January 10 - Lira

Discussion with Dr. Awio at Lira University Hospital. Photo Credits: Justine Inhensiko, MAKSPH

We started our day back at Lira Regional Referral Hospital (LRRH). We were accompanied by Rashid, who knows everyone in town. When we mentioned Dr. Awio, he whipped out his phone and got on a call with him immediately. Within minutes, we were on our way to Lira University Hospital to meet with Dr. Awio.

Dr. Awio is the head surgeon in the Lira region. He specializes in urology, and is a teaching professor at the Lira university hospital. He also works at the Lira Joint Medical Clinic, a private HC2-3 equivalent clinic. We had a fruitful discussion with him and he offered his time to us for future discussions.

Lira Regional Referral Hospital (LRRH)

We next went back to LRRH to collect data on breast cancer visits to LRRH. Surprisingly, over the past 3 months only 15 women passed through LRRH for breast cancer. Of these, 7 were referred and 8 were outpatient. For a regional hospital, this number is low given that the national incidence for breast cancer is at around 2600 annually.

We then visited the lab at LRRH. It is currently being renovated, with new paint and a new equipment (fridge) sitting at the doorway. We spoke with the lab director and resident microbiologist. The key takeaway here is that the highest stage they can do in the pathology pathway is the preparation of FNA slides. They also mentioned that with the right equipment, most lab technicians and technologists here can prepare slides for excised masses and core biopsies. Who they lack eventually is a pathologist -- they are mainly concentrated in Kampala.

The lab director referred us to the radiology department to understand other modalities used in the detection of breast cancer. We learnt that radiographers (and not radiologists) staff the hospital. As a result, images are interpreted through the combined effort of radiographers and a brand new CT scan sits in a room without an operator.

MBM Lancet, a private laboratory service

We went to a renowned private lab service - MBM Lancet to get an understanding of the services offered, equipment available on-site, how they work with patients coming in to have their breast cancer samples tested, and what considerations they may have for procuring new equipment. All tissue samples are sent to Kampala for diagnosis with equipment and pathologists and Path Diagnostics. Results are expected in a week - a stark contrast with the minimum 2 weeks to the more frequent months of wait time for the results to be returned. Patients are also emailed the results which they can bring to the doctor with an option for a stamped hardcopy. When asked on what it would take for a new equipment to be procured, the lab technologist mentions that there needs to be 1) frequent use for the machine and its ability to serve the community and 2) a demand for faster turnaround time than the current standards.

We then returned to LRRH where we spoke with 2 general surgeons. Dr. Mumbere shared his views on key challenges being a lack of community awareness, the inaccessibility to investigation of breast cancer in the form of detection facilities (devices, FNAC, imaging), and government collaboration. He shares that it is important for government, academia, and innovators to collaborate in creating novel solutions that can benefit the patient population.

We ended the day by revisiting Dr. Awio - this time at Lira Joint Medical Center. We learnt that private clinics can be more accessible than government health centers. On top of that, the lack of resources given the cycles of medical supplies from the National Medical Stores (free) can lead patients to visit private clinics (paid) to avoid delay in their treatment. It is common for patients to hop between government and private healthcare systems as supplies become available.

Breast cancer, he said, is considered a neglected disease. Women who are requested for further testing (mammography) expect to travel for more than 6hrs from Lira to Kampala to access the facilities.

Common Ugandan transport (Source: https://www.kcca.go.ug/news/405/#.Y77S1HZBw2w)

In addition, people with painless disease do not seek care even when they are told of the dangers of cancer symptoms. More delays are caused by traditional healers who lack the competence to diagnose cancers, the need to convince patients of undergoing a costly, inconvenient, and psychologically-demanding treatment, and doctors who are overwhelmed and do not follow the prescribed ‘hair-to-tie’ screening procedure that can help catch more breast cancers at an early stage.

He shared that most patients are referred for additional diagnostics only when patients specifically complain of pain in breasts, when masses or swelling are found on the breast, when there is breast asymmetry, breast discharge, or other suspicions communicated. As we completed our interview, he shared that there are barriers throughout the breast cancer patient pathway -- except for the case of connecting a surgeon with a patient who is diagnosed and ready for surgery.