January 16 - Return to Jinja

It is Monday again. On our first workday in Jinja, we started with a visit to the District Health Office (DHO). It was a place filled with activities, and Monday was a busy day. We saw World Health Organization’s presence there and there was a tent for World Food Programme. Darius led us to the District Health Officer’s office, where he appeared to be busy. We caught hold of him right as he was about to leave the office, and he agreed to a 3-minute conversation. As usual, we shared our project and got some places and people of interest from him.

From there we headed for Bugembe HC4, which was a little way off Jinja. We stopped by and it was bustling with activity. We were told Monday was the day most people show up for work and the patients know it too - they wanted to take advantage of the maximum staffing. There were other days where specialized clinics were held, and patients would be present for them on those days.

Directions at Bugembe HC4

We found ourselves in the gynecology clinic where we met with sister Betty and midwife Lillian. It was unfortunate to find that biopsies were not taken at HC4, and women who present here for breast cancer are referred to Regional Referral Hospitals (RRHs). This is a challenge given that VHTs and other lower health centers usually refer patients suspicious for breast cancer to HC4s, but instead of adding value to the patient treatment pathway, HC4 becomes a passthrough station. This is added on to the fact that HC4s can only make referrals to RRHs and not the national hospital. This is for good reason, given the limited capacity of the central hospital where all patients positive for breast cancer would eventually end up, there in Kampala. They shared that the Uganda Cancer Institute (UCI) used to have a more supportive referral system for HC4s. Women on suspicion for breast cancer would be monitored, and there was direct contact for referral to UCI for serious cases. For some unknown reason, that initiative has been discontinued. A big takeaway here is that it is important for community HCs to add value to the patient care pathway by being a diagnostic center -- so patients who are tested negative can safely be given antibiotics and sent home, while only those who test positive can be efficiently referred for further diagnostics and treatment.

Next, we returned to Jinja Regional Referral Hospital (JRRH), where we spent a majority of our time during August. We introduced ourselves again to Sister Susan Alero, who seem to show interest in the problem we are tackling. She shares that even within the hospital itself, there is confusion about whether the breast cancer patients should be referred to the gynecology department or the surgical department. This is consistent with our findings in Gulu as well, which leads us to wonder if this is a problem that should be addressed at the national level. We did learn that like in Gulu, there is a push for breast cancer clinic to be integrated with the cervical cancer clinic in the cancer unit, which is directly affiliated with the UCI. After initial introduction, we then proceeded to speak with nurses and doctors at the gynecology ward, as well as the cancer unit.

We took our call with Dr. Judy Mella from here

We then returned to our hotel where we had a Whatsapp call with Dr. Judy across the world in the UK, who was 3 hours behind us. Dr. Judy is a retiring breast surgeon who has worked on understanding the disparity in breast cancer mortality rates in LMICs during her time in her masters in public health (MPH) program. She has worked in collaboration in Lira University hospital as part of a twinning program with a hospital in Southern UK.

She had shared that access to the rural community is a large problem in Uganda. Many members of the rural community are subsistence farmers who do not use or carry cash on a daily basis. They have no one to go to at the community level and cannot afford treatment. They also have fear of mastectomy, and often lack counselling about the procedure. As an initiative, she has purchased and put ultrasound in HC4s around Lira and setup training for nurses there. Apart from that, she helped establish good rates for histology and organize transport to Kampala. She is currently helping organize suture and surgical packs so patients who cannot afford medical resources that are short in hospitals can have access to surgery. Dr. Mella estimates that it costs ~$30 per patient with these initiative to get women the care they need.

She also shared that she worked with the pathology lab in the university hospital to procure resources to enable cytology. She also mentioned that she added a digital lens to the microscope that enabled cytology slides to be digitized and sent to a pathologist in the UK for a second opinion. She also mentioned that there is a stain that works with FNA samples that can identify estrogen receptor (ER) status. This would be a game changer given that tamoxifen could be prescribed for women with these status, which can help avoid the removal of breasts and enable treatment at a local level without the hassle of traveling to Kampala. In this way, a good portion of women can receive treatment without having to be displaced. All in all, she shared the vision for a decentralized diagnosis, and is a knowledgeable partner with a practical project that we can work with. This was a refreshing conversation that helped us end our day on a positive note with reassurance that we were on the right track to move the needle for breast cancer patients.

Key takeaways:

• HC4s are often not well-resourced for FNAs or Ultrasounds and act as a passthrough for referrals

• There is confusion about whether breast cancer should be treated by the gynecology or surgical department within the hospital structure

• Decentralized pathology/diagnosis can help move the needle for patients living in rural communities