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A piece of my mind. Collaterals.

Collaterals IN A SUNLIT WARD OF SUNKEN BODIES, THE YOUNG UGANdan woman’s full, round face hinted at health. As the white coats marched toward her bed, she passed her nursing infant to her mother and fastened the large button at her shoulder in one fluid motion. She had recently arrived at Mulago Hospital, the large public hospital in Kampala, Uganda, complaining of difficulty breathing, unable even to hang a load of laundry. I too had just arrived at Mulago, but from the United States, and had joined my first resident report. When the Ugandan physician paused in his English discourse on superior vena cava (SVC) syndrome to address the young woman briefly in Luganda, she smiled with her lips tight and held out her arms for inspection. As a group looming over the bed, we assessed the pertinent findings: no swelling in the legs, no wheeze or crackles in the lungs, no thrush in the mouth. Her thin lower body contrasted with the pillowy edema of her face, neck, and arms. We traced the map of engorged veins on her chest and neck, milking the vessels to see which way they filled. The Ugandan residents quietly showcased their anatomical fluency, mentioning the azygous, internal mammary, lateral thoracic, paraspinous, and esophageal veins. With the SVC largely blocked, these collateral veins had already created a crucial backup system, opening alternate paths back to the heart. We talked pathophysiology, running through a list of possible culprits, from bronchogenic to thrombotic. The initial hope, always, was that this could be extrinsic compression from tuberculosis, because TB would mean treatment and possible cure. But her initial studies had come back negative for TB, and other infectious possibilities seemed unlikely (she did not have HIV). We crowded around her chest film at the one working light-box, studying the shadow of her massively enlarged mediastinum, discussing approaches to biopsy, even reviewing which potential neoplasms would be more responsive to radiation or whether steroids might be indicated. I was impressed by the high level of discussion among the residents and curious to see how this woman’s treatment course would evolve, and how closely it would compare with what she might have received in the United States. Many Americans working in hospitals outside the United States speak unthinkingly in these comparisons. Mulago Hospital is always contrasted with a US hospital that seems increasingly utopian with each missing blood test, unavailable antibiotic, and dying patient. Visiting physicians underscore the “otherness” of the non-US system, partly to process experiences, partly to reassure that ineffectual flailings at disease can be blamed, at least in part, on the resources at hand. It is a hollow reassurance, but a common source of comfort. There is an unspoken assumption in the United States that US physicians go “to help Uganda.” But young US-trained physicians are less proficient at bedside procedures and physical examination skills than Ugandatrained physicians and are less accustomed to working with minimal supervision. In general, US physicians don’t speak the language, have little first-hand knowledge of major tropical diseases, and often spend a lot of emotional energy getting through each day. We want to be of use, we want to learn, we want to treat this woman with SVC syndrome and the wards full of patients even sicker than she is, but we are not adept at making things happen in a system that is opaque to outsiders. Visiting physicians’ comments on daily rounds highlight systemic differences. Comparisons are made in deference: “In the United States, we just don’t see malaria, so please teach me what to look for first in cerebral malaria.” In frustration: “At my hospital back home, this surgery would have happened two weeks ago.” In relief: “Thank God I don’t have to admit this many patients at home.” In wonder: “I can actually feel his aorta. Patients here are so much thinner than patients in the United States.” In anger: “I just watched a 38-year-old man die in front of me who would have walked out of a US hospital.” Mulago is portrayed as a collateral system, rising out of a fundamental need and working hard to meet demand but overwhelmed by the surges of patients and fundamentally not always up to the task. I fear that this constant refrain, this distancing, makes us at times insufferable to our Ugandan colleagues. “I am not you,” these phrases remind everyone, over and over. “These problems are yours. I only visit them.” The temptation is for everyone to throw up their hands, laugh the continent catchphrase “T.I.A.—This Is Africa,” and promise each other to meet back in the States. Even when the Ugandan interns ask eagerly for review tips on US board examinations and jokingly compare our lives with those of the physicians they see on Grey’s Anatomy, the distance widens. Together, we emphasize differences in experience and opportunity and imagine the health facilities of the United States as gleaming centers of infallibility, wide-open veins bringing streams of patients back to health. In so doing, the resourcefulness that is as much a part of Mulago as hopelessness is downplayed. In the relative ab-