Uganda's Irish connection under the knife

A virtual School of Surgery set up in Ireland is becoming a key part of surgical training in nine countries, including Uganda, writes NIAMH GRIFFIN

The wide corridors of Mulago Hospital in Uganda’s capital are thronged with people, but, in one small room, surgical interns sit in peace, in front of screens displaying the Royal College of Surgeons Ireland logo.

This website, complete with case studies, online tutors and satellite dishes for some hospitals, arose from collaboration between RCSI and the College of Surgeons in Eastern, Central and Southern Africa. Funded by Irish Aid, it works like a virtual school and is becoming a key part of surgical training in nine countries.

Dr Jane Fualal bustles along the corridor, heading up to the darkened room next to the busy TB wards. She says improved training is making surgery more attractive to interns here in Kampala and elsewhere.

And with just 175 surgeons treating 33 million people around the country – Ireland has 495 – she says support is needed. But the first step was finding space in the building for computers.

“Our association is only 12 years old, so RCSI can advise on technical things. And without them we would not have the IT lab for training, or the website access,” she says.

Since 1996, she has watched interns leave surgery to work in better-funded areas such as malaria or HIV/Aids. She says the online School for Surgeons gives a clearer academic path to qualified status.

“We have 13 accredited hospitals to our association but only five of them are actively training. But our membership and fellowship programme are expanding now because we have more material for them,” she says.

Part of the €500,000 per year provided by Irish Aid for 2011 to 2013 is spent on gathering African case studies for the website. Trainees chat online with their peers and lecturers in other hospitals to assess their approach.

Senior surgeons also receive Train the Trainer courses, delivered by RCSI surgeons volunteering their time.

Registrar Dr Kintu Luwaga says he is on the endocrine ward. But his day is always busy, he says, as he also operates on road-crash victims.

“The website is useful in terms of reducing the time we spend looking for information, and the programme helps us access it. We need to constantly update ourselves and buying hard-copy books is very expensive,” he says.

A student could spend more than one million shillings – three times the average monthly salary in Uganda – on just four books, he says. In contrast, monthly wifi packages average 51,0000 shillings (€15).

Dr Asuman Luwago of the Ministry of Health says the department wants to use this programme as a model.

“We plan to evolve this work and support the surgeons with nurses, anesthetists and other complementary staff. We are hopeful of increasing the specialisms on offer here,” he says, speaking just after the health budget was decided for 2013.

However, even in the capital regular power cuts mean relying solely on the internet is not practical. And outside of Kampala, the surgical programme has hit a few snags.

Dr Martin Ogwang, head of surgery at St Mary’s Hospital near Gulu, says he almost had to join the IT staff when the system was first installed. “We have had some difficulties,” he says, bringing wry chuckles from colleagues in the department.

Surgeons in this walled-in compound in northern Uganda have a strong reputation. It was the only hospital to treat Ebola victims 12 years ago, when 13 staff died; it was the sole hospital open during decades of conflict with Josephs Kony’s army; and it acts as a shelter for thousands of children running from the Lords Resistance Army. Practical training is not hard to come by here.

But it is isolated, sitting 6km outside the town and along a dirt road, which turns into a quagmire when it rains. Interns tend not to stay long, says Ogwang.

“In 1993, landmines were very few,” he says of his start here. “But by 1996 there were so many landmine injuries, it was very difficult. Now road traffic has increased so travel-related injuries are the most common trauma we see.”

Today’s interns want to connect with colleagues and international training. But the IT department says the satellite dish which provides coverage to this Comboni Mission hospital is struggling under the extra demands. When the RCSI project manager visited to demonstrate video conferencing last year, Ogwang says he was interested. But the interns’ enthusiasm for online study flooded the hospital’s intranet system with viruses.

Pointing at the tangled web of wires running around his office, Ogwang says they are installing a separate system now for the School for Surgeons. “We tried to have it on wireless. But when they used it, they could access the hospital too – accounts and patient administration. Another donor is putting up a mast for the whole region; this will improve the coverage,” he says.

Ogwang has to balance innovations such as online training with basics such as salaries, he says, adding that much of the hospital’s funding comes from countries such as Ireland and Italy, so there is less now. And it usually does not cover salaries.

Standing in the dusty yard, as a 4x4 ambulances roll in, his colleague Dr Nelson Alema says Irish support has been crucial in the past decade. One of nine surgeons being trained in how to deliver courses himself, he says educational changes go beyond the website.

“Our big challenge here is accessing information. The website is there, but the internet is unreliable. But more importantly, the support for developing materials and courses means we have five surgical interns now here. When I came, in 2004, I was the only one,” he says.

Before the new mast arrives, interns will continue to use their laptops to download and save the case studies when they can get online. So while the School for Surgeons is the most visible aspect of the RCSI partnership, for rural doctors the behind-the-scenes work is more important, says Alema.

“Three years ago there were two choices of specialism; now there are six. The old way of thinking in Uganda was everyone should be a general surgeon, but that is not useful now,” he says.

Developing and maintaining an online course that can be effective across different locations is just one of the challenges for the programme, says its project manager, Eric O’ Flynn.

“These are developing countries; there are a lot more hiccups that can happen than [in Ireland]. There are lots of problems, but there is a way around everything,” he says. As the only full-time member of the project, O’ Flynn’s job is to coordinate the nine countries and make sure funding goes to the right places. The project covers exam development and training as well as the website.

Director of professional development with the project, surgeon Dermot O’Flynn (no relation), develops the training packages. He says he volunteers his time because it’s more sustainable than just sending money.

“A lot of the surgeons would be made a trainer without having any training or structure to what they’re supposed to do. We are training the future of the health service there,” the director of professional development says.

Niamh Griffin travelled to Uganda with support from the Simon Cumbers Media Fund.

Jervis Street links between Africa and Europe

Thirty years ago, two men trained as surgeons at the now-closed Charitable Infirmary on Jervis Street, in Dublin.

Gerry O'Sullivan, who died last year, went on to become a leading cancer researcher and surgeon. Krikor Erzingatsian has spent his career in Zambia practising and promoting surgery. He has been involved with the College of Surgeons of Eastern, Central and Southern Africa since it was founded.

The professor visited Dublin recently to discuss the partnership between the African college, RCSI and Irish Aid.

Sitting in a hotel lobby as the rain pours down outside, he says the two men kept in touch. And five years ago, he invited O'Sullivan to address the African college.

"We had obtained our fellowships at the same time. Then, in 2007, he was president of RCSI and I was president of COSECSA. What an extraordinary situation," he says.

Erzingatsian said the college had been set up to stop "the brain drain" of African surgeons who trained abroad and never returned. Discussing this with the Irish surgeon, he says O' Sullivan realised a partnership would be beneficial."He was extremely keen to get involved. And now this is our strongest relationship," he says.

"I'm aware of the financial hardships Europe is facing. But even if there is no financial co-operation next year, I hope the education links will continue into the future."

From Dublin to Kampala 'I've completely left Irish surgery behind'

Later this year the Surgical Fellowship programme at Mulago Hospital in Kampala takes in an unusual student. Unusual because Nollaig O'Donohue is bucking the trend for trainee surgeons and has moved from Ireland to Uganda.

"When I was doing my training, I'd have one eye on what was happening in Darfur rather than the RCSI ladder. I was always looking for an opportunity to come out and work in the humanitarian medicine field," the Dubliner says in a Kampala café.

"I came as a volunteer first, self-financed. I wanted to see if I really had something to offer," she says. "Now I've completely left Irish surgery behind – the experience I'm getting here I would never need in Ireland."

O'Donohue talks of TB patients needing surgery to drain lungs filled with pus or remove infected spinal bone. And says she has removed TB-damaged testicles from patients.

Her move to Uganda came after a chance meeting with a nun from the Medical Missionaries of Mary in Drogheda.

This led to volunteering with Sr Maura Lynch - perhaps one of the best known of these nuns for her work on fistula surgery.

One year on, O'Donohue is sure she's ready for the African college's Fellowship programme. Later, driving confidently through Kampala's traffic, she says it's because volunteering isn't a long-term option.

"I like the vision behind COSECSA: it's structured training. And it's Irish-funded, that's a nice little link. My generation, we are interested in humanitarian work but not in being missionaries. Working is more sustainable," she says.