Doctoring the Future in Uganda

As a former kayak guide and Nile River Explorer, Alex Mihailovic is not exactly your typical surgeon. 

But she's breaking new ground in her field and making a difference for a generation of kids in Uganda.

"People were going berserk," laughs Dr. Alex Mihailovic. "We'd see them running along the riverbank screaming and waving. Most of them had never seen a Muzungu [white person] in their lives and they'd definitely never seen five of them all at once, floating down the Nile in a rubber raft."

"I took one look and was pretty sure what it was—this kid had a tumour the size of a grapefruit in his belly."

Mihailovic is sitting across from me in a busy restaurant in Kampala, Uganda, talking about her most recent adventure: a month-long expedition tracing the Nile from its dribbling source in Rwanda, to Lake Victoria. The relentless equatorial sun has scorched her a deep brown. Her nose is raw and painful looking.

"Any time we stopped at a village, and people found out that I'm a doctor, they would gather up all the sick people and bring them to me."

Mihailovic sits back in her chair and her expression darkens.

"I had two waterproof cases of medical equipment—stuff for the team—and I was able to use some of it for treating people in the villages. But lots of times, people would show up with illnesses that I could do nothing about."

She describes a young mother leading a shy little boy to her, his belly grossly distended.

"I took one look and was pretty sure what it was—this kid had a tumour the size of a grapefruit in his belly."

Mihailovic glances up from the table. She looks close to tears. "How do you tell a mother 'Your little boy has cancer, he's going to die very soon, and I can't do a damn thing about it, sorry. Next.'"

This sense of helplessness is something that Mihailovic has had to deal with over and over again while working in Uganda. It's also the reason that this young surgeon from Nipigon, Ontario is here.

A student and resident doctor in the Surgical Sciences programme at University of Toronto, Mihailovic graduated from medical school at McMaster in 2001. Back in Canada, some of her friends jokingly refer to her as being on "fast forward." And it's no wonder. A little over a year ago, she decided to slide a PhD into the middle of her residency. For the past year, she's been living in Uganda, doing some groundbreaking new research that, if implemented, could save thousands of young lives.

With the help of funding from University of Toronto, the Canadian Institute for Health Research, Johnson and Johnson, and the UN Development Programme, Mihailovic has set herself the goal of studying and trying to understand the long-term effects of traumatic injury and surgical illness in the developing world and how to begin to prevent these injuries from occurring in the first place.

"Many of the world's top twenty killers are related to surgical disease," she says, referring to illnesses that require surgical treatment, "things like obstetrical disease, congenital disease, war and violence related injury, burns, motor vehicle accidents."

Since August of last year, she and a team of Ugandan health workers have been gathering information from communities in the capital, Kampala, trying to get an idea of who's getting injured, how they're getting hurt, whether they are seeking medical attention and whether they even have access to it.

Surprisingly, there has been very little research by the community of surgeons in the area of global health, according to Mihailovic. "Even doctors involved in global health conferences are surprised when surgeons show up."

"War surgery is the main area that surgeons involve themselves with overseas. You join the Red Cross or Doctors Without Borders, go over to Liberia, patch up as many people as you can in a few months, burn out and go home."

When she first proposed the idea of researching the impact of surgical illness on global health, Mihailovic was sure that people in the Surgical Sciences department would not take her seriously.

"Surgery is a very disciplined, academic and mathematical branch of medicine. Most research is looking at tissue healing and immune response to sepsis and that sort of thing. Opening up this whole new branch of surgical research, you really look like a hippy do-gooder," she laughs.

"When I started, I was sort of quiet about what I wanted to do—you know, you don't want to stir the pot, you just want to fit in and have people believe that you're going to be the greatest academic ever."

Support however, came from several key people in the department and it gave her the confidence to keep going and develop her ideas further. "As I got more into it, U of T recognized that it was brand new research—no one had done anything like this before."

As if to re-affirm the importance of her work, the World Health Organization estimated recently that injury is killing more people in sub-Saharan Africa than tuberculosis and malaria combined, and by 2020 it's going to skyrocket.

"The problem is, that's not the end of it," says Mihailovic. "For every death, thirty people survive with severe disabilities. It's a huge burden to families already struggling to get by." In Mihailovic's opinion, the lack of understanding and proper surgical care of traumatic injuries is stealing the working class from developing nations.

"Go into any children's ward," she says, "they're filled with burn victims who usually lose limbs or die because the wounds go septic." Most of them are kids under the age of five who have crawled or fallen into cooking fires.

Others have been poisoned after drinking kerosene stored in soda bottles or drowned in water collection tanks while trying to get a drink.

One of the biggest causes of injury and death is traffic accidents. In Uganda, as in many developing countries, driving can sometime seem more like a gladiator sport than a mode of transportation. Dilapidated and overloaded vehicles with dodgy brakes careen over pot-holed roads, overtaking if there's even the suggestion of an opening. At night, there are no streetlights and many of the vehicles either don't have working headlights, or drivers don't bother to turn them on.

Mahailovic hopes that her work will lead to spending on simple, low cost solutions that she is convinced would have far-reaching effects—things like lighted cross-walks and cooking shields.

"These problems aren't like fighting HIV/AIDS which requires massive social, cultural and financial interventions. I'm talking about simple solutions. I could get fifty cent aluminium shields and totally change things in the coming generation," she says.

Gathering the information hasn't been easy and Mihailovic gives full credit to the hand-full of doctors, nurses and health care workers at the Injury Control Centre Uganda (ICCU) at Kampala's Mulago hospital. Challenges that she would never have anticipated while designing her study back home in Canada have been deftly handled by her Ugandan colleagues.

"I'm talking about simple solutions. I could get fifty cent aluminium [cooking] shields and totally change things in this coming generation."

For instance, while reviewing a questionnaire, one of Mihailovic's colleagues exclaimed, "You can't ask a Ugandan that!" The question simply asked whether the person ever visited a traditional healer.

"The implication is that you are probing into someone's spiritual life," Mihailovic explains. "If someone is ill, there is the thought that they've done something wrong or there is some sort of disgrace. It's not something you ask about. HIV/AIDS, on the other hand, is not a taboo subject."

Mihailovic says that being a westerner in a situation like this, and seeing what's going on, it's easy to become cynical. "So many NGOs and health organizations are doing surveys. People are overrun by them. People will say 'you're the third person who's handed me a survey today and I still haven't seen anything happen. Who are you people? Why do we keep doing these interviews? What do we get out of it?'"

The question "Who are we really serving?" is something that is always in the back of her mind, admits Mihailovic. "The problem is huge and these people need basic basic things. Why am I studying this complex model of health care to do with surgery? I kept asking myself, 'What am I doing, what am I doing?'"

That sense of doubt became even more pointed in the operating room of Lacore hospital in Uganda's war-torn north, while she was picking shrapnel out of eleven year-old soldiers and stitching up the faces of women mutilated by the Lord's Resistance Army.

Mihailovic decided early on that if she wanted to approach international health issues from a surgical perspective, she would need to have an appreciation for what African surgeons deal with every day. She says that conditions are basic, supplies are often lacking and patients sometimes die needlessly.

"I don't consider myself to be a naive person—I've worked in numerous African countries and have seen horrific things, but what really shook me was the endlessness of it. This is 18 years that the civil war has been going on. These people have been living like this—dodging ambushes—for 18 years and nobody cares."

"The resignation of a six-year-old boy who's just been shot, that lack of expression in his eyes, just killed me. He'd probably seen his nine-year-old brother have his hands cut off the day before and this wasn't that surprising. It was just his lot in life."

"I found myself becoming just as mechanical and detached after patching up one after another of these people. You start to think that you're making so little difference, there's so much apathy, why should I even bother when the situation is so convoluted and there's so much western influence keeping this war going, and the rest of the world doesn't give a shit—why do I care?"

Ironically, it was this very situation that helped her to realize her work was not just an exercise in futility.

"The only thing that helped me get over it was watching the Ugandans who worked there. The nurses and doctors who laughed and joked in the coffee room, who chatted about this and that in the operating theatre and who had been working there ceaselessly for nearly twenty years, never resting, endlessly giving to their own people."

Mihailovic says that she's begun to understand that her research into global health issues and how she views her work as a surgeon is really guided by the effects it will have on the individual. It's the one-on-one attention that shows her what she is doing is meaningful.

"It's the personal interaction that you never want to lose," she reflects. "You know, late one night in the operating room at Lacore, I was having a bad moment. Critically injured kids just kept coming in, we were running out of supplies and I just thought 'what's the point?'"

"A Ugandan surgeon who I was working with looked at me and said, 'You know, Alex, when you save a life, for that person, you have saved the world.'

Produced with the financial support of the Government of Canada through the Canadian International Development Agency (CIDA).

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Published in Work Abroad
Jeff Minthorn

Publisher, Editor-in-Chief

A co-founder of Verge Magazine and the Go Global Expo, Jeff is a well-known voice in the area of international working, studying and volunteering and was writing about gap years before the term even appeared the Canadian Oxford Dictionary. Having worked, studied and travelled on six continents, Jeff is passionate about the important role international experience plays in developing responsible, caring global citizens. He has spoken to audiences across Canada and the United States on subjects ranging from how to plan an international volunteer experience, to developing effective media skills and literacy.
Jeff holds two degrees from the University of Waterloo. Before co-founding Verge, he spent 10 years in the field of experiential education, including several years training experiential educators. Through Verge and the Go Global Expos, Jeff has been helping to connect international organizations and global citizens for nearly two decades.

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