The American neurosurgeon leaned in to take a selfie with his patient, chuckling with excitement when she raised her hands. That was a good sign the day after Michael Haglund and his Duke University team opened the patient's skull to remove a tumor.
The operation was one of many complex, life-saving surgeries the team performed for a week on Ugandan patients who otherwise had little hope of survival.
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The operations, which would cost up to $20,000 here, are free while a group of American doctors take part in a "surgery camp" during which they also train local doctors. Scores of hopeful patients crowded the hallways of Mulago Hospital in the Ugandan capital of Kampala this past week, forcing Haglund to triage, what he called doing "death rounds."
Although many were turned away, at least 22 people were operated on, including some who "were probably going to die," Haglund said.
Public health services in Uganda have long been poor because of limited government funding, and many qualified but poorly paid health workers have sought opportunities in Europe and the United States. Although private hospitals are springing up, most people cannot afford their services in a country where many live on less than $1 a day.
The highly specialized field of neurosurgery is one of the hardest hit, with only six qualified neurosurgeons working across this East African country of 36 million.
Uganda's main referral hospital, Mulago, presents a picture of decay and neglect. Just outside the operating theaters the floors are smeared with dried blood and the paint is peeling off the walls. The elevators fail at times, stranding nurses moving patients from operating rooms to the intensive care unit.
Vil Kengoma, the 21-year-old university student with whom Haglund took a photo, had a likely fatal brain tumor that left her in severe pain and paralyzed in her right hand. In the crowded ward where she rested after surgery to remove it, she looked dazed but smiled at Haglund as he asked her to raise her hands.
"She had been admitted for three weeks and she went straight from the intensive care unit to the surgery room," said her sister Janet Karungi. "We are so grateful."
Haglund, a professor of surgery and of neurobiology at Duke, said he was shocked by what he saw when he first visited Mulago in 2007. There were 1,500 beds but just one ventilator for the operating theatres, he said.
"The patients who were having brain surgery, they were getting into their brains with something like a hand drill," he said. "Very crude ... like 1930s U.S. style."
Haglund said he decided to improve Mulago's neurosurgery capacity, which has required fundraising and spending his own money. His plan was to bring a surgical team of 20 to 40 people, including biomed engineers and anesthetists, who would join local surgeons to operate on dozens of patients each year.
Haglund's team has come to Mulago nine times since then, bringing 45 tons of donated or used equipment worth $6.5 million. The machines have transformed what used to be a tea room inside Mulago's main operating theater into a modern operating room — used primarily for neurosurgery — that is now named for Haglund.
Juliet Nalwanga, a Ugandan physician who is one of four doctors being trained in neurosurgery under Haglund's mentorship, said the Duke team was doing an "amazing" job to improve local competence in neurosurgery while helping poor patients who would need up to $20,000 to get life-saving care.
Haglund noted that Ugandan neurosurgeons were getting more confident in taking on complicated cases, and said he hopes Mulago can build a reputation for safe brain surgeries over time.
One indicator of progress is the rise in number of cases the Ugandans handle each year, from 65 in 2007 to more than 500 last year.