Only 6 years ago very few people could believe that we would be graduating Medical Doctors in Gulu. The phrase that I cannot forget was ‘ No one will ever put a foot in Gulu…’ and today, how many thousands of feet have been put in Gulu ? ( there are 5500 attendances !)
Medical Training is a great investment for development
The impact of Medical Training is certainly not limited to the sphere of health, in fact ‘better health = better well-being’. especially in developing countries. Better Health, better Human Resources, better Equity, better Justice, better Quality of Life, both for healthy people and for those who suffer. Enormous energy, both human and financial, was required to reach this day, but these 40 young doctors are today themselves the best reward for so much effort.
THERE IS A GREAT NEED FOR DOCTORS
Africa bears 24% of the world’s disease burden, but enjoys only 3% of the health workforce and only 1% of the world’s economic resources. 36 (almost all) Sub-Saharan countries fail to guarantee a minimum standard of health care in terms of doctors, nurses and midwives (1). In order to reach this minimum level, it would be necessary to increase health expenditure per capita per year by about $3: in Uganda alone, $90 million is needed every year (2).
We therefore had good reason to fight for Peace by starting a Faculty of Medicine in tormented northern Uganda.
So today we don’t just say ‘we can’ but ‘we did it!
The beginning was totally daunting. The University of Gulu in 2004 received a small, dirty, dilapidated building of the old maternity hospital in Gulu to install the new Faculty, an impossible adventure! But our hopes increased when the nearby St. Mary’s H. Lacor Hospital agreed to participate and the Italian Cooperation guaranteed the first counterpart funds to support the initiative.
In March 2004, the Rector of the Federico II University, Prof. Guido Trombetti, signed, with the Vice Rector of the University of Gulu, a Framework Agreement to support the development of a Faculty of Medicine in Uganda: thus began the GULU-NAP project that founded the Faculty and followed its development up to this day of graduation for the first students. Since then, 48 Neapolitan professors have gone to teach in Gulu, without receiving any remuneration.
And the new Faculty of Medicine in Gulu has grown thanks to their efforts, in synergy with those of the Ugandans, mainly Prof. Nyeko Pen-Mogi, Vice Rector, the Administrative Director, and the Dean Prof. Jasper Ogwal Okeng. And today we have a Ugandan Faculty with 30 lecturers, wisely led by the new Dean Prof. Emilio Ovuga.
The current situation
We like to talk about the past: but now let us look to the future!
Today we have, in Gulu, a precious treasure: 370 medical students! They are, without any doubt, the best component of the newborn Faculty of Medicine of Gulu! Since the first year, they have organised themselves into stable and representative Elective Associations, which have had a considerable influence on the development of the Faculty. The students designed and produced the Gulu Medical Journal, a unique scientific journal in Uganda and a great communication tool for the Faculty. The students organised the first International Scientific Congress in 2009, and similarly, as we write, are conducting an International Course in Social Medicine with American, Canadian and European students.
With the few sporting resources we donated, they won the national and African championships: they became African university champions with a ping-pong table built by yours truly! All the students who came on the prize trip to Italy impressed elderly Italian professors with their professional skills and enthusiasm. They alone do caesarean sections, abdominal surgeries, emergencies.
The energy of the development of the Faculty of Medicine in Gulu was provided by the students, with their enthusiasm!
They were able to tolerate the limitations of a fledgling Faculty, acting as guinea pigs, and helped to establish the right climate for learning and becoming professionals.
COMMITMENT AND DEDICATION
The mission of the Faculty of Medicine in Gulu consists of Commitment and Dedication to the care of the sick and underprivileged. I hope that the selfless example of the Italian Professors on mission has helped the students to understand what this mission means. I am also sure that the wonderful St. Mary’s Hospital in Lacor, founded by Pietro and Lucille Corti in the 1960s, provided a very special environment for the students to learn not only professional skills, but also commitment to the sick and the poor, in a word, Professional Ethics, which is by far the most important discipline of the Medical Profession.
The new white coats of the students have brought light to the once dark and abandoned wards of the Gulu Regional Hospital, like a thousand butterflies in a forest, and today it is a pleasure to see how much renewal is contaminating the Gulu Regional Hospital.
Commitment, dedication to those in need is not a choice for a doctor: it is the core of his profession! No one would take a perfectly running, healthy car to the mechanic: that is why Doctors are professionally dedicated to those who suffer, to those who are poor, to those who need help, not only on a physical level, as the students of Gulu themselves have well understood since the 4th year of the Course.
Based on the needs of the community
When we wrote the Curriculum of Studies in 2004, we decided that Medical Education would be based on the needs of the community:
The Faculty of Medicine at the University of Gulu is based on an innovative student-centred method of teaching, with the aim of training doctors dedicated to patient and community care, with special emphasis towards disease prevention and responding to community needs.
The Faculty adopts the international trend towards scientific excellence, but also intends to emphasise the fields of medicine closest to the current needs of the population, such as Primary Medicine and Disease Prevention, Maternal and Child Health, Tropical Medicine, and the Integrated Approach to Therapy.
This is the time to start being ‘Community Based’ for these young doctors, this is the time when our efforts will be evaluated. Have we succeeded in stimulating commitment to Community ?
Scientific Excellence
But we also said ‘…adopt the international trend towards scientific excellence’: there is no other way. Progress will come from scientific development: these doctors will not work in the global scenario with the same diagnostic and therapeutic tools they have today. From a single drop of blood, but also of saliva or faeces, we are now collecting enough DNA to make hundreds of tests on genes of invasive agents or even genes that predispose to immunity or even genes that allow precise diagnoses or help adapt a therapy to the individual. A solid basis in biological and molecular sciences is the key to the training of doctors who will work in the near future. And these changes will not be so important in scientifically advanced countries, but they will make a huge difference here now! It will change the therapy of Malaria, the treatment of Diarrhoea or that of Tuberculosis.
And the Future? There is a looming danger: the brain drain.
We are often providing doctors to the rich with money from the poor.
Doctors imported from abroad make up 23% to 28% of the medical workforce in developed countries :
developing countries supply 40% of the doctors to Australia and 75% to Great Britain!
12683 doctors in rich countries come from African countries. At least 250 come from Uganda. With a net loss of at least 20% of those trained. The exodus of specialised personnel from Africa to rich countries has been estimated to cost African countries at least 500 million dollars every year (3).
But these doctors do not go to France, Spain, Italy, Japan, where only a very small proportion of doctors (2-3%) come from abroad. It is certainly easier in English-speaking countries (4).
Doctors like Football Players: for Doctors like Football Champions!
‘We need to train many more doctors than will then work in Ghana,’ says Tsiri Agbenyega, Dean of the Faculty of Medicine in Kumasi. Ghana has 13 doctors/100,000 citizens, while the US has 256/100,000. But today 532 Ghanaian doctors work in the United States: they are 20% of Ghana’s entire medical population of 2600 professionals. And yet 259 Ghanaian doctors work in England and Canada. In Liberia, 60% of locally graduated doctors work abroad. This is a punctured bucket: there is no reason to build a bigger bucket to compensate for the loss of brains (5). On the other hand, the United States, England and Canada have for years only trained ¾ of the doctors they need: it is all too easy for them to rely on the rest of the world suffering to get the missing 4th at no cost.
But we cannot ignore the great help of international cooperation.
There is no doubt that international cooperation is the key to the development of new health workers in Uganda. But it must be a two-way contact: Ugandan doctors are encouraged to qualify abroad in short internships and foreign doctors come to Africa to gain clinical experience.
We must think of the next generation of Health Professionals in a Global dimension. Twenty to 30 per cent of graduates in the Western world participate in training abroad. These young people bring enthusiasm, recent knowledge, different points of view and gain very valuable real-life contact, medical decision-making skills and extraordinary clinical experience (6). 14 paediatrics residents came from Italy to Gulu for 4-month internships: all of them, without exclusion, brought back a fruitful clinical experience that, in various ways, changed their lives much more than several years of training in their own country.
The near future should consider :
The expansion of basic sciences
The cultural strength of the doctors of this century will be their familiarity with scientific progress in the field of molecular and cellular biology. Every day our thinking at the patient’s bedside is changed by new discoveries even in the simplest procedures. The appearance of malaria, infections, chronic diseases is changing day by day: the New England Journal of Medicine and the Lancet have sections devoted to updating doctors in the Basic Sciences. Nowadays, the Internet connection makes the latest discoveries available at the tip of your fingers within hours, even in the forest! There is no longer any excuse: you must be contaminated by first-class science!
A Multidisciplinary Approach
The medical profession increasingly requires a multidisciplinary approach: this must start from the time of training. And the Faculty of Medicine in Gulu was, even by necessity, a splendid example of this: surgeons taught Anatomy and internists Physiology. Now, multimedia networking has increased the possibilities of getting opinions and consultations from specialists and combining knowledge in a multidisciplinary way.
Patients, like doctors, will benefit greatly from a multidisciplinary approach to patient care.
Listening to the Community
The Curriculum Philosophy states to be ‘Based on Community Needs’: difficult, and the more we grow and specialise, the less time we have to listen to the Community. Young doctors are attracted to clinical work in hospitals and for them the most interesting challenge is difficult and complex clinical cases. We must therefore develop a ‘third ear’ to listen to the needs of the Community. The young doctor must be familiar with the 1990 WHO statement : Those who need the most are precisely those who demand the least from health services’: those who do not come to the hospital. Those who do not come to the hospital are often those with the greatest needs! That is why when a doctor is assigned to a community he must first know the denominator, the population: where are ‘my’ people, not those who come to me, but especially those who do not come.
Field activities
We need to give more space to field activities for medical students. Field practice is a better teacher than many of us senior professors! We must develop in students the enthusiasm to go outside the faculty, to face the limitations and difficulties they will encounter. We all need to improve our communication skills: it is not impossible to become familiar with local languages and dialects, thus gaining an extraordinary tool to improve listening and comprehension.
A mobile team
We must respond to the mission of the University of Gulu ‘ dedicated to the transformation of rural North Uganda’. In many developing countries, mobile teams have been organised to make basic health services available in rural areas. Our students can also be greatly supported in their activities on the ground if we have mobile equipment. We have a van equipped with an echocardiograph, electrocardiograph, microscope, simple diagnostic kits and a small generator to rotate between districts and rural centres to strengthen the link between the territory and training hospitals.
But how do we deal with the brain drain?
It is now proven that coercive measures do not work. The easiest way is to offer better salaries: in Ghana, doctors assigned to rural areas double their salaries with overtime. In Uganda too, benefits such as meal vouchers have been provided. Doctors who agree to work in rural areas for three years have been offered a supplement for difficult areas, as well as grants for their children’s schooling and facilities for a car and house. But young doctors are entitled to Postgraduate training and often migrate for this: Postgraduate training programmes are vital to limit losses, and all of us here today are engaged in this difficult challenge. The University of Gulu is making every effort and the Italian Cooperation, with the Italian Universities, is ready to accept this challenge.
But, first of all, the first motivation to stay in Uganda is the pleasure of living in a wonderful country, enjoying an ideal climate, both geographic and human. We must add to this the privilege, the honour, of living and working in Uganda, in the place that worked so hard for my training and allowed me to arrive at today’s graduation ceremony.
These young doctors must make their contribution and show their commitment. Many years of hard study, many nights on the books, a great commitment to caring for the sick. But many people, and the people of Uganda, have helped them to reach today’s graduation ceremony. And as of today they are waiting for their help.
In conclusion I cannot list how many people I have to thank for these achievements . Above all, it is the Ugandan people and close to them, the great friendship of the Italian people.
My job has been and will be that of a carpenter: I build furniture often using old and recycled wood.
I thank you for accepting my limitations and giving me back a hundred for every one I was able to give!
Luigi Greco, Schoolboy at the University of Gulu
REFERENCES
- WHO World health report 2006- working together for health.
- Kumar P. Providing the providers –remedying Africa’s shortage of health care workers. N.E.J.M., 2007, 356 ; 2564
- Mullan F. The metrics of the Physician Brain Drain. NEJM. 2005, 353, 1810
- Chen LC Boufford JI. Fatal flows-Doctors on the Move. N.E.J.M. 2005, 353:17, 1850
- Mullan F. Doctors and Soccer Player- African Professional on the Move . N.E.J.M., 2010, 356, 440
- Panosian C, Coates TJ The new Medical “Missionaries” – Grooming the next generation of Global Health Workers. NEJM 2010, 354 ,1771