dean of Makerere University College of Health Sciences in Kampala, she took out a notepad and wrote “SILENT KILLERS” across the top. She began to describe the intricacies of the biological, social, and economic factors that lead to diabetes and hypertension’s being “silent.” In the two months I was in Uganda, I came across this phenomenon twice. The story, both times, went something like this: “I saw my uncle over the weekend at a family gathering. He seemed to be in good condition. I got a call this morning – he passed away in the night…” There is a lack of knowledge of these diseases and their risk factors, both in the public and healthcare personnel. There are now 560,000 registered patients in Uganda with diabetes, but it is predicted that an additional 560,000 people are unaware they have the chronic disease.[viii] One major reason for this is the lack of screening and early detection of NCDs.
In order to tackle this issue, the Ugandan team proposed a strategy of improving awareness and risk factor screening. With the objective “to build capacity in prevention, clinical care, health worker training, and research to enable the provision of effective and integrated management of NCDs,” the overall strategy became known as the Uganda Initiative for the Integrated Management of NCDs – UINCD, for short.
UINCD’s first year goals include the implementation of two pilot programs: 1) improvement of screening and 2) integration of NCD care in one clinic, both taking place in the Mulago hospital. In a pre-project audit, we found that an adequate number of blood pressure and blood sugar screenings were happening only in the wards you would expect – cardiology, diabetes, and hypertension. Meanwhile, little to no screening was going on in more general wards, like the Assessment Center, similar to a walk-in clinic, and the Casualty Ward, which we would consider an emergency room. High blood pressure and blood sugar are modifiable risk factors for NCDs. Early detection of these vital signs can prevent the progression of diseases such as hypertension and diabetes mellitus. Although the hospitals and clinics are overburdened with the number of patients each day, even more people do not use the established healthcare system due to lack of money or transportation to the hospital, use of alternative methods, or other reasons. It is important to catch people with risk factors when they eventually do make their first contact with the hospital. They may have come in with a broken ankle or the flu, but screening is a cost-effective method that has the potential to reduce mortality from NCDs and increase awareness of NCDs and their prevention.
Once patients do come into the Mulago National Referral Hospital to receive care, they find a fragmented system. As a health system built to care for infectious disease, it is not prepared to effectively manage the complexity of patients with chronic disease. The medical units are organized by subspecialty in Mulago. For instance, the Heart Institute is on the ground floor, while the Diabetes Clinic is on the fourth. The wards are independent of each other and each has its own staff. Due to the overlap of some diseases, a patient with NCDs may end up receiving care in three of these clinics. This fragmented system leads to low quality care, repetitive tests, poor follow-up and compliance, and more issues as well. Per the suggestion of the Yale School of Medicine Dr. Asghar Rastegar, Dr. Jeremy Schwartz and Dr. Tracy Rabin, the Ugandan team decided to use this concept for their second goal this year, the piloting of an integrated clinic for NCDs. The plan is to turn an empty space in the hospital into this pilot clinic and hire one physician and a few nurses to go through training and run it. They will conduct assessments on the quality and improvement of their work to see if it is successful. If both of these pilot projects are successful, they will look to officially establish them as permanent programs and expand them to smaller hospitals and clinics across the country.
Without a degree in clinical medicine or hospital administration, there were a few aspects of these two projects to which I could not adequately contribute. This is often an issue we come across with summer internships in college – with limited practical skills, how can we make an impact? My summer in Uganda taught me that I have skills that I took for granted, like paper writing and people skills, which turned out to be the skills I relied on the most. I used these as I wrote the Ugandan team’s proposal for the Innovation Award, a chance to receive $25,000 from GHLI in cash and in-kind contributions to help their strategy. Half of my summer was dedicated to developing the proposal. I like to think of this intern work, not as “busy work,” but rather “behind the scenes work.” Much more than just writing, I conducted background research, reached out to similar organizations, and, most importantly, managed the team. The founders of UINCD, the delegates of the GHLI conference, are exceptionally successful professionals, which means they are exceptionally busy. They are invested in many projects along with their full-time jobs, so finding a time all six of us could meet was difficult. As the summer went on, I realized that the most efficient way of gathering the team’s ideas and opinions on proposal drafts was to meet one-on-one with each member. This was a benefit not only to the progression of the project, but also my own growth, as I had the opportunity to directly learn from such knowledgeable health professionals.
While NCDs have not been prioritized in the past, there has been recent development to change this. In 2006, the Ministry of Health (MoH) established a NCDs program. Dr. Gerald Mutungi, one of the conference delegates and a MD/MPH by training, is the Program Manager. I had the opportunity of joining the program for the second half of my summer and conducting a project that I will use for my Masters of Public Health thesis. The NCDs program has recently partnered with the World Diabetes Foundation and will receive funding for the improvement of NCDs programs and policies in the near future. To see what areas of the NCDs care spectrum were lacking the most resources, the MoH needed to conduct a needs assessment. This is where I came in – with the supervision of the assistant program manager, I had the responsibility of writing a 14 page needs assessment that tried to comprehend the situation of personnel, medicines, equipment, guidelines, standard operating procedures, referral system, and more within the regional referral hospitals, district hospitals, and health clinics around the country.
The second to last week of my time in Uganda was spent on a road trip throughout the eastern and northern parts of the country to do a trial run of the needs assessment. As fulfilling as it was to see my hard work implemented by the MoH, the situations we saw were disheartening. Hundreds of patients and family members waited on the hospital grounds to receive care. Images from this trip, of bulging bellies on malnourished children and disabilities that are easily prevented in Western countries, will remain with me forever. In a hospital that sees 300 diabetes patients in one day alone, there was one functional blood pressure machine for the entire facility. Some of the hospitals experienced stock outs of critical medicines, like insulin, at least once in a financial year. At the same time, however, we met inspirational people along the way. There was Nurse Evelyn*, a hospital nurse who specialized in diabetes in Arua, a district part of the region that was devastated by Kony and the Lord’s Resistance Army. With one or two assistants, depending on the day, she was the only nurse to staff the diabetes ward of the hospital. She managed hundreds of patients each day by herself, working long hours and maintaining the most organized patient registers we had seen during our trip and in Kampala. People like Nurse Evelyn and the members of UINCD prove to me that there are determined NCDs leaders and advocates to champion the movement to prioritize NCDs and improve their prevention and management.
Global health internships offer the opportunity to become an integral part of groundbreaking movements that will hopefully progress to countrywide changes. My inclusion into the Uganda team gave me real responsibility and tasks that strengthened my program management, proposal writing, and needs assessment skills, and gave me a firsthand view of Uganda’s complex health issues. I observed the spectrum of malnutrition in Uganda, from undernutrition, subsequent infectious disease, and disability, to obesity and diet-related diseases. The double burden of undernutrition and chronic disease offers a new area of global health to explore, one that is just starting to gain interest. Just this October, The New York Times published two feature articles examining breast cancer in Uganda, issues of delay in diagnosis and treatment and also efforts for improvement.[ix],[x] We must use this momentum to generate more partnerships and innovation, and thus raise NCDs as a global priority, strengthen research and health system capacity, and develop comprehensive strategies to prevent disease
*Name has been changed.
[i] World Health Organization. Noncommunicable diseases fact sheet. Available at: http://www.who.int/mediacentre/factsheets/fs355/en/. Accessed October 20, 2013.
[ii] World Health Organization. 2008-2013 Action Plan for the Global Strategy for the Prevention and Control of Noncommunicable Diseases. Geneva: World Health Organization; 2008.
[vi] Lasky D, Becerra E, Boto W, Otim M, Ntambi J. Obesity and gender differences in the risk of type 2 diabetes mellitus in Uganda. Nutrition 2002: 18: 417–421.
[vii] Mondo CK, Otim MA, Akol G, Musoke R, and Orem J. The prevalence and distribution of non-communicable diseases and their risk factors in Kasese district, Uganda. Cardiovascular Journal of Africa 2013; 24: 103-108.
[viii] Wassma H. Uganda struggles to cope with rise in diabetes incidence. BMJ 2006; 333(7570): 672. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1584399/.
[ix] Grady, Denise. “Uganda Fights Stigma and Poverty to Take On Breast Cancer.” The New York Times. Available at: http://www.nytimes.com/2013/10/16/health/uganda-fights-stigma-and-poverty-to-take-on-breast-cancer.html?_r=0.
[x] Grady, Denise. “For a Young Woman, Late Treatment and a Grim Diagnosis.” The New York Times. Available at: http://www.nytimes.com/2013/10/16/health/for-a-young-woman-late-treatment-and-a-grim-diagnosis.html.