A Global Links Experience in Uganda
I’ve travelled multiple time to various cities in Kenya and have travelled on road through Tanzania but somehow in all of my previous trips to East Africa, Uganda managed to escape. In 2016, I found myself packing for a 6 month trip to the country better known as the Pearl of Africa. I went on a programme called Global Links - a partnership between the RCPCH and Global Health Uganda. I would be working in the capacity of a paediatric doctor in a district general hospital in Kamuli, a town an hour north of Jinja.
What initially was a ticket to escaping the treadmill of full time employment and winter, turned out to be one of the most rewarding experiences of my medical career. I spent a week in London on a pre-departure training session along with colleagues who were to de despatched to various districts in East Africa and South East Asia. However, nothing could really prepare me for an environment so alien and circumstances I never thought I’d find myself in.
I attended a talk recently by an experienced medical educationist, Dr Gerard Byrne, who has vast experience working in low income countries. He called for the NHS training system to embrace the global learning platform and to think of the world as one big clinical learning unit. He mentioned how many of the skills NHS staff bring back from their stints abroad, come from being in unchartered territories, especially after spending time in lower income countries and low resource settings. One develops soft skills such as resilience, leadership and stress management under different circumstances. These are powerful lifelong learning experiences that help build character and in the long run are invaluable to the NHS.
Thinking back to Uganda now, his words cannot ring more true. I was an ST3 trainee at the time (on the junior rota for those not familiar with the paediatric hierarchy); hence had not had much experience in management and leadership in my work environment up until that point. Even at the times when I took on more responsibilities it was with the reassurance that I had a more senior colleague to fall back on to. Many a times in Uganda I found myself in a position where I was ‘it’. The buck stopped with me.
One example of this was a pair of premature twins I was asked to review in the neonatal room. The maternity unit was a very busy one, not surprising given that Uganda has an infant fertility rate of close to 6 births per woman. As with many units in the country, they were understaffed and under resourced. The twins weren’t feeding well and the midwives were too busy attending to the labouring women. I wanted the babies to have nasogastric tubes put in; I needed the mother to start expressing breast milk; I wanted the babies to be kept warm, I wanted them to have cannulae and receive antibiotics. I also knew it would take time for all this to happen had I just given instructions, make a written plan and prescribed antibiotics on the blank sheet of paper used as a drug chart. I was a mixed bag of emotions - angry because the midwives couldn’t seem to care less about these babies, frustrated at having to communicate in sign language with the mother because there was nobody to translate, clueless about making my own makeshift CPAP device, tired, hungry and mostly worried about the babies. I used what was available at my disposal and in the meantime delegated some task on the paediatric ward because I anticipated I wouldn’t have time for them that day. I walked home that evening wondering if I had done enough or if I had the right things. There was no senior colleague to reassure me, I didn’t have the ‘phone a friend’ option. I was reminded of what Dr Tagoola, a local paediatrician had said to me when I first visited the Jinja Children’s Hospital en route to Kamuli. He said “You will see so many things that will bother you. Just step outside, take a breath, don’t carry everything on your shoulders because you can’t. Take weekends away, see the rest of Uganda. We have waterfalls, we have gorillas. You will be frustrated, sad, tired and stressed. You must step outside.” In retrospect, days like this were character building for me. It taught me I could manage stressful situations and I’m tough enough for whatever curveballs life throws at me.
Other than developing my own intra-personal skills, I developed a new found interest in medical education; something which I am keen to develop further along my medical career. Teaching in Kamuli was a challenge. I was entrusted to run the once weekly medical education programme, a bit like the grand rounds we have here. Nobody turns up on time and the power cuts mean the projector almost always fails. Similarly, on the ward, I tried to incorporate some learning in the ward rounds for the nurses but with poor staffing, low morale and heavy workload, their attention just wasn’t there. Many a time I felt all this effort was pointless and I’d go home wondering what I could do differently. On some days however I go onto the ward and see that they have taken on board some of the things I tried to teach and I felt rewarded as if I was sipping a coconut drink on the beach in the shade on a scorching hot day. If one patient has benefited from that little change, then that’s one step in the right direction.
One of the small changes that made a big difference was the introduction of triaging in the outpatients department. This project was started off by Katie, the doctor placed in Kamuli before me. I inherited this project 6 months down the line and assessed whether it had improved conditions for the patients. Prior to the project, every patient would wait in the same area (worse case but very real scenario: the newborn baby next to the man with TB coughing profusely!) and wait on a first come first serve basis. With the introduction of triaging, the paediatric patient would wait in a separate area and have their vital observation and weight taken. This helps the staff to identify sicker children. I audited the practice of triaging and it shows that we were able to avoid children getting sicker in front of our eyes because we were identifying them quicker. We started measuring their weight routinely, and were more easily able to identify children and families who needed nutritional advice or intervention. As a team at Kamuli, we managed to present this project at the Uganda Paediatric Association Annual Conference and I asked Susan, one of the local nurses who works in the outpatient department to present. For her it was like a dream come true speaking in front of a big audience and I am glad she had that opportunity. It’s been a year since I left Uganda but I wonder if they are carrying on with this practice. I certainly hope so.
Learning is always a two way street. I certainly learnt a lot from my experiences probably more than they learnt from me. I mean this in both a clinical and non clinical sense. The cases I saw on the ward made my final year infectious disease textbook come to life! I saw clinical manifestations of HIV in the late stages, and signs and symptoms that I probably would never see in the UK. I remember the time leading up to my clinical examinations and I had to attend multiple sickle cell & haemophilia clinics to try and feel a big spleen and liver. In Kamuli splenomegaly seemed to be the default in every child. I also saw many of the undesirable consequences of sickle cell disease. Sickle cell is very prevalent in Uganda and management of the condition still needs a lot of work in Kamuli.
Another new found interest of mine post-Uganda is global health. With a postgraduate training programme to complete, I will most likely be staying put in the UK for the next few years. The good thing is that global health isn’t just about leaving everything behind and moving away to Sub Saharan Africa. With the increase in immigration into the UK and increase in refugees across the world, there is a lot of work to be done closer to home, both in clinical work and advocacy. I have signed up to newsletters from the Royal Society of Medicine, the London School of Hygiene and Tropical Medicine and the MSF to keep updated as they regularly organise events and conferences related to global health. These platforms are great for networking. Alternatively there are short term overseas missions that don’t require long leave from work (you can read about my Jordan experience here).
The Ugandans I had the pleasure of meeting will always have a special place in my heart. Their hospitality is second to none. The little town of Kamuli turned out to be a home away from home; from the green frontyard I woke up to every morning, to the pitter patter of naked children making a fuss about a Mzungu walking past their homes. I remember endless waving and smiling and pleas for sweeties, the scent of remnants of last night’s charcoal fire as I took the dirt road to work, and the rainbow affair of the day’s backyard harvest, artfully laid on wooden planks along the main road with calls from women telling me the avocado was ripe that day.
If you are interested in a stint abroad, the RCPCH run the Global Links Programme. You can check it out here https://www.rcpch.ac.uk/global/programmes/volunteering-programmes/global-links/global-links-programme
If you are looking into more formal qualifications to buff up your CV with global health experience the MSF run the Global Health and Humanitarian Medicine course (https://www.msf.org.uk/global-health-and-humanitarian-medicine-ghhm-course) With this course you can also sit for the diploma in tropical medicine!
Dr Munirah Mazlan
(Edited by Dr Katy Smith)