I spent the month of July working at the Radiotherapy Department at Mulago Hospital, Uganda’s flagship public hospital located in the teeming, rambunctious capital city of Kampala. This is the only radiation oncology center in Uganda, a country of 36 million people. The clinic also draws patients from South Sudan, Eastern Congo, and parts of Kenya. The workhorse of the clinic is a singular Cobalt-60 machine, originally installed in 1994. The cobalt source has not been changed in 12 years. In order to accommodate the patient load, the machine treats patients 24 hours a day, Monday through Friday, reserving most Saturdays for larger palliative fractions.
The physicians, house officers, nurses, therapists, and staff embraced me from the moment I crossed the clinic threshold and quickly incorporated me into their busy practice. As I arrived early each morning for LDR brachytherapy insertions, dozens of patients would be lined up. Many of them had spent the previous night camped out on the hospital grounds. By the time the morning chart rounds and tumor boards were over and we were ready to start, new consultations, patients under treatment, and follow-ups filled every inch of the waiting area.
Clinic was ripe with both learning opportunities and challenges. I developed a level of comfort managing cervix, nasopharynx, and other cancers common in Uganda but less prevalent in the US. Seeing the radiation oncology zebras like endemic Kaposi’s sarcoma and penile cancer seared these sites in my mind. The neglected breast, rectal, or vulvar cancers called attention to the lack of screening and general cancer awareness in the country.
Soon after settling in, I was given my own cramped office and a stack of patient files to see each day. Although the physicians were available for help, they encouraged autonomy. I was forced to overcome language barriers (60 tribes in Uganda, each speaking their own language), work around limited medical records, and navigate a foreign healthcare system. There were frustrating and stressful moments. But there were many more moments of the privileged patient provider connection that drove me to pursue medicine in the first place.
Exposure to 2D planning was a highlight. The clinic lacks a CT sim, so the majority of cases were planned using fluoroscopy. Others were planned using tumor and bony anatomy alone. Field dimensions and separation were measured, recorded, and outlined with marker and torn pieces of plaster. There were many times I missed the seemingly limitless planning tools and image guidance available at home but I also came to appreciate the simplicity, efficiency, and efficacy of 2D planning. In between procedures, meetings, and clinics, I managed to deliver twelve radiation oncology -focused lectures. This teaching component enabled me to share educational resources and insights from the West. This peaked the curiosity of my Ugandan colleagues and generated robust discussions.
My experience in the Radiotherapy Department at Mulago Hospital was transforming professionally and personally. My commitment to working in resource-limited settings domestically and internationally has been solidified. I look forward to building upon the relationships I have made in Kampala and helping others in our field connect with cancer care providers around the world.
John Mac Longo is a fourth year resident in radiation Oncology at the Medical College of Wisconsin in Milwaukee, Wisconsin (USA).