1. Lessons from Uganda: Chronic Disease and Palliative Care in a Resource Limited Setting Kuang-Ning Huang, MD UVM Family Medicine Residency PGY3

2. 2 Activity Disclaimer ACTIVITY DISCLAIMER It is the policy of the AAFP that all individuals in a position to control content disclose any relationships with commercial interests upon nomination/invitation of participation. Disclosure documents are reviewed for potential conflicts of interest (COI), and if identified, conflicts are resolved prior to confirmation of participation. Only those participants who had no conflict of interest or who agreed to an identified resolution process prior to their participation were involved in this CME activity. Kuang-Ning Huang have indicated they have no relevant financial relationships to disclose.

3. Uganda 3

4. Mulago Hospital National Referral Hospital Teaching hospital for Makerere University –Attending consultants, House officers (Residents), Interns, Medical Students –1790 beds (on average >3000 patients daily) 4

5. Global Health Elective High Risk Obstetrics Infectious Disease Pediatric Malnutrition Palliative Care 5

6. Global Burden of Disease What diseases are affecting what people and what are their risk factors – in the world? Paradigm shift of the 1990s –Comprehensive –Internally consistent Chronic disease, trauma/injuries, morbidity Quality of Life 6

7. Chronic Disease / Management Leading causes of death worldwide –Cardiovascular Disease (Ischemic heart disease and stroke) –Chronic Lung Disease –Diabetes –Cancer Leading risk factors –Increased systolic BP –Smoking –Obesity –High blood sugar –Diet –Pollution HIV/AIDS Mental Health 7

8. Quality of Life / Disease Bruden Quality-adjusted life years –Quality and quantity of life lived Disability-adjusted life years –“extends the concept from years of life lost to premature death… years of healthy life lost due to poor health or disability” –Not all diseases created equal –DALY = YLL + YLD 8

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11. Palliative Care 1970s Advances in the UK and US Relief from symptoms, pain, distress at any point from diagnosis to death for patients with serious of life-limiting illness 11

12. Palliative Care Uganda Hospice Uganda 1993 Palliative Care Association of Uganda –Palliative Care Unit at Mulago 2006 –Team: Doctors and Nurses –Consulting service Progressive policies: –“Essential Clinical Services” for HIV/AIDS patients –Morphine as part of the “National Essential Drug List” 12

13. Chronic Disease in the Global Context What can palliative care do? –Pain and Symptom Management –Diagnostic support –Treatment options –Coordination of Services –Home care, caregiver support 13

14. Quality and Dignity 14 “OKUYAMBA”

15. Barriers to Palliative Care in Resource Limited Settings Education of health care staff –Medical Students, Residents, Attendings Medication availability Staff availability Regulatory Procedures Cultural context Integration into mainstream medical care 15

16. Global Health Education Curriculum Integration Medical Education Residency Education CME 16

17. Preventative Care/Family Medicine FM as an emerging specialty Role of FM physicians in Global Health? 17

18. Thank You! 18

19. References Beaglehole, R., Epping-Jordan J., et al. (2008). Improving the prevention and management of chronic disease in low-income and middle-income countries: a priority for primary health care. The Lancet (372), 940-948. IHME Health Data for Uganda from http://www.healthdata.org/ugandahttp://www.healthdata.org/uganda Levack, PA. (2014). Palliation and the caring hospital – filling the gap. J R Coll Physicians Edinb (44), 98-102. Murray, CJL, Lopez, A. (2013). Measuring the Global Burden of Disease. New England Journal of Medicine (369), 448-457. Merriman, Anne. (2002). Uganda: Current Status of Palliative Care. Journal of Pain and Symptom Management (24), 252-255. Okuyamba from http://www.okuyamba.comhttp://www.okuyamba.com Yach, D., Hawkes C., Gould, C, Hofman, K. (2004). The Global Burden of Chronic Disease Overcoming Impediments to Prevention and Control. JAMA (291), 2616-2622. 19