Uganda Charitable Spine Surgery Mission

July 20 August 4, 2012 Trip Report Team Isador Lieberman MD - Orthopedic Surgeon Paul Holman MD - Neurosurgeon Ejovi Ughwanogho MD - Orthopedic Surgeon (Fellow) Krzyzstof Kusza MD - Anesthesiologist Zbigniew Szkulmowski MD - Anesthesiologist Jason Ehrhardt - Neuromonitoring Technologist Elizabeth Wohlfarth - Surgical Technician Sherri LaCivita - Surgical Technician Ngozi Akotaobi - Physical Therapist Brian Failla - Equipment Technician: Globus Medical Robert Davis - Equipment Technician: Synthes Spine Rachelle Lieberman - Photographer, Teacher Erin Sadler - Medical Student Locations Mulago National Referral Hospital Case Medical Center Society Sponsors Health Volunteers Overseas (Orthopaedic Overseas) Scoliosis Research Society, Global Outreach Program Corporate Sponsors Globus Medical Synthes Spine SpineGuard Philanthropic Sponsors MedWish International AmeriCares Veahavta Organization Local Physicians Dr. Titus Beyeza (Chief Department of Orthopaedics - Mulago) Dr. Norbert Owrotho (Department of Orthopaedics - Mulago) Dr. Mallon Nyati (Department of Orthopedics Mulago)

Table of Contents Executive Summary ........................................................................................................................ 3 Day 1 - July 22 - Arrival to Entebbe International, and onwards to Kampala ............................... 4 Day 2 - July 23 - Mulago: Inpatients and Outpatients .................................................................... 5 Day 3 - July 24 - And the Operating Begins................................................................................... 8 Day 4 - July 25 - Divide and Conquer ............................................................................................ 9 Day 5 July 26 - Finding Our Stride............................................................................................ 10 Day 6 & 7 July 27-28 - Putti Village ......................................................................................... 11 Day 8 July 29 - Seeing More of Kampala.................................................................................. 13 Day 9 July 30 - Second Week Begins ........................................................................................ 14 Day 10 July 31 - Ebola? ............................................................................................................. 14 Day 11 August 1 - Last Day of Surgery at Mulago ................................................................... 15 Day 12 August 2 - Last Day in Uganda ..................................................................................... 16 Personal Epilogues ........................................................................................................................ 17 Photo Album..................................................................................................................................25

Executive Summary Mission Statement To our patients, our partners and our colleagues, the Uganda Charitable Spine Surgery Mission exists to provide the best possible spine care to Ugandan patients afflicted by infectious, degenerative, traumatic and congenital spinal ailments. In addition, the Mission will strive to provide a fertile environment for the education of those who treat these patients. Vision Statement The Uganda Charitable Spine Surgery Mission will become a self sustaining program, with a philanthropic base, and a volunteer core. The Mission will aim to have a quarterly presence in Uganda. Value Statement All involved in the Uganda Charitable Spine Surgery Mission will be relentless in their pursuit towards enriching the lives of Ugandan patients by providing the best possible care of their spinal problems. We will endeavor to provide and to teach the most appropriate care for spinal ailments. We will pursue these goals in a collaborative fashion with any other entity or resource willing and able to assist. Achievement Philosophy The individuals involved in the Uganda Charitable Spine Surgery Mission will fulfill the mission and pursue the vision and values; by fostering collaborative associations with philanthropic organizations, by promoting the Mission to those interested in participating or supporting, by volunteering their personal time and resources, by forging relationships with Ugandan health care providers and organizations Mission 2012 Summary The Uganda Charitable Spine Surgery Mission 2012 brought together 13 members from the United States, Poland and Canada, it quickly became apparent that there was a synergistic bond despite the diversity of backgrounds. Over the duration of the 2 week mission the team evaluated 67 patients, operated on 12 patients, delivered over $250,000 in medications and supplies to Mulago Hospital, Case Medical Center, the Putti Village, and touched the lives of countless of Ugandans directly, and indirectly. The complimentary dynamic of the seasoned veterans and the new team members created an atmosphere that was full of enthusiasm, focus, and a common vision to accomplish as much as possible in the short time they had, despite numerous setbacks, obstacles, frustrations, disappointments, and an Ebola scare. With each mission it seems the relationships between the team members and the Ugandan colleagues is strengthened, and it is with great excitement and anticipation that the Mission continues to flourish on the already established foundation to create lasting and sustainable change in the state of spine care in Uganda.

Day 1 - July 22 - Arrival to Entebbe International and onwards to Kampala The team all congregated at Heathrow Airport Terminal 5 for a 9:15 pm departure to Entebbe International Airport. After some brief introductions the team seemed to quickly mesh well together and a warm dynamic was instantly evident. The team this year was quite large with thirteen members with various backgrounds, from the United States, Canada, and Poland. After boarding the plane many were exhausted from their travels to Heathrow, and thus tried to take advantage of the 8 hour overnight flight to Entebbe and get some sleep! We landed in Entebbe at 07:45 hrs after a few false touchdowns as the flight crew attempted to negotiate the heavy cross winds. Once off the plane we were all pleasantly surprised by the beautiful weather with temperatures in the mid 20s. We gathered our gear, minus a lost bag from Poland, and made our way to meet the buses that would be responsible for our transportation over the next 2 weeks. Along the route to Kampala the rookies got their first glimpse of the fertile Ugandan landscape, the vibrant Ugandan people everywhere you look, the pop-up stalls along the road, and the many handmade bed frames for sale along the roadside, without any mattress stores in sight. The veterans reminisced about the sights and sounds from past trips and tried to reconcile the subtle differences in the scenery. On arriving "home" at the Golf Course Apartments in Kampala we designated the sleeping quarters in the two 3 bedroom apartments between the 13 team members. Dr Holman was the odd man "out" or "in" depending on your perspective, having been assigned to the apartment with the 5 women on the team. Once we had moved our luggage in and had a chance to refresh ourselves and brush our teeth for the first time in far too long, we were once again off into Kampala to stock up on supplies and food items for breakfasts and other necessities like water, hand sanitizer, and the odd bottle of wine! One hefty shopping bill later (1,579,419.00 UGS) and vans packed to the brim we headed back to the apartments to unload and organize ourselves before taking off again to visit the Case and Mulago hospitals. We first visited Case Hospital, which is a private hospital, considered affluent with decent equipment, services and patient care, striving to achieve a standard similar to a hospital in North America. In contrast, we then went to Mulago Hospital, which is the national public hospital, located on a sprawling campus of single story bunker-like buildings that serve as different wards. The spine and orthopaedic wards at Mulago were decaying open style wards with several beds lined up side by side, filled with patients, and much to the rookies surprise, the patient beds were surrounded by their families. The dynamic of patient care in the Mulago setting, dictates that the families be the primary care givers despite the inpatient nature of the hospital accommodations. The families were huddled around the patients, sometimes having created a small area near the patient`s bed where they have essentially set up a temporary squatting home, feeding them self-prepared food, bathing them, and really the only people in the hospital providing vigilant care to these patients. Furthermore, the familial presence extends beyond the hospital walls, where as you walk outside you notice families having found a space to call their own on the hospital property and are essentially squatting there as their loved ones
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remain in hospital. During this first visit the new team members couldn`t help but question how these native Ugandans view the team: as foreigners who are coming to try and help, or perhaps do they question our role in their medical care? In the event that there was not enough initial culture shock with the hospital visits, Dr. Lieberman decided to continue this enlightening experience, with a walk through a nearby shanty slum in Kampala. As we walked through narrow dirt alleyways, which were covered in garbage and had waste water running down the middle, the local inhabitants waved and smiled at us through the hanging laundry, and curtained doorways fondly yelling Muzungu (code for white person) as we passed them by. Many of the team had never experienced anything quite like this before. Not by virtue of the fact that they had not seen images like this on television or in other popular media outlets, but because of the contrast in the sense of community that they had witnessed in this incredibly extreme and impoverished environment. The team clearly appreciated the difficulties of life in such an environment which conflicted with the throngs of beautiful children with toothy grinned smiles from ear to ear, whose spirits outshone any despair that they, or more likely the team members, were feeling. As the team returned to the relatively "insulated" apartments it became very apparent how contrastingly different Ugandan life can be, just simply a few blocks apart. The team couldnt help but feel incredibly spoiled as they spent the rest of the afternoon cooling off by the pool, and then enjoying an amazing Indian restaurant for a lively dinner and some delicious curries, in anticipation of the upcoming days of hard, yet extremely meaningful work to come! Day 2 - July 23 - Mulago: Inpatients and Outpatients The team began the first full day of work at Mulago Hospital bright and early. Even earlier that morning, a few fitness diehards hit the gym or went for an early morning run to help shake off the airplane stiffness, for what will prove to be a tough two weeks both physically and mentally. Once fueled with the aromatic Ugandan coffee, the team loaded onto the vans, where the new team members quickly established squatting rights for particular seats. On arrival we first made our way to the Spinal Inpatient Ward. As described earlier, this is quite a distant cry from the inpatient wards we are accustomed to seeing used in North America. As a team we rounded on each patient and heard the patients stories from the Mulago doctors: from
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presentation to their current state, discussing the pathology, imaging, diagnoses and planning next steps for each patient; always keeping in mind the risk benefit analysis for each case, and prioritizing who needs something done now, and who can afford to wait a bit longer. These are decisions and discussions that are universal in the medical field, but become much more significant when resources are scarce in such a place as Mulago. Even a decision that we take for granted in the developed world between choosing a CT or an MRI based on its appropriateness to the management of a case becomes more complicated when one must consider that an MRI costs three times as much as a CT, and thus at Mulago we must often settle on CT imaging regardless of its clinical limitations. There were several cases that the team identified as priorities for operations. The patients ranged from a 17 year old male who was knocked off a boda boda (highly dangerous local motorcycle taxi, and possibly the most popular mode of transportation in Uganda) and required a procedure to reconstruct his vertebrae, to a 36 year old male with suspected TB spondylitis (tuberculosis infection of the bones of the spine) who had rapidly progressed to a paraplegic, to a 20 year old male with an incomplete cord injury resulting in tetraplegia but showed promise for recovery, to a suspected osteoblastoma (tumor of the bones of the spine) case; and many others along this spectrum.

Upon finishing the inpatients review in the Spine Ward, we set ourselves up in the Orthopedic Ward to see the outpatients. Much to the surprise of the new team members, these outpatients had already been lined up since 8:00 am to secure a spot in line in order to be evaluated. As a team we were able to split up into two clinic rooms and thus double our capacity to see patients. These clinics were definitely a mixed bag of cases, and provoked a mixed bag of emotions. From the elated patients who have recovered remarkably from their operations last year, and are so grateful to Dr. Lieberman and his team; to the frustrated and disappointed patients who were told their condition will not be operated on, and will need to wait and return in a year as we will continue to monitor them. Although there were many incredible patient stories witnessed on this first day, there was one that stuck out in the team's and deserves to be shared. His name was Desire, a 14 year old boy with a smile that could melt an iceberg! Travelling from his orphanage, he came to be seen if he could be operated on for severe kyphoscoliosis. Unfortunately, after much deliberation, it appeared that the surgery would be extensive, requiring four stages with traction in between and a long rehabilitation process. Realistically, this type of procedure may be of benefit to him, but the co-morbidities that may result from the recovery, and what would most likely be insufficient rehabilitation and follow up, would make this a far too risky endeavor. Although disappointed in this news, Desire gave us all a big grin and waved goodbye, and most importantly left us with the lasting impression of a boy who truly makes the best out of his difficult life situation and can find something to smile about even in the toughest of times. Everyone should meet a kid like Desire. After a long day of seeing 40 patients in 5 hours, the team was once again off to prepare for the following day when they will begin operating at Mulago, and continue to see new patients in clinic at Case Hospital. This preparation involved visiting the Missions storage facility to get the equipment that would be necessary for the upcoming surgical cases, and hauling the many boxes, out to the vans, all the while dealing with a massive tropical downpour and thunderstorm. The evening involved finishing up any unfinished paperwork, unloading and sorting equipment to get ready for the next few days of operations, and last but not least, trying to keep up with the blog! As a team we once again gathered for a glorious dinner at a local Chinese restaurant, where we proceeded to each share what we had learned during the day. These lessons ranged from the very profound and deep, to more practical advice regarding bathroom facilities at Mulago Hospital.

Day 3 - July 24 - And the Operating Begins... Today we undertook our first surgical procedure at Mulago Hospital. This first case involved 20 year old male H.S. who had fallen off a boda boda and suffered a C6 sagittal split fracture with a C8 level complete neurological injury. The team was planning to do a C6-C7 corpectomy with a C5-T1 instrumented fusion with an interbody expandable cage. The team was eager and excited to get started, but we were quickly reminded of the Ugandan work ethic. We arrived at Mulago in the early morning, and anticipated getting started right away, but unfortunately we found that the sterilizer had broken down and the instruments that were required for the case had not been sterilized. This really setback the schedule, as the team had to wait until the instruments were sent to New Mulago, another part of Mulago located a short distance away, to be properly sterilized before we could operate. While half of the team was dealing with the setbacks at Mulago, the other half traveled to Case Hospital to see patients in a "back pain" clinic, and prepare the equipment for a surgical case that would be occurring the following day at Case Hospital. The team quickly appreciated the interesting contrast between the patients who presented to the outpatient back pain clinic as compared to those who presented at Mulago. While those at Mulago tended to have extreme pathology, they expected so little; whereas the Case patients had relatively milder pathology, yet expected so much more. Once finished with the back pain clinic patients, everyone congregated at Mulago to catch up with how their day had been going, and to see what progress they had been able to make under the extreme conditions of this Hospital and its amenities, or lack thereof. Everyone was relieved that even with the delays the procedure had gone relatively smoothly, but not entirely without its trials and tribulations in regard to equipment availability, room and body temperature incompatibilities, and getting started much later than they had anticipated. As the operating team closed up, we all breathed a sigh of relief that the first case of the mission had been completed without too many hiccups, and everyone felt that as a team we were coming together as a very high functioning group, where we are learning each others working styles, and building trust and confidence in our working relationships. After what seemed to be a very long day, we went out for a very animated dinner at a local pizza restaurant: Mamba Point. Although the service was slow the lessons of the day were very entertaining with stories, confessions, and tasteless comedy. Todays lessons coincidentally had a P theme, with lessons around the concepts of perseverance, power, polar: for bipolar, pressure, personal lives, promise, and a few other profound morals of the day. Once the pizzas finally arrived, we quickly realized they were well worth the wait, and the fresh avocado that adorned most of our pizzas lived up to its reputation. We all delved in to these delicious pies,
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amid beautiful mood lighting provided to us by several Iphones at the table, as the power had gone out and left us in pitch black darkness. Day 4 - July 25 - Divide and Conquer Today surgical cases were taking place at both the Mulago and Case Hospitals simultaneously, as the team had been split up into two groups. As the Mulago group arrived at the Spine Ward, they were absolutely in disbelief by what they had discovered. They were told that the patient they had operated on the previous day had passed away overnight. This was incredibly shocking and upsetting as the patient had tolerated the procedure without incident, was a young man with a good prognosis and was expected to make a promising recovery. Unfortunately, as the events of the evening were relayed to the team by several sources that had been present, it was suspected that the patient had been given food or drink by his family, unbeknownst to them that this was dangerous to do with a post-operative patient of this nature. This may have led to aspiration (swallowing fluid into the lungs), but ultimately the patient began to have breathing difficulties and was transferred to the intensive care unit. Tragically once in the intensive care area, the staff on night call were unable to resuscitate him, and he passed away. Later, after an autopsy had been performed we were informed that what had actually happened was that a feeding tube was inserted, and misplaced in the lungs rather than the stomach, leading to respiratory distress and the patients eventual death. This tragic outcome was obviously very difficult for the team and Dr. Lieberman to accept, however the team understood that events beyond their control will occur, and that they must be constantly vigilant to avoid such tragedies. After regrouping, the Mulago group returned to the operating theatre of the Spine Ward to do another operation on a suspected osteoblastoma (bone tumor) case on patient P.K. This patient had presented with progressive lower limb weakness, which had been showing some improvement with bed rest. The team proceeded to carry out a T2 laminectomy with a marginal excision of the tumour mass, and biopsy. In addition they did a T1-T3 instrumented posterior spinal fusion. Once again, there was never a dull moment in the theatre at Mulago, but upon completion of the case the team felt more comfortable and confident in their ability to adapt to the cultural, time, and equipment differences that exist within the confines of the theatre walls at Mulago. Upon taking P.K to the ward for recovery the team was bombarded by his incredibly grateful family, reminding them how much their efforts are appreciated and affects lives beyond the patient themselves. Across town, the other half of the team was operating on a 19 year old female H.A. with congenital scoliosis. This procedure involved instrumentation and fusion from T8-L4 and a left thoracoplasty T4-L1. Prior to starting, the group at Case Hospital also ran into setbacks similar to
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those experienced at Mulago, from repeat blood work delaying the procedure, to equipment failing to work, to recognizing the limits of surgery as adeptly identified by Jasons neuromonitoring; needless to say it was also a long day at Case. The afternoon at Case Hospital concluded with seeing clinic follow ups from Monday, and making operative decisions for the next day. One small 14 year old boy, I.B., learned that he would be admitted to have surgery the following day. He was either tremendously stoic or completely un-aware of what laid ahead, yet all we were sure he realized that this was his best opportunity to take care of his spinal deformity. Arriving back to the apartments at 7:50 pm, the team was instructed to get ready for dinner within 10 minutes: stragglers will be left behind! The women on the team were pleased that they were in Uganda, where glowing with sweat is fashionable, because all were able to make the aggressive timeline. Once again, as a team, the day started and ended together, around a big table, sharing laughter and stories of the day, and always the new lessons that each and every one had learned, and will keep in their hearts forever. Day 5 July 26 - Finding Our Stride Once again the team split for another day of surgery at both Mulago and Case Hospitals. The Mulago group came up with a strategy the previous evening to try and circumvent the resistance of the local Mulago staff from completing two cases in one day. They figured that they would tackle a shorter case first, so it would only be mid-morning upon completion, leaving lots of time to start a second longer case. This tactic proved worthwhile especially with the strong leadership from Liz. The group was very efficient and productive with only minor setbacks. It was very clear to see that as a group we could find our stride, achieve an immense amount, with great outcomes, in a relatively short amount of time. The cases that we performed included a discectomy on F.N, a 42 year old female with a L4/5 herniated disc; and a T12-L1 decompression, posterior spinal fusion and instrumentation on a 36 year old male K.S. who had suffered a T12/L1 spinal fracture dislocation (bone and soft tissue chance injury) after falling from a tree he had been pruning. Across town at Case, the events of the day were a little bit more hectic. At Case, the other half of the team were operating on a 12 year old boy, I.B., with kyphoscoliosis, in addition to spina bifida occulta. This case involved performing a posterior T6-T11 thoracoplasty with a T5-L2 fusion with rib graft. After a difficult intubation, the procedure went on without complications until, much to the surprise of the group, the hospitals oxygen supply ran out. Thanks to the astute surveillance from the anesthesia team, what could have been a potential disaster was averted, and thankfully the procedure was completed successfully. During the day there was also a heroic display of taking one for the team from Jason, the neuromonitoring technician. After questioning the signal he was receiving from the patient, he proceeded to hook up and shock himself to ensure
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the equipment was working properly. The entire team had to pause for a moment of disbelief when Jason's voice was suddenly raised by three octaves as his hair stood on end. Everyone was impressed and touched by his dedication to the well-being of the patient, at his own expense. In the early evening the groups reconvened at the apartment, shared their respective experiences of the day, and then proceeded to dinner, at a new restaurant that Rachelle had scoped out on line. On arrival, the veterans enthusiastically realized they had been here before for a wonderful reception dinner on a previous trip. As traditions are established, the pleasant ambiance and great menu, provided for many laughs, and several toasts highlighting the great work of the team, especially those who have really stepped up and provided great leadership, poise, and selflessness in order to provide the best care possible to the patients. Day 6 & 7 July 27-28 - Putti Village Over the weekend, four team members: Dr. Lieberman, Rachelle, Brian and Erin, ventured off to visit the village of Putti. Putti is a small rural village near Mbale, about 200 miles northwest of Kampala. This village, of approximately 300 people, striving to be recognized as Orthodox Jews, came to the attention of Dr. Lieberman a few years ago. Now, 3 years later, Dr. Lieberman has maintained strong links with this community, in concert with the Putti Village Association Organization and with the support of the Veahavta Organization, and has provided the resources for this village to strengthen their Jewish culture, health care, and education. On this occasion, we were heading to Putti to deliver medical supplies, in addition to other provisions including shoes and shirts for the children, re-usable sanitary napkins for the women, and educational tools including colouring books and markers.

After a stop at Case hospital to see the post operative patients, and grabbing fresh pineapple from a local street vendor, we got on the road heading northwest. Although some took the 3.5 hour drive as an opportunity to catch up on much needed sleep, others enjoyed the scenery and sporadic villages spotting the countryside. Travelling the roads of Uganda is a great way to see authentic Ugandan life that is more representative of the approximately 34 million people that live in this country in comparison to the urban setting of Kampala. Once in Mbale, a moderately sized town at the foot of Mount Elgon, we stopped for a lunch at the Mount Elgon Hotel. This was also the meeting point for the delivery truck bearing the packages we were bringing to Putti, and Rabbi Enosh, the resident Rabbi of Putti. Once
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congregated and refreshed we loaded into the vans again and proceeded to visit the local village doctor. Dr. Martin has faithfully served the Putti community for many years as their sole source of health care. We visited his very modest clinic and supplied him with equipment and medications that will allow him to diagnose and treat the Putti villagers for at least the year. Finally, after a long afternoon of travel, miles of two-way paved roads, giving way to narrow, single lane dirt roads, we arrived at the Putti village. The village itself is a tiny settlement, situated on a rural landscape spotted with corn fields, with a few single story mud and clay buildings. We were hardly out of the van when we were surrounded by the most welcoming group of smiling people with outstretched hands and warm greetings from young and old alike. As we made our way to unload the delivery van, we were pleasantly surprised to see the throngs of children eagerly jump into the back of the van and unload its contents without hesitation. The official welcome took place a short while later, in a small thatched roof building, that serves the dual purposes of synagogue and the school house. After a few words were spoken and translated, from the citizens of Putti, Rabbi Enosh guided us to a shaded area under the trees where the women of the village set up a welcome performance. Rachelle and Erin were overwhelmed by the display of talent, enthusiasm, warmth, and community among women of all ages. The Putti women dressed in a sea of beautifully colored authentic African dresses shared inspirational messages through traditional song and dance. Upon conclusion of their presentation, we returned the favour by handing out t-shirts and candy for the children, which almost started a riot! along with Dr Martin, we then distributed the re-usable cloth, sanitary napkins to the women, who were very grateful for this new amenity that they have not had access to in the past. After a quick power nap (Brian & Izzy), the community convened in the synagogue for Friday night Shabbat services. It was a lovely service, lit only by a single light bulb, in a single room filled with the Putti village residents. Once it was over, the team accompanied Rabbi Enosh to his home for Shabbat dinner. The meal consisted of rice, macaroni, and red beans. With only 3 forks available in the whole village, the team rookies were encouraged to volunteer and eat in the traditional way: hands only. Erin verified the adage "that everything tastes better with your hands!" After dinner, Rachelle and Erin were escorted to the womens house, provided with a bed each, but also, to their surprise, a room full of babies. Upon getting ready for bed in the pitch
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black and brushing their teeth in a corn field, they retired to their beds. Shortly thereafter, the door was bolted shut, and they felt trapped in this small two-room building with a small army of "wailing" babies. As you can imagine, this made for a relatively sleepless night, and reaffirmed in their minds the importance of family planning. To make matters worse, they were awakened only a few hours later by a rooster wake-up call at 6:00 am! The morning started with a breakfast of peanuts and eggs. After breakfast we returned to the synagogue for Shabbat services. During the traditional Jewish Shabbat service the Putti villagers expressed many words of thanks to the visitors. After services we gathered all the village children, who seem to have doubled from the day before, to distribute newly purchased shoes. Later that afternoon, we bid farewell to the villagers and began the trek back to Kampala. Along the way we were delayed by a massive traffic jam due to an accident, and then another traffic delay near the Nile Bridge. To pass the time, Brian and Erin played body contact scrabble on their iPads. By the reaction of each it was clear that Erin was struggling for words. After a 5 hour drive, that seemed more like 10, we arrived back to Kampala to hear about the others adventures, mostly highlighted by their trip to the equator, with their van breaking down several times en route. It seemed like both groups had many interesting stories to share over dinner at the Pyramids Casino. In an effort to switch things up, instead of sharing a lesson of the day, Dr. Lieberman encouraged the team to dig deep to share a humorous joke or anecdote. By the end of the evening all agreed that "we are not a group of comedians!" Day 8 July 29 - Seeing More of Kampala The day started with some of the team heading off to round on post-operative patients at the respective hospitals. The others who remained at the apartments spent the morning doing laundry, finishing up some work, catching up on other odds and ends, plugged into the Olympics, and in Dr. Holmans case: fighting a suspected case of food poisoning. In the early hours of the morning, by virtue of the constant flushing, it came to Ngozis and Erin's attention that Dr. Holman was not quite "right". By the time the morning arrived he was feeling worse and we all were concerned with his ashen appearance. We collected some intravenous tubing, needles and fluids from the supplies we had brought, and initiated project "Holman Resuscitation". After starting an intravenous and getting some antibiotics into him, to no one's surprise, Liz took over the nurturing role of nurse to keep a close eye on him. Once everyone had returned from rounding, the team decided to spend the afternoon going to the art market and gain a more inside look at Kampala by visiting the city market. The art market is an area in the center of town where various vendors have set up booths and sell their goods. There is everything from jewellery, to art, to authentic Ugandan clothing, pottery, and other trinkets. Going from booth to booth the team began to appreciate not only the art of the vendors, but the science of barter. This was best demonstrated by Brian when he attempted to exercise his negotiating prowess to try and get a painting from 150000 shillings ($53) to 80000 ($28). Although he claims he won since he did not end up paying more than he wanted, he also walked away empty handed because the artist wouldnt budge below 90 000
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shillings. Others were more successful, and came away with treasures that they had negotiated to a reasonable price. From the art market, the team courageously ventured to the Kampala city market where goods are bought, sold, and traded. This was an absolutely incredible experience, to gain an insiders look at the local commerce of Uganda. There the team also gained important knowledge regarding appropriate attire to wear in Ugandan public: women should not wear shorts. Unbeknownst to Erin, wearing shorts is the closest thing to being naked, as in Ugandan culture, a womens thighs should only be exposed to her husband. Erin had to learn this lesson the hard way, as many of the locals were taking pictures of her with their smart phones (go figure) and were quite interested in the Muzungu (white person) who was naked. Day 9 July 30 - Second Week Begins This day marked the beginning of the second week of surgery. Procedures were taking place at both Mulago and Case Hospitals. At Case Hospital, Dr. Lieberman was performing a revision of hardware on A.H., a 60 year old female. This procedure involved removal of loose hardware from L2-L5, repeat instrumentation from L1-L2, and a posterolateral fusion from L1L2. Meanwhile, at Mulago, Dr. Ughwanogho and Dr Holman (still a bit weak) worked on a 20 year old male, L.S, who had fallen from a tree and suffered a C6 burst fracture and C6-C7 traumatic spondylolisthesis. This procedure required a C3-T3 instrumented posterior cervical fusion with a C6 and C7 laminectomy. After another long operating day, reconvened at the apartments and turned on the television to watch some Olympics, but were quickly distracted by the CNN headlines of the Ebola outbreak in Uganda. After a few seconds of watching we were even more surprised to see a screen shot of the Mulago hospital, the hospital where we had just returned from and operated at all last week. Although we had been aware that Ebola was present in the Kibaale district, they only found out about its presence at Mulago from CNN. This made most of the rookies quite uneasy, and in no time family members were sending emails and texts sharing their concerns for the team's safety. After a few local phone calls the team was reassured that Mulago had not yet confirmed the cases as Ebola, but there were several health care professionals being quarantined. In an attempt to take our minds off the current situation, we decided on dinner at the Kampala Serena Hotel. This buffet dinner had the most delicious fresh avocado, smoked tilapia, beef kebabs, and a smorgasbord of desserts. After gaining our fill and before calling it a night, much to the delight of our Polish anesthesiologists, we cheered on the Polish Mens Beach Volleyball team (or as Jason astutely puts it, sand volleyball since they are not playing on a beach during this Olympics) defeat the USA team. Day 10 July 31 - Ebola? Day 10 was distinct in that there was only one case booked at Mulago hospital. All woke up a little bit unsettled because of the conflicting media stories as to what the state of Mulago was in regard to the Ebola situation. Although most of the stories involved New Mulago,
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which is a part of the greater Mulago hospital, but located a short distance away, the team was still not completely clear what was true and what was hearsay. As it stood, only half of the team was meant to go to Mulago for surgery. There definitely seemed to be some tension within the team because it seemed like people were unhappy about this situation, but no one was speaking up. Thankfully, before heading out, there was a team meeting called where Dr. Lieberman shared his conversation with the acting director of Mulago Hospital, and from his perspective it was safe for us to go in and perform the operation. After all, there had not yet been confirmation of Ebola being present at Mulago. Furthermore, any health care workers that had been suspected to be in contact with a potential Ebola case, were under quarantine, and the threat was felt to be contained sufficiently. This days surgery was an idiopathic scoliosis T4-L2 instrumentation, reduction and fusion for a 21 year old female. Despite being slightly nervous about the Ebola situation, the we all pulled together and supported each other, mostly with lighthearted humour about the situation, and got through the case very successfully. Day 11 August 1 - Last Day of Surgery at Mulago For day 11 the schedule was back to two planned cases, one at each of the hospitals. At Case Hospital, the group had scheduled a difficult procedure on a 3 year old female, with presumed neurofibromatosis (elephant man disease), and a mass in the cervical (neck) region putting pressure on her spinal cord. Knowing the delicate nature of this procedure, Dr. Holman had organized to have some of his more specialized neurosurgery equipment shipped from the United States to help perform this procedure. Unfortunately, although it appeared that the shipment had arrived in Uganda on time, as confirmed by multiple calls and visits to the courier company offices locally and abroad, it was determined that the equipment was being held up by Customs officials at Entebbe Airport for a payment equivalent to $8 US. Consequently, this case had to be cancelled. This was such a frustrating outcome, after having planned to perform this procedure, and hopefully make a real difference for this littles girl life. After the fact it was determined that a series of miscommunications between the courier representatives and the customs officials was the culprit of the delay which led to this tragic disappointment. While the Case Hospital group were dealing with their setbacks, the other half of the team was working on a 50 year old female patient at Mulago with a suspected infection in her spine. This procedure involved an L1-L4 instrumentation and fusion, including a biopsy for culture to determine the underlying infectious process. This group at Mulago also faced their own set of obstacles in trying to undertake this case. When they arrived in the morning they found that the instruments needed for the procedure had not yet been sterilized, and furthermore, the truck that was supposed to come and pick it all up to take it to where it can be sterilized, was out of gas. As they waited around for the necessary equipment, they rounded on patients, caught up on writing operative reports, grabbed a quick power nap, and Dr. Ughwanogho cracked the whip to ensure that the patients were getting their post-operative x-rays after being told that they couldnt get them because they had to pay for them themselves. Dr. Ughwanoghos persistence paid off and sure enough, all did get the appropriate post-operative x-rays.

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Finally, at around 1 pm, after much insistence the instruments were sterilized and returned, the patient was ready, and the case began under the very competent leadership of Dr. Ughwanogho, with assistance from two Ugandan orthopedic residents. There was some uncertainty going into this case because this particular patient had been investigated for an infective process in her spine, but the team did not know exactly what they would find. What they did find was a very inflamed spine, with cavitating lesions. Due to the precarious state of this patients bones, likely due to prolonged bed rest and underlying osteoporosis, this case took longer than anticipated. When all was completed, it was a late night at Mulago. That same evening the rest of the team had gone to an evening reception, hosted by the Mulago Hospital administration, but as they too had had a long and frustrating day, exhausted and hungry, all reconvened for an even later dinner. Day 12 August 2 - Last Day in Uganda The final day in Uganda, was spent operating on a 5 year old male with congenital scoliosis at Case Hospital. While half of the team was at Case operating, the other half of the team went to Mulago to wrap up any loose ends, check in on post-operative patients, and clean and pack the equipment. Once finished at Mulago, the team bid a bittersweet farewell to this place that had quickly become a home away from home for several of them. Although they had only been there for two weeks it became very apparent to them that they had established very strong and special relationships with the health care staff they had been working alongside; not to mention the relationships they had formed with the patients they had operated on and were now on their way to recovery. Once finished up at Mulago, those of us who were not part of the operating team at Case went back to the apartment to work on outstanding reports, sorting of the thousands of pictures that will be necessary to supplement the trip report, and catching up on other odds and ends. Unfortunately, just as a reminder of where exactly we were, our ability to do work was interrupted by a building-wide power outage. Thankfully a generator was brought in, but only lasted as long as a full tank of gas, and then they we were once again powerless. This made for more of relaxing afternoon than what we originally anticipated. The operating team finished up the surgery at case hospital successfully and without any complications. Upon their arrival to the apartment, we all packed up, sorted out the equipment that would be getting shipped back to the United States, and cleaned up the apartments, as we had an early morning departure on Friday morning. After all the departing chores were completed, the team gathered for our traditional final team dinner at a restaurant called The Lawn. It was a lovely evening, with great food, drink, company and lasting stories and memories shared amongst us all. As became the custom we all shared personal lessons, but this time it was "the lesson of the trip." It very quickly became obvious that this trip could never be summed up in a single lesson. Each participant has learned invaluable lessons from our patients, colleagues, from the Ugandan way of life as a whole; and more importantly learned more about themselves than they probably even realized at that time.

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Personal Epilogues Isador Lieberman MD - Orthopedic Surgeon The team this year consisted of 6 veterans (Krys, Zee, Brian, Ngozi, Rachelle and I) and 7 rookies (Paul, Ejovi, Sherri, Elizabeth, Erin, Rob & Jason) who even with the diversity and cultural differences within the team all came together with unique "spirits," and dealt with the issues at hand for an overall successful mission. A respected colleague of mine taught me that "if you do not have expectations you will not be frustrated." Even with that lesson I found this year's trip the most "taxing" and frustrating. In retrospect I feel I set my expectations too high. From the outset we were able to run two teams simultaneously at the Case Hospital and Mulago Hospital, we doubled our output and tackled more complex cases, yet still struggled to encourage the local initiative to be truly productive. Even though we were able to accomplish quite a bit, we did experience many situations beyond our control that felt like body blows from a championship boxer. The trip budget collapsed with the added burden of unforeseen and unexplainable customs and duties charges, we were faced with clinical circumstances that forced us to abandon a patient in need and also led to the untimely demise of another. All the while as I was trying to recover from the body blows, I noticed a dramatic change in Uganda both in the rural and urban areas. The Sino and Indo influence is omnipresent, absolutely everyone has a cell phone, and now it seems everyone has a car or motorcycle. The price of petrol runs about 3600 UGS per litre ($6 per gallon). The Ugandans have found oil in northern Uganda and are getting it out of the ground and looking for buyers. They also found gold in the mountains and have started mining for it. The Ugandans are absolutely paranoid of terrorist influences, and the government and media are touting the anti-corruption efforts. Inflation is running high, restaurant prices were being changed daily, and banks were offering 11% to 20% for fixed deposits, with many new banking companies on the scene. Throughout Kampala there is construction of massive shopping complexes and office buildings but there is still no infrastructure development i.e. roads, electrical grids, water and sewers, nor did I see any new housing projects. While there we witnessed an overnight blackout in Kampala and many power surges and minor outages that necessitated rebooting equipment during surgery. Even with what seemed to be advances in their society, the Mulago hospital is crumbling, the wards are decaying, the ancient sterilizer was still not working nor has it been replaced, and the service is deteriorating. There are so many simple things that could be done and year after year the "low hanging fruit" simply do not get picked. Likewise in the rural settings we visited the dependant attitude is still predominant. Everyone expected a "handout". In the past it was a few dollars at a time. Now it is cell phones, computers and "internet time" they are asking for. These issues have not changed in the 7 years I have now been going. Despite the lack of forward progress my resolve and commitment are even stronger. After all they were body blows not knockout punches. We can make a difference and I can change my expectations. Meeting up with some of my past patients reinforces exactly why we are there. I have new strategies for next year to deflect the body blows. I would like to thank the entire team and give special mention to Kris and Zee for orchestrating the donation of a brand new anesthetic machine for the spine operating room, and to Elizabeth who generated many donations through the website, and single handedly collected and supplied all sorts of OR supplies and medications which allowed us to safely care for our patients and ourselves.
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Paul Holman MD Neurosurgeon My personal goals for the mission trip to Uganda initially seemed quite simplistic to me. We all know there are millions of people throughout the world who do not have the resources to receive even the most basic medical treatment let alone complex spinal surgery. Our team would travel to Africa, provide the necessary supplies and surgical expertise to treat as many patients as possible, and come back home feeling great. Pretty straight forward right? Maybe not. A little over two weeks later, the reality of the situation in Uganda has finally set in and it is difficult to deal with such mixed emotions. I learned more about the human spirit than I could have ever imagined. In the shadows of buildings that would look quite typical in any cosmopolitan US city, we met just a small sample of the dense population of Ugandans living in the most impoverished conditions imaginable. To see so many people, particularly children and animals, the most innocent of us, malnourished and poorly clothed made me angry. It also made me question what we were really going to change here. But we couldn't leave the slums of Uganda without noticing so many smiles. Amazingly, the Ugandans seemed to live life the only way one could conceivably do so in such conditions day by day. They displayed kind hearts and what I sensed was an appreciation for what little they have by our standards. I was reminded that the smile of a child, particularly a child in need, is infectious in any country. Treating many of these amazing kids during our trip reminded me that being a physician is a privilege and that to practice medicine without a happy heart will most certainly limit one's ability to heal. The experience also reminded me when people with a common goal and an unwavering passion to accomplish a goal are challenged to succeed, they will. Thirteen medical professionals, largely strangers to one another, went above and beyond and in the process even managed to treat their own sick team member. Thank you all again. I would be remiss not to acknowledge some of the frustrations I encountered. Working without some of the most basic equipment, let alone the latest technological advances that we take for granted at home was frustrating at times but also reminded me that we should never lose sight of the most basic aspects of our medical training and fundamental skills. Working at a pace that 13 "Type A" individuals would consider inefficient was also tough, but these issues are not unique to the Ugandan medical system. We can do better, here and at home, but it takes an unwavering committed effort from the top down and the bottom up. Sacrifices have to be made to achieve idealistic goals. We all have to look inside to decide if we have the passion to achieve them. I want to thank my family and colleagues back home for supporting my decision to go. I encourage others to volunteer. I will be forever indebted to my mentor, Dr Izzy Lieberman, for giving me such a wonderful opportunity. It is a clich but "unless you've been there" it is hard to appreciate the impact that this mission has had on the medical community in Uganda. He would humbly disagree, but does deserve the credit for advancing the mission so far. I know many fine physicians but it takes a truly special person to break these seemingly impenetrable barriers..."slow steady pressure."

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Ejovi Ughwanogho MD Orthopedic Surgeon (Fellow) The 2012 Uganda spine mission was an interesting and gratifying introduction to international orthopedics. In Uganda, as with many developing nations, chronic abuse of human/natural resources by corrupt and morally derelict leaders with no accountability to its citizens is the norm. Indeed, a majority of the impediments we faced during this mission can be attributed to the failures of these cock-ups (excuse my English.and anger). Unfortunately, these problems were far beyond the scope of our mission. Ours was an honorable mission as was reflected by the gratitude demonstrated by the patients we treated. Of course, some may question the cost-effectiveness of extensive spinal procedures in a society where malaria is an endemic and often fatal disease. However, the young kiddo whose wonky spine (deformed spine .for those not familiar with the British language) has been prevented from potentially disabling progression will not question the cost effectiveness of his surgery. In a vacuum, can I really disagree with this child? Can we place a numerical value on the impact of his surgery? Ultimately, missions such as ours should continue to strive to maximize its overall impact. Part of this, in my mind, involves teaching those on the ground to use local and readily available resources to optimize healthcare delivery. I intend to frequently participate in medical missions abroad. Its value to those we care for is undisputable. Furthermore, working amongst different groups provides one with an appreciation and respect for their culture I hope. This experience cannot be attained from the vantage point of a tourist or from the discovery channel. I thank Dr. Lieberman for this incredible opportunity and I also thank all the participants of the 2012 spine mission for this memorable experience. In this situation, I drink 2 glasses of Baileys. Peace! Elizabeth Wohlfarth Surgical Technician I am fortunate to have been chosen to be a part of the Ugandan Spine Mission, a team of professionals assembled from far and wide, and to have shared the experience of giving patients life changing surgeries, that they would not have had available to them otherwise. Not only did this positively impact the patients but their families as well. After being welcomed warmly by the staff in Uganda, and witnessing their willingness to help us perform complex spinal surgeries, despite the lack of "luxuries" in the operating room that we are accustomed to, such as abundant sutures, drains, lighting and air conditioning, I have a new found respect for "the can do attitude. And this carried over to the Ugandan people where the entrepreneurial spirit is alive and well. I witnessed this in many ways and everywhere I traveled, as there were street vendors, and small shops, and the local open air market where everything was for sale, in neatly stacked piles. One thing I found helpful was to read Tips on Ugandan Culture, A Visitors Guide, by Shirley Cathy Byakutaaga. The insights that it provided helped me understand the differences between our cultures, which led to me having a more patient attitude towards those differences. For instance our sense of time seems to be different than their sense of time. After seeing the staffs resourcefulness in not wasting anything that might be useful for another purpose, my attitude towards our wastefulness in this country has changed. Because we have so much we tend to take it for granted, and in that respect we can learn a lot from the Ugandan People.

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Krzyzstof Kusza MD Anesthesiologist This is my second time in Uganda as a member of the spine surgery mission, working as an anaesthesiologist. Since a significant number of new people have joined the mission, we had to get to know one another on a professional and personal level. The process of adaptation was accomplished without any problems. We have worked together to complete yet another set of tasks that should be performed with increasing frequency, without interruption, week after week, as only this can bring educational benefits and engender a habit of continuous work. I no longer felt any emotions connected with my stay in Kampala and beyond. This is probably the effect of a process of evolution within me. This time I focused more on reflections of a sociological and professional nature. Though no doubt subjective, they indeed had this character. Teams such as ours, motivated by good intentions, are not always perceived by the hosts in a manner consistent with their mission. Sometimes I feel that we interfere too much by working long hours, occasionally as late as 9 pm, by requiring the involvement of other units of the hospital (such as the ICU), by using up resourcesfor instance, syringes, needles and infusion fluidswhich would probably suffice for another six months if used by the local doctors. Though we have largely brought our own medical supplies, we should perhaps contemplate the question of whether a more prolonged effort might not achieve better results than shock therapy repeated 2-3 times a year. Only a sense of duty will be able to fix a system that is short on resources and lacks the mentality sensitive to the good that comes from work. Subsidised medical equipment and supplies are of little use when training is not available or when there is no interest in such training. Thus, for instance, the letter of intent from the University Mulago Hospital, expressing an interest in cooperation on the part of hospital and university authorities, is still not forthcoming. The university and hospital have achieved their short-term objectives. A new anaesthetic machine, disposable equipment, infusion fluids, etc. have been secured. And while HVO may report these gifts as an official donation, this will not alter the fact that the disparity between the worlds we represent is the consequence of our focus on intermittent efforts. We should think in terms of continuous processes in order to train indigenous leaders with a different mentality and better medical skills. The missions require medical professionals. This means that these people should be fully aware of the realities of their destination and the associated risks. The passport of even the greatest country in the world is no protection against a dangerous infectious disease especially when such risks are in the nature of the profession of doctor or nurse. There is no question that I am subject to a process with which experienced missionaries are surely familiar, though they never give up their mission. Ngozi Akotaobi Physical Therapist I returned to Uganda without the feelings of uncertainty that plagued me last year, and I had high hopes and great expectations for what could be achieved during this mission. Though there were quite a few bumps in the road and frustrations along the way, I do believe that good things were accomplished. Its been said that you can only conquer a mountain one step at a time, and this is a theme that continues to reign true with this mission. The foundation of each of these steps is kindness, passion, and persistence. I am honored to have been associated with some individuals who truly exude these qualities, and I am once again humbled by my experience in Uganda.

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Sherri LaCivita Surgical Technician I have been a Surgical Technologist for 17 yrs, specializing in spine surgery, and I felt very honored to be invited on the Mission Trip to Uganda. I was very excited to take my surgical experience abroad. I didn't know what to expect from living and working in another country. I have returned from this trip with a greater appreciation of living and working in life. The nursing staff in Uganda showed me what it means to use all of your resources to the fullest, by using what I would consider to be disposable again and again. They take pride in who they are, and how they live with the barest of necessities. This trip was a truly humbling experience as to what I take for granted everyday again at work and in everyday living. There were 13 of us that volunteered our time and efforts on this mission, with success' and also upsets, and we are bonded together for the good of others less fortunate. I would like to thank Dr Lieberman and HVO Foundation for such a great opportunity and life experience, and I look forward to do whatever I can for further missions.

Rachelle Lieberman Photographer Ever since my first trip to Uganda I have wanted to come back. As you all know, the first time I came I did not work at the hospital with my dad. Instead, I worked at a local school and foster home with my mum. Needless to say, this experience was very different, but just as rewarding. I was concerned going into the trip about what exactly my role would be, given that I was the only one without any medical experience or training. I know being the photographer for the trip does not require any medical expertise, but I did want to feel like my role would have a positive impact on the patients, their families, and other trip members. After this trip I do feel that I did more than just take pictures. I tried to capture the essence and emotions of the patients before and after surgery, as well as the moment they found out they would be getting the surgery many of them could not live without. I also tried to capture the emotions and effort put forth by everyone on the team. Each team member brought something different to the table and I wanted my pictures to show how valuable each and every one of you was. I've learnt and re-learnt a lot from this trip. Given that this was my 5th time to Africa I was reminded of lessons and experiences from past trips. I've learnt not to take the life I have for granted. It is crazy to think that more than 3 billion people on this planet live like they do in the slums and villages of Uganda. They think that we are rich because we own our own cars and homes, but often I think they are the ones that are rich. Rich with a sense of community and simplicity, and not always wanting or thinking they need more. I like to think that I have learnt as much from them as they have from us, and that a blend between our two cultures can lead to a better world. We can learn how to be less wasteful and they can become more medically advanced, among many other things. As an educator, I believe that everyone deserves an accessible and equal education, and in providing this education to less fortunate countries we can create a more unified and advanced world.

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Brian Failla - Equipment Technician Cumulatively, I've spent two months now in Uganda over the course of four trips with the Uganda Charitable Spine Surgery Mission. It's interesting to reflect on things I've observed changing rapidly while wondering about others that stay the same. The number of vehicles on the road is staggering compared to years past. Traffic at all hours is heavy and traffic jams are everywhere. I'm told that used cars are coming in from Japan and can be bought for a thousand dollars - fuel is expensive. But, we still see children horribly disfigured by tuberculosis infecting their spines that just $50 worth of antibiotics could have prevented. Everyone has a cell phone now. There are multiple companies providing service, and advertising for each is everywhere. But, almost as frequently, I see signs offering to charge those phones for a fee. It strikes me that someone would own a cell phone and not have electricity to recharge it for themselves. We split our time and the team between the public hospital in Kampala and a private facility that generously allows us time in their operating room. Conditions at the public hospital are just as I found them years ago. Even a basic piece of OR equipment used to take X-rays during surgery, which was damaged years ago, has not been repaired or replaced. While the private hospital has adopted some medical practices from our team and acquired equipment that is helping them to elevate their level of patient care. One positive thing that remains constant even as it changes though, are the people that donate their time to this undertaking. Once again, a group of veterans and rookies left their families, traveled halfway around the world and rolled up their sleeves to help others in need. It's especially gratifying to see the first-timers inspired to return or participate in philanthropic endeavors elsewhere. So the mission this year was a lesson in contrasts for me which clarified something I already know - that I should push forward and effect the world positively where and when I can.

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Robert Davis - Equipment Technician When people found out I was going to Uganda I was asked on almost every occasion whether I was nervous about the trip. Id simply respond that it probably wasnt going to be much different than visiting my family now living in Alabama. I believe it was this thought that kept me from becoming nervous as the trip came closer and kept me calm once we actually set foot on Ugandan soil. I was immediately struck by how beautiful the landscape was and almost instantly it wasnt hard for me to imagine that our lives probably wouldnt have been much different had our leaders, and the people that inspired them, made only a few different decisions over the last 50-75 years. I found it interesting that so many doctors had gone to school outside the world that exists in Uganda but when placed back into the environment didnt have the vision necessary to inspire the people around them and truly change the place for what I perceive would be the better. I heard someone mention one of the doctors who the previous year had been so full of hope and expectation having changed since they last saw them to become accepting of the role everyone, including him, plays each day. It made me wonder what might happen to each of us if we were placed in this environment on a long-term basis. Would we find ourselves, like the young doctor, overwhelmed by centuries of culture and a broken system that we would eventually become part of the machine as it exists? This is what I saw happening to the people and resources of Uganda and the environment we were interacting in. New equipment, buildings and infrastructure had been introduced and when it failed to make the intended change it became a footstool, prop, or a haunted house filled with the ghosts of dreams seemingly lost and waiting for someone to set them free. The people too seemed like they wanted to embrace our example for them but they lacked the drive that an individual and ultimately the country needs to fulfill its potential. After being there for two weeks I began to believe that an entire nation of strong, resilient, happy people have been relegated to utilizing every ounce of their intelligence and resourcefulness to simply make what they have been given work. I was impressed by Dr Liebermans resilience in the face of the challenges hes encountered over the years and his assessment of such an intriguing environment as well as his vision for the program going forward. It was interesting to hear about the past, see the present and visualize the future of the program and what he thought would make it a more effective mechanism for change in a place whose people and culture seem so willing, but unable, to embrace. Perhaps his vision will allow it to overcome the current political environment and local interferences that exist. I only wish Id had the opportunity to see his effort in its infancy while he worked with his co-creators to organize the first trip so I could have an even greater appreciation for what they have undertaken and the advancements they have made. His resourcefulness and passion for change will likely prove to be the catalyst that inspires someone internally to help take up the charge and be a constant voice whose purpose is to not only maintain, but advance the programs efforts. If Uganda is going to live up to the potential of its people and more specifically to the reason we were there which was to help Mulago Hospital fulfill its mission and vision to offer state of the art healthcare services and be the leading center of healthcare delivery in Africa its going to take, as Ejovi pointed out, leaders that are willing to look out for the interest of their people rather than their own self-interest. Thank you for allowing me to become a part of something so special and introducing me to such wonderful people

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Erin Sadler - Medical Student Although I consider myself very fortunate to have experienced a multitude of outstanding adventures in my life so far, the opportunity to be a part of this years Uganda Charitable Spine Surgery Mission has definitely been one of my lifes greatest privileges, so far. This privilege lies in the chance to get to work and learn alongside an amazing group of people, meet and help to treat such incredibly strong and courageous patients, and gain first hand exposure to the day to day struggle that is the reality for many Ugandans, and a large proportion of our worlds population in general. I was admittedly nervous embarking on this trip, not knowing what to expect, wondering how I would fit in with the team, and whether I would be able to find a niche for myself where I could feel like I could make a contribution amidst all of the experienced and highly competent team members. However, the warmth and camaraderie I immediately felt, made me feel right at home surrounded by an incredible group of individuals that quickly became family to me. I am so grateful for each and every one of you: for the laughter shared in good times and bad, the words of wisdom and one liners that made any mood lighter, and the life lessons that you can only learn from like-minded individuals working towards a greater common goal. Beyond the personal relationships that made this trip so special, I am incredibly grateful for the professional role models that took the time to teach and share their knowledge despite the intense workload and responsibility they had on their shoulders. As I progress in my training towards becoming a physician I look forward to taking what I have learned from your compassionate patient-centered care, and dedication to overcome adverse situations. Your ability to provide the best possible care despite the many obstacles that stood in your way on a day to day basis never ceased to amaze me, and I will strive to follow in your exemplary ways. I am fondly reminded of the dark Friday evening when a few of us found ourselves sitting in the pitch black of the Putti Synagogue. As a single light bulb came on to light up the whole singleroomed building Dr. Lieberman said, unbeknownst to the profundity of it, It is amazing what a difference a single light bulb can make. This observation truly resonated with me especially in light of this mission. As a team we may have only been a single light bulb, but there is no doubt we brought life-changing light into the lives of many needy and deserving Ugandans. However, we must work towards creating sustainable change, and not only bringing light in the form of isolated light bulbs, but help to establish a movement of change; a movement where each life is considered valuable, and where physicians can advocate for the betterment of their patients, and a movement towards the idea that a little compassion can go a long way. We are all role models for each other, and can each share and learn lessons for better and for worse; but it is missions of this nature that can help to open these lines of communication, encourage change, and promote growth in the direction of creating a better world for each and every global citizen.

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The Team; Lt - Rt standing, LaCivita, Failla, Wohlfarth, Sadler, Davis, Akotaobi, Ughwanogho Lt - Rt seated, Ehrhardt, Szkulmowski, Lieberman, Lieberman, Holman, Kusza

Operating Room Mulago Hospital

Sister Sarah and Elizabeth

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Surgery schedule planning

Handing over book donation from Dr Zigler

Ngozi with one of her patients

Ejovi with one of his patients

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The welcome reception at the Putti Village

Izzy with Rabbi Enosh and Sarah

Erin with her new friends

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In the Mulago Clinic

On the Mulago Spine Ward

LaCivita, Akotaobi, Failla, Sadler

Holman, Lieberman

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