Our Experience at Rugarama Health Centre

Hannah Ruffell and Anne Hounsell
University of Cambridge, England

Uganda is one of the countries which make up East Africa and has borders with Sudan to the north, Kenya to the east, Tanzania and Rwanda to the south and Congo to the west. It is arguably one of the most beautiful countries in Africa and was referred to by Winston Churchill as the "Pearl of Africa."

We spent our elective at Rugarama Health Centre in Kabale in March 2005. Situated in the south-western corner of the country, Kabale is the second most densely populated rural area in Uganda and also, at 2000m above sea level, Uganda's highest town. The town is surrounded by intensively cultivated, terraced hills which, combined with the backdrop of the Virunga chain of volcanoes, make it a spectacularly beautiful place to spend your elective!

The health centre is a small missionary hospital, and we were the first medical students to have visited! Both of us had wanted to do our elective in Africa, and it was through a friend that we made the contact. The hospital deals with general adult medicine and paediatrics, as well as having a specialised premature baby unit, and good ophthalmic and dental departments. It performed no surgery except cataract removal, but that was good for us, because we are both more interested in medicine than surgery.

Although, other doctors visit from time-to-time and offer specialist services, there is only one fully qualified doctor in the hospital with the rest of the work being covered by three Clinical Officers who have had three years of training. As a result we were given lots of responsibility and were able to really feel useful.

Each day starts with morning prayers at 8am. Handover then takes place during which the various ward rounds are assigned. Out-patient clinics are more like "A&E" with no prior appointments and begin once the ward rounds are finished. We spent our first two weeks shadowing the doctors on ward rounds and in clinics, but by our third week, were given the responsibility of conducting our own ward rounds and out-patients clinics each day as well as some of the overnight on-call duties. This was rather daunting to begin with as we often had to manage conditions such as malaria and typhoid that are rarely seen in the UK and the facilities for dealing with them were somewhat more basic. However, there was usually someone available to ask if you got stuck and it was a fantastic way to learn.

The case-load in Uganda is very different to the UK for several reasons. It is currently estimated that of the 26.5 million people living in Uganda, 35% still live below the poverty line and hence problems such as malnutrition (both kwashiorkor and marasmus) and communicable diseases (including TB, pneumonia and typhoid) are rife. Children form a large proportion of the case-load as over 50% of the population are under 15 years old and the population is growing at a rate of nearly 3% per year. The average life expectancy is only 45 years and the infant mortality rates are high (86/1,000 live births).

HIV and Aids have also had a huge impact. Uganda was one of the first countries in Sub-Sharan Africa to be affected by the HIV epidemic and although the prevalence of HIV has fallen from 25-30% in the early 1990's to its current rate of about 6%, due largely to committed political support, it is estimated that the epidemic has produced over 1 million orphans so far and more than 0.5 million people are currently living with HIV or AIDS. Manifestations of AIDS such as herpes zoster reactivation and Karposi Sarcoma were therefore common.

Also, patients often present late, with florid signs as many people simply live too far away from the nearest health centre, along dirt roads which are impassable in the wet season, to seek treatment easily. Conditions which are no-longer really seen in England are also seen, e.g. I saw a little boy with the classical appearance of rickets

The organization of the hospital was also different to the the UK. For example, nurses in Uganda are not responsible for washing/dressing/cooking for the patients; instead, each patient has an attendant (usually a family member) who does all of this for them and sleeps on a mat under the patient's bed at night. As a result, there are always at least twice as many people in the hospital as there are patients! The wards are therefore crowded and the lack of curtains around the beds often means that privacy and confidentiality are not possible. There is also a huge disparity between the need for health care and the ability to provide it as there are only three medical schools in Uganda and therefore, far too few doctors.

The national language is English. However, many of the local villagers only speak their local tribal language, Rukiga. (pronounced Rusheega) Although we learned a lot of Rukiga during our time at the health centre, it was still necessary to conduct most of our consultations through one of the nurses acting as an interpreter.

The medical facilities are rather basic with very limited investigations. The hospital does have a laboratory but it can only do microscopy and ESRs, FBCs, HIV tests, and some biochemistry. Other tests have to be sent off to another hospital which is expensive, slow and therefore not routinely done. There is an X-ray machine and two ultrasound machines, but there is no full time radiographer. This lack of available investigations often meant diagnoses were impossible to confirm and so treatment on-the-whole was "blind." On the plus side however, it meant that we had to rely much more heavily on our examination findings to come to diagnoses and as a result my clinical examinations and my confidence in them have improved considerably.

As well as participating in the work at the hospital, we were abl to go on two "out-reach" clinics. These involve going to small, remote villages in the region in order to run clinics for the local community. THis was quite an experience, not least because many of the children in the villages had never seen white people before. On our first out -reach clinic, we were virtually mobbed by children who wanted to touch our skin to see if it felt any different to theirs and to check we weren't ghosts! The clinics themselves were brilliant. Many of the cases were ante-natal check-ups so we got plenty of practice at our obstetrics examination which was really useful.

In the afternoons, we set up a playroom for the paediatric inpatients. Many toys had been donated to the health centre. We washed and sorted them out and then encouraged the children to come along. Many had never played with toys before, and didn't know how to play. Even a simple ball fascinated them. Many cried because they didn't like our white faces, but they gradually got used to it, and began enjoying themselves. Their smiles and laughter were lovely to see. Even the mothers who came enjoyed playing too.

We had an absolutely brilliant time at Rugarama and learnt an enormous amount. Everyone we met was extremely friendly and welcoming which really helped us to settle in and get the most out of our elective. The large amount of responsibility we were given did mean there was quite a steep learning curve initially but ultimately, it definitely, increased my confidence in my abilities and it was good to be able to make a positive contribution to the work of the hospital. I would definitely recommend Rugarama to anyone who wanted a general medical elective in a developing country as you see a wide range of diseases and get to work under very different conditions to those we are all used to in the UK.

Contact details

Doctor in charge:
Dr. Gilbert Mateeka
Rugarama Health Centre
Diocese of Kigezi
P.O. Box 785
Kabale, Uganda
East Africa

Approximate Costing

Flights from UK: £575
Visa: £25
Vaccinations and malaria prophylaxis: £105
Accommodation: £30
Food: £15-20/week
Travel Insurance: £65

Extras: Gorilla Tracking US$265