Uganda Spine Surgery Mission, Isador Lieberman MD

As a kid, Mark Kayanja, aspired to someday make a difference. By virtue of his families status he received a better than average education and went on to become an orthopaedic surgeon at the Mulago Hospital in Kampala. After ten years of service in the sparsest of medical conditions, Mark realized the limitations of all his efforts. In 2000, Mark showed up on my doorstep, willing to work for free as a spinal research fellow. As impressed as I was by his offer I was more intrigued by what brought this brilliant young man to my doorstep. After four years of working directly with Mark, listening to his stories about the lack of spine care in Uganda, I had succumbed to his encouragement to accompany him on a visit to Uganda. In retrospect I now realize Mark had this all planned the day he met me. Our first Spine Surgery mission was preceded by much anxiety and anticipation. I was deeply concerned about the conditions and wanted to ensure that we not leave disasters in our wake. After having done the first ward round it became obvious that we could improve the plight of many of these patients . The care of spinal trauma, osteomyelitis/discitis and spinal deformity were all far below contemporary North American and even basic standards. A second potentially limiting concern was the availability of spine surgery equipment and funding. Thankfully, I have found over eight years of missions that many are truly generous with their support and that the major medical device companies were willing to provide us with all the supplies needed. Spinal pathology in Uganda is relentless, and health care provision is inconsistent at best. The system is plagued by many different constraints than what we experience in North America, yet much of the time the outcome is surprisingly similar.  For example, trying to obtain a CT scan in a timely fashion; In Uganda the patients can’t afford to pay for it, in North America the insurance companies frequently deny coverage, the ultimate result is that if someone does not take responsibility treatment is delayed or denied. The hospitals in Uganda are typically cramped and in disrepair. In contrast the operating theatres were surprisingly clean, however the equipment was aged and lacking in maintenance and repair. There are no reliable intra-operative x-ray facilities. The OR lights typically do not function, the backup portable OR lights are weak and there is a shortage of surgical linens, sheets and gowns. Along with the preceding the lack of water and electricity renders the sterilization of equipment predictably un-predictable.  In addition much to my chagrin, I found that the hospitals recycle everything including the suction tubing, the cautery hand pieces and even the surgical sponges. With each trip I remain troubled as I realize that what we take for granted or consider disposable in our high tech, high cost health care environment, is absolutely priceless in Uganda. The simplest things like tape, gauze bandages, sterile dressings, OR linens are all considered a limited resource and potentially re-usable by the Ugandan health care professionals. The Ugandan health care professionals are compassionate, caring and for the most part a dedicated group. What is lacking is education, experience and a basic infrastructure, i.e. appropriate trauma triage, adequate ward conditions, appropriate equipment maintenance, etc. At this stage of the development of their health care infrastructure, the acquisition of new modern and more costly equipment would be counterproductive. What is absolutely essential is a concerted effort in education and training of all tiers of the health care delivery team. After the first trip I began questioning myself and the purpose of the Spine Surgery mission. Are we really making a difference? Are we premature in our efforts? Are we causing more harm? Are we upsetting the balance? Are we introducing false hopes? On one hand, for myself providing spine care in Uganda is most gratifying. On the other hand, leaving so many patients uncared for is troubling. Today, after eight mission trips to Uganda, having provided spine care to well over 400 patients, and establishing lifelong relationships, I am deeply indebted to my friend and colleague Mark Kayanja, who by virtue of getting me involved in Uganda, has re-affirmed in my mind why I am a physician.