Why it takes a degree of insanity to be a surgeon at Mulago Hospital

Why it takes a degree of insanity to be a surgeon at Mulago Hospital

When Dr. Joseph Buwembo, an Associate Professor of Neurosurgery at the University of Saskatchewan, Canada, visited Uganda in 2012, his mission was not only to see his relatives and enjoy his homeland, but also to give back to his people. He offered free neurosurgery on a baby that had a very complex brain problem. This would help that baby and teach skills to younger colleagues. 


With this offer, Mulago and Makerere Medical School were getting the best of the best, for Dr. Buwembo is one of the most highly educated neurosurgeons around. A graduate of Makerere Medical School, Kampala, Dr. Buwembo qualified as a neurosurgeon in South Africa before relocating to Canada in 1996. He underwent another four years of training in neurosurgery and became a Fellow of the Royal College of Surgeons of Canada in 2000. He is an Associate Professor of Neurosurgery at the University of Saskatchewan, Canada. 


Prior to arriving in Kampala in 2012, Dr. Buwembo had made arrangements to commence the operation on the baby at 07:30 a.m. on the appointed date. However, when he and his Canadian team of nurses arrived at Mulago National Referral and Teaching Hospital, they found that there was no anaesthetist to put the baby to sleep and manage her heart and breathing during the extremely delicate procedure. There was no explanation given and there was no other anaesthetist to do the job. The baby, her family, Dr. Buwembo and his team simply waited, in the dark so-to-speak. 


When the anaesthetist showed up at 10:00 a.m., he appeared unperturbed by the delay and simply informed the team that he had been busy attending to his parent who was unwell. Dr. Buwembo and his team proceeded with the surgery which lasted 3 ½ hours. The team then spent another hour speaking with the parents and accompanying the baby to the post-operative unit. Needless to say, the team’s other engagements were disrupted. The compensation was that the baby did well, at least in the short term. 


When Dr. Buwembo shared his experience with me six years ago, I was as concerned as he was, but I felt optimistic that Mulago had learned a lesson from it and had identified opportunities for improvement. However, an experience last week by Dr. William Manyilirah, a consultant cardiothoracic surgeon at the Uganda Heart Institute, suggests that, if anything, the situation at Mulago needs radical intervention. 


Dr. Manyilirah, a Makerere Medical School graduate who trained as a general surgeon at Mulago and as a cardiothoracic surgeon at the University of the Free State, South Africa, returned home in 2015 to serve Uganda and his alma mater. He wrote an anguished letter last week that invites urgent and close attention by all who care about our once famous hospital. A full copy of his letter, which he posted to a WhatsApp group on Friday October 26, is available on this website.


The letter describes the last-minute cancellation of planned operations on two patients with very serious chest diseases. The reasons for the cancellation? First, there was no oxygen. When Dr. Manyilirah borrowed an oxygen cylinder from the thoracic surgery ward, he was told that there was no anaesthetist. The senior anaesthetist on duty was reportedly “indisposed” and there was no back-up plan because all the Senior House Officers (SHO) were busy attending a research conference. The other anaesthetists were attending to patients in other theatres. 


It is enough to make one give up. So why does Dr. Manyilirah continue to offer his skills to Mulago Hospital?  “I go to operate at Mulago to share my thoracic surgery skills and knowledge with the SHOs and other surgeons,” he wrote. “I do so to help operate on needy Ugandans with more complex thoracic disease who would otherwise not afford the cost of the same surgery in private hospitals, and to prevent attrition of my hard earned thoracic surgery skills and knowledge.” He adds: “Other than the above reasons, I have no obligation to work on the Mulago thoracic surgery ward!” 


Dr. Manyilirah says that “the setup of the Mulago theatre calls for a high degree of sacrifice by right-thinking surgeons and other staff.” To him the situation goes against most standard operating protocols and common sense. He sometimes feels that “it takes some degree of insanity to accept to perform specialised surgeries in that operating theatre.”  


“On some days, if it is not lack of essential supplies, a surgeon has got to literally beg and cajole the anaesthetist or theatre staff to have a case operated on at Mulago”, he continues. “Sometimes it appears as though the surgeon owns or has a special interest in the patient!”


Dr. Manyilirah observes that nurses and doctors at Mulago Hospital often turn a blind eye to problems in their units because they fear admonition by the hospital administration and even loss of employment. “This is very disturbing and is a source of despondency among the staff - a recipe for poor service delivery,” he writes.


After offering excellent suggestions for remedying the situation, Dr. Manyilirah urges his colleagues to boldly voice their concerns about the poor working environment. “We should not directly or indirectly perpetuate it,” he implores them. He advises the hospital administration to find a way of encouraging the staff to come forward and discuss “the issues openly without fear of being unfairly reprimanded.”


Reacting to Dr. Manyilirah’s letter, a senior consultant surgeon who knows him, said: “I was in charge of theatres at Mulago for over five years. What Dr. Manyilirah, my former student, is talking about is just the tip of the iceberg. Unfortunately, whenever and however one complains makes no difference. One creates more enemies. You just simply keep quiet or give up just as I did.”


Dr. Manyilirah’s choice to go public suggests deep frustration with the absence or failure of internal mechanisms for resolving these problems. His letter is a patriotic act by one who could have chosen to stay in South Africa or sought opportunities in many other countries. Instead of the Mulago Hospital administration going on the defensive or taking punitive measures against him, they should engage with him and other stakeholders to find a sustainable solution that provides the best care to patients. 


Beyond celebrating the newly renovated hospital building, the executive and legislative branches of the Uganda government have an urgent duty to act on Dr. Manyilirah’s concerns. The place to start is a thorough and independent external review of Mulago Hospital, with a view to making necessary radical changes. 


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