Remembrances and Reflections: Global Health, Local Needs, and One Very Special Patient

This paper is originally published through Society of Teachers of Family Medicine (STFM) here.

Penina. I will never forget her. She was a beautiful 3-year-old girl with sparkly brown eyes, smooth dark skin, and a captivating smile. She lived in a village near Kasangati, Uganda, with her parents and five siblings. We met in 1986, toward the end of my family medicine residency, during a 3-month-long experience that would alter the course of my life.

Uganda at the time was emerging from a brutal civil war that had ravaged the country almost since independence from British rule in 1962. Its weak health system was in complete shambles. Malaria, tuberculosis, vaccine-preventable diseases, and HIV were rampant. One out of three Ugandan children died before the age of five.

My job, according to the description I received prior to my departure from the United States, was to train village health workers to prevent and manage common health problems. Once on the ground in Africa, reality took hold: I was the only doctor caring for a dispersed rural population of about half a million people.

The Kasangati Health Center, my professional home base in Uganda, had not had a full-time physician for well over a decade. It consisted of bombed out shells of buildings with no electricity or running water, supplied with scant medical equipment and very few drugs. We were surrounded by grim reminders of the recent war, including stacks of bullet-ridden skulls and piles of human remains. The locals were busy resuming their lives and were reluctant to bury partial bodies until they could be identified. Josiah, the administrator of the health center, sat me down on the first day and provided this sage advice: “I know you’re a doctor, and you’re trained to treat patients. But our needs are so great that you could see patients here 24 hours a day for the rest of your life and not make much difference. Yet, if every time you see a patient you also teach one of our staff, you will make a long-lasting difference. We need you to teach.”

I spent most mornings working at the health center alongside a courageous and dedicated group of nurses, medical officers, and midwives who had continued working at the health center through the war and despite lack of pay. I taught them examination and diagnostic skills, and they taught me about tropical diseases, local resources, and creative problem solving. In the afternoons I trained village health workers in the basics of child survival based on World Health Organization standards; the health workers shared stories and taught me their values, culture, and language. Along the way, my family and I settled into routines of daily work, community life, and sleeping under mosquito nets. My husband joined locals in gardening and rehabilitation projects. Our three young children joined new friends in chasing chickens, feeding goats, and climbing mango trees.

About a month after our arrival in Kasangati, one of the health workers asked if I could examine and treat his daughter, Penina. She had a fever, rash, runny nose, and harsh cough, all telltale signs of measles pneumonia, a condition rarely seen in the United States, where most children had been immunized. Immediately upon seeing her I knew she might require more intensive therapy than was available at our center. I urged Penina’s father to take her to the hospital in Kampala. He declined: there were five other children at home; the cost of the journey was too great; he could not afford to spend time away from the family and farm. Reluctantly, I treated Penina with amoxicillin, supportive therapy, and daily visits.

Two days later, I woke to a gentle knock on my door. Penina had died during the night, her father calmly explained. I was devastated, filled with remorse. I felt responsible for Penina’s death.

The following day my husband and I visited Penina’s family to pay our respects. Her family thanked us for doing the best we could to help. They forgave me for not being able to save Penina. They were not angry, as I was expecting. They were grateful for our presence.

I know I should have done more and could have done better. I also know that Penina died due to a complex web of harmful conditions: inequity born of a long history of colonialization, two decades of violent internecine strife, and the utter collapse of a poorly developed infrastructure, not to mention insufficient human capacity and the lack of basic health resources.

Fast forward 10 years. I had settled into a teaching practice in beautiful rural Wisconsin, caring for patients from womb to tomb, delivering babies, watching children grow strong, caring for parents, grandparents, and patients at the end of life. My practice partners and I joined local leaders to promote community health through programs with teachers, farmers, and seniors. We set up walking trails, developed safety programs, and offered “doc talks” about sex, drugs, and guns.

I loved patient care. I still do. And yet I have remembered this, as Josiah advised me in Uganda years ago: medical care is a necessary but not sufficient component of promoting health for those in greatest need. If I wanted to make a difference, I needed to look beyond individual patients to design and lead educational programs; to cultivate skills to influence systems of medical education; to recruit, train, and retain motivated, well-trained family physicians and other health professionals where they are needed most; and to raise my voice as an advocate for justice in health care. I needed to find others with similar goals, to build teams to strengthen medical education and health systems and to target efforts where they had a chance to make long-lasting impacts.

Reflecting back on almost 30 years ago, I had no idea how my experience in Uganda would influence my career as a family physician educator in Wisconsin and launch my career in global health. This seminal experience heightened my awareness of the social determinants of health, the power of community, and the resilience of the human spirit. It galvanized my commitment to work with medically underserved people, to promote health equity and humanism in medicine, and to develop my skills as a health advocate for individuals and communities at home and around the world. It strengthened my resolve to work for health system improvement and expand access to high-quality, primary health care for all.

In doing this work, I have often considered the words of the poet Mary Oliver: “What is it you plan to do with your one, wild and precious life?” I remember Penina, and how her precious life was cut so very, very short. I am deeply grateful for the lessons I learned long ago in Uganda. I continue to honor Penina’s memory through my work today.

Acknowledgement: This paper is based on remarks shared with medical students on the occasion of receiving the national Gold Humanism Award at the annual meeting of the American Association of Medical Colleges in Chicago, IL, November 2014. Thank you to William Ventres and Mindy Smith for their input on the manuscript.

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