Edinburgh EM partnership feasibility visit to Makerere University & Mulago Hospital, Uganda

Background

Uganda is a rapidly developing East African country that has been through a lot over the last 40 years, and yet is now a stable economic hub for the region, and is developing and progressing every day. Over the last 25 years the population has doubled to 39 million people, resulting in a huge strain on the health care system, facilities and resources. Yet despite a crippling burden of emergency medical, surgical and trauma presentations, there are currently no emergency medicine trained physicians in the country.

Sarah Richardson, one of our EM trainees, has had a connection with East Africa for almost a decade having first visited as a medical student. She has spent several extended periods of time living and working in Uganda, and has made a number of connections with staff working in Mulago Hospital, in the country’s capital Kampala. 

Mulago Hospital is the National Referral Hospital for the country, supported by Makerere University, which houses one of the top medical schools in Africa. The staff of the both these facilities have recognised the need for immediate access to triage, diagnosis and treatment of emergencies. And as such emergency medicine has been identified as an area that staff wish to develop, specialise in and use to reduce the morbidity and mortality they see every day. 

Makerere University are now in the final stages of developing a Specialty Programme in Emergency Medicine (MMed EM) and have developed a full local faculty of support. However, due to the lack of the specialists in the country they are looking internationally for support and assistance in how to take emergency medicine forward in their setting and system. 

As a result of 2 years of meetings, discussions and emails, the team from Edinburgh was invited for a feasibility visit to understand the situation in Uganda, and look towards a possible partnership with Makerere. The visiting team comprised of Professor Alasdair Gray, Dr Ed James, Dr Katy Letham and Dr Sarah Richardson. The trip was made possible in part due to funding from the Medic 1 Charitable Trust.

Blog, part 1: Our first few days in Uganda

After landing in Entebbe, the Edinburgh EM team travelled to Jinja, a town by the banks of the beautiful White Nile, to spend the weekend recovering from the long journey and acclimatising to the surroundings. It was the perfect place to spend a few days getting used to being on ‘Africa Time’ – life is fairly laid back and everything happens at a different pace to what we are used to at home.

Monday brought an early start in an attempt to beat the traffic on the road to Kampala. The journey was somewhat hampered by hazardous potholes, speeding matatus (dangerously overcrowded local buses) and, of course, the boda bodas – motorcycle taxi drivers with no respect for road rules, their own lives, or anyone else's for that matter. It was easy to see why major trauma due to road accidents is so common here.

We arrived at Makerere medical school and had our first meeting with Dr Tonny Luggya Stone (an anaesthetist with an interest in trauma who is heading up the MMed programme), Dr Joseph Kalanzi (a local doctor with an interest in EM, soon to be the first student on the MMed) and Susan, who coordinates international education programmes at Makerere.

Makerere University Medical School

After a few minutes in Susan’s office, it was clear she was the Liz MacDonald of Makerere – she knows everyone and everything, she made us feel very welcome and she had some wise words about Uganda. She explained that Ugandans are very friendly but talk quietly – visitors often struggle to hear them so we should just ask them to speak up! Instead of ‘yes’ and ‘no’ there is a slight eyebrow raise with a ‘hmm’ noise, or a slight head shake with a similar ‘hmm’ respectively. Good to know for our many upcoming meetings! Susan describes Kampala as organised chaos, which is funny because we often describe our ED using the same words, with the crazy traffic and bodas everywhere. Perhaps this helps prepare people for what they will see on the wards. She warned us to be careful of using our iPhones in public in case they are stolen – just like home then! Susan also warned us about the current small outbreak of Ebola in the neighbouring Democratic Republic of Congo, advising us to ‘be on high alert’ when interacting with patients just in case.

Tonny and Joseph gave us an insight into the issues facing EM in Uganda. While our Royal College is currently celebrating 50 years of EM in the UK, Joseph describes EM in Uganda as ‘0.1 years old’. There is no EM training programme in the country (the only place on the continent it is established is in South Africa) and there are no EM-trained doctors. The A&E at Mulago hospital is run by a combination of orthopaedic and general surgeons. They have many of the challenges that you might expect from working in a resource-poor country, but in particular they struggle with large patient volumes and lots of major trauma.

Katy, Alasdair, Joseph and Ed at Makerere Medical school

Our next stop was a visit to A&E at Mulago, where we met the formidable Margaret, the Principal Nursing Manager. She told us ‘like MTN [the mobile phone network in Uganda], I am everywhere and anywhere!’ We discussed triage, training emergency nurses and patient flow. It was beginning to feel a bit familiar. The hospital layout provides other challenges for A&E patients, such as the long journey to the x-ray department which Margaret described as ‘going to London then back to Kampala’! We continued to tour around the rest of the hospital and the inequalities were becoming obvious – there are brand new buildings for the Infectious Diseases Institute and the Cancer Institute (supported by funding from international organisations) while other wards appear almost derelict. It’s clear that the chance do conduct research brings money alongside it – for better buildings, equipment, resources etc. But emergency care remains underfunded and under-resourced.

Alasdair and Tonny discuss the layout of the new A&E

Over lunch with Tonny and Joseph it becomes clear that they have a fantastic vision of where EM in Uganda could go. They are very aware of some of the difficulties that a fledgling EM specialty might face – lack of recognition by other specialties might be a particular issue. Joseph plans to tackle this by embedding himself in the Mulago team, studying locally rather than travelling to another country for EM training and using the time to build relationships with other specialists in the hospital. During lunch a monkey runs right past Prof Gray and we are all reminded that we are in Africa! We’re reminded of the other differences when we discuss common EM presentations. How could you manage a patient with chest pain if you couldn’t access troponin tests, or even an ECG (the one in the A&E is broken)? They have many issues with donated equipment, which often breaks down and can’t be serviced locally. It’s clear that they see our potential collaboration as a chance to share skills and experience, not to donate resources. We’re still not sure exactly what that might look like, but hopefully the rest of the week will give us some inspiration.

6 months and we've had our 200th GREATix. Well done #teamED.