A WALK WITH UGANDA
A series of
conversations about Uganda
in the 1960s
THE DOCTORS
In 2008 a British doctor working as a volunteer in war-torn Congo was faced
with having to do a very difficult operation to save an injured man’s
life. It’s an operation that is rare
even in the UK, but he knew
of someone who could do it, his teacher Professor Meirion Thomas in London. He sent a text
message asking for advice. Prof Thomas’
response was a text message telling him, in eight short sentences, how to do
the operation (the last sentence was "Easy, Good Luck"). The operation was
successful.
I saw the story online and was interested because I had met
Thomas years before. In 1982, soon after
he finished his surgical training and I was starting mine, we both spent some
time at New York’s
Sloan Kettering cancer center. We
chatted once and he told me he had been to Uganda in the late 60s as a young
doctor. He told me of spending time
working under a Mr Miro at Masaka, and recalled with awe the surgical skill of
the Ugandan (Ugandan surgeons use the title "Mr" rather than "Dr"). “He was a gynecologist but could
do anything, he taught me tons of things, tons of things”, said Thomas.
Meirion Thomas was one of many non-Ugandan doctors I met in
the 1980s who had worked in Uganda
in the sixties. They all told the same
story: the numbers of patients were unbelievable,
as was the skill of the Ugandan surgeons.
And they all added, every single one of them, “I had a wonderful
time”.
It was indeed a wonderful time, a time of great personal and
professional success, but it had not always been so.
Medical training in Uganda started in the 1890s when the
great missionary Dr Albert Cook opened a school for midwives. Government involvement came in the First
World War, with the training of dressers.
In the 1920s a formal medical course was started at Makerere. The young men in the course (the school was
not to graduate East Africa’s first
woman doctor, Josephine Namboze, till 1959)
were trained to a standard
derived from the Indian Civil Service, called “Sub-Assistant Surgeon” but due
to the huge demand they actually worked as doctors.
The qualification was upgraded in acknowledgement of this
reality to a “Licentiate in Medicine and Surgery” but the doctors could only be
appointed as “Assistant Medical Officers” because the title of Medical Officer
required a degree acceptable for registration in the UK.
Their numbers were small; even by 1962 Makerere Medical
School, serving all of East Africa, still had less than twenty Ugandans
graduating every year. Getting there was
brutally hard. President Binaisa, in his
old age, once told me of how he initially regretted failing the entry exam but
later felt better when he realized the torture his successful mates were being
put through. “They had no life, those
chaps. My friend Semu Nsibirwa, he had
no life for the seven years of Medical
School. I told him so”.
On graduation the usual fate of the young doctor was posting
to an upcountry hospital where life was lonely, the workload huge and the pay
poor. “The shs 600 a month salary was an
insult, I resigned from the government”, recalled Dr Samson Kisekka, later Prime Minister of Uganda.
The young Ugandan doctors also believed that their British
supervisors avoided posting them to a hospital where they would end up giving
orders to British Nursing Sisters. The
rate of resignations rose to a point where the survival of the government
hospital network was at stake, and the government was forced to raise salaries
to a very generous level. By 1955 some
experienced doctors were earning shs 2000 a month, a huge salary in those days. At the top of the profession were the senior
consultants, whose pay was raised to the “Upper superscale”. This top rank of the public service contained
only a few officers, notably including the Principal of Makerere and the Chief Justice. The first Ugandan specialists only reached that
rank after independence, at which time it entailed a shs6000 monthly salary.
Better pay was welcome, but the Assistant Medical Officers
were pressing for professional recognition.
They were doing doctor’s work but were not fully recognized as
such. Most galling was that in 1952
Makerere started awarding University
of London degrees to its
graduates, that is all graduates except those from its most demanding course,
the medical one. Eria Muwazi, our first academic
medical scholar, managed to get to England and actually get a specialist
qualification, the Diploma in Child Health, in 1950. He still could not get appointed Medical
Officer at the time. Benjamin Kagwa, who
trained in the US, could not get any job, the Uganda Government refused to recognize his American MD and he only finally returned to Uganda at
near-retirement age.
Because of the acute need for surgical services the Ugandan
doctors were all trained in emergency
surgery. Some, notably S. Kyalwazi, S. Kyewalyanga and A. Odonga, were in fact
skilled general surgeons in all but name and were pressing for formal
qualification as such. Formal
qualification from the Royal Colleges, however, required a stint in a British
hospital, which required a registrable degree that the Makerere could not yet
deliver. Recognition allowing
registration with the General Medical Council in the UK finally came in 1957,
so a handful of Ugandans departed for specialist training in the late 1950s. The degree itself, however, would not arrive
till the University of East Africa was constituted after Independence. In the 1964 graduation ceremony over 150
doctors, including all the senior Ugandan staff at the Ministry of health, were belatedly awarded the Makerere M.B;Ch.B. degree.
Dr Kyewalyanga, tired of waiting for the rare scholarships
to the UK,had resigned from the
government and opened his own hospital at Kako in the late 1950s. Equipped with an operating theater, the
hospital was the first such institution in East Africa
owned and operated by an African.
His colleagues S. K . Kyalwazi and John Kibukamusoke
returned to Uganda from Scotland in 1961 with Royal College certification in
Surgery and Medicine respectively, followed a year later by another surgeon, Alex
Odonga. They returned in an exciting
time. The hospital moved into a new
building in 1962, a building which
doctors of that generation, both British and Ugandan, noted was vastly more modern than the
antiquated buildings that still housed Britain’s teaching hospitals. The work was exciting; this was the heyday of
Mulago at the forefront of medical research and teaching in Africa.
Mr. S. K. Kyalwazi
The first generation of Ugandan specialists rose rapidly in
the profession. Prof. Samuel Kajubi, who joined the Makerere faculty
as a lecturer in the late 1960s, once told me of the awe he felt for John Kibukamusoke,
Professor of Medicine at the time. “We
saw him as almost godlike”. It was a
well-deserved respect. Kibukamusoke had
made a major discovery, describing a newly-discovered type of kidney disease
caused by malaria, and had authored a textbook.
It was just one of many such contributions. Prof Kyalwazi was to become a world-renowned
cancer surgeon while Prof Odonga rose to become Dean of the Medical School. Prof Odonga
even in the early 60s was a noted polymath who loved poetry as much as
surgery. In retirement he has published
a history of the Medical School, as well as a Lwo-English dictionary.
A medical student at Makerere in the 1970’s had the
privilege of being taught many courses by “the guy who wrote the
textbook”. Among the books on our
shelves in the seventies were these by Makerere authors:
Embryology, by Haines and Mohiddin
Haematology, by Woodliff and Herman.
Medical Statistics, by S. Lwanga
Diseases of Children in the Tropics, by D. Jelliffe
Medicine in a Tropical Environment, edited by J.
Kibukamusoke,
Guide to Polio, by R. L. Huckstep
Guide to Trauma, by Huckstep
Anaesthesia, by Vaughan
Culture and Mental Illness, by J. Orley
Medical Laboratory for Developing countries, edited by
Maurice King
Medical Care in Developing Countries, edited by Maurice King
Maternal and Child Health, by Jelliffe
A Short Practice of Surgery; one of the editors was W.
Cleland,
Atlas of Disease distribution in Uganda, edited by B. Langlands
(Prof of Geography)
Kaposi Sarcoma, by Lothe
Cardiovascular Disease in the Tropics, edited by Shaper
Companion to Surgery in Africa,
edited by Davey , with many Mulago contributors
Interestingly some of the proudest examples came from the
outside the prestigious ivory tower of Mulago-Makerere Medical
School. The Professors of Surgery, Sir John Croot and Sir Ian McAdam, set
up a training program that was to win international recognition for excellence
but were to be eclipsed in fame by Denis Burkitt, a humble and deeply religious
surgeon working in Lira, a small upcountry town.
Mr. Denis Burkitt; humble,
religious and blind in one eye!
Burkitt used to travel around East
Africa on his vacations, taking pictures. He noted that a certain type of jaw tumor was
very common in children, and his curious mind led him to map out the locations
where the tumors were common. The map
showed a distinct geographical pattern which was similar to that of malaria. His
investigations led to the discovery of a new type of lymphoma that was named
after him (Burkitt’s Lymphoma), and to the discovery of the first virus known
to cause cancer in humans.
A Ugandan Asian lad called Sultan Karim failed to gain
admission to the Medical School and got a degree in Pharmacology instead (or so
went the popular story, I never asked him!). He ended up as a Professor at
Mulago, where he gained worldwide fame as one of the pioneer researchers into
the prostaglandins, a set of chemicals that carry signals from cell to cell. He also gained a huge research grant from an
American pharmaceutical company and an ostentatious lifestyle which led to
endless malicious gossip.
What was to be probably Mulago’s biggest contribution to
medicine, the concept of high quality care with limited resources, was also
born in a remote part of the country. A
lecturer in Microbiology, Maurice King, worked for three months in Karamoja as
a “locum”, covering for a friend who was on vacation. Now, Karamoja was by far the least developed
part of Uganda,
and civil servants posted there actually had a hardship allowance added to
their salaries (the line on the payslip actually said “Karamoja Allowance”).
As he soldiered away in Karamoja the challenge of limited resources
stimulated King to ask questions and write letters, and two years later to the
organization of an international conference at Makerere on “Medical Care in
Developing Countries”, out of which came a seminal book. The theme of the book was “In a country whose
medical budget is about $ 1.00 per resident per year, how do we deliver good
care?” Yes, that is one dollar, not a
misprint. That was about the size of an
African health Ministry budget then (and, allowing for inflation, still is).
I still have my copy of King’s book and on thumbing through
it I am still awed by the sheer excellence of that generation. Here were a set of medical workers in some of
the poorest countries in the world and the constant message is “yes, we can do
well”. None of the contributors to the
book was an “international expert”, all were medical workers in Africa. There is no grandstanding, no slogans, no
bombast, just a pervasive sense of a commitment to excellence and practicality. The examples of a ‘can do” spirit are
endless; they include a wheelchair made with bicycle wheels, wooden test-tube
racks and architectural plans employing only locally available materials.
When those who recall Uganda’s medical system of those
days say, “We had a wonderful time” you can definitely believe them.
A fifty-year old
sign outside every ward in New Mulago.
Prof Kibukamusoke
examining a patient; the young intern to the right is Dr Charles Seezi.
