In the fall of 2005, Asghar Rastegar, M.D., and Majid Sadigh, M.D., travelled to Kampala, Uganda, to explore a collaboration with Makerere College of Health Sciences and Mulago National Referral Hospital. Sadigh, an associate professor of medicine, had been traveling to Kampala since 2002, to teach under the umbrella of the Academic Alliance for HIV Prevention and Care. During his visits he noted a contrast between the advanced clinical and epidemiologic research activities at Makerere University and the challenges of patient care on the wards of Mulago Hospital.
Over the course of that week in 2005, Sadigh and Rastegar, professor of medicine and director of the Office of Global Health, met with the leadership of both institutions—including the then-chair of medicine, Harriet Mayanja-Kizza, M.D., Ph.D., and dean of the medical school, Nelson Sewankambo, M.D.—to work out the basics of the partnership. Under the agreement, Yale physicians, residents, and medical students would travel to Uganda for clinical rotations, and Ugandan physicians and students would train in New Haven. Among the goals of the collaboration were improving patient care through education, training, and research, building up the educational and clinical infrastructure, and supporting research that could be easily translated into practice.
Mayanja-Kizza was at Yale in September to celebrate 10 years of the program, which has seen 18 junior faculty from Uganda come to Yale for between six and 12 months of subspecialty training at Yale. More than 150 Yale residents have spent six-week rotations in Kampala, Uganda’s capital, along with 119 medical students who have completed clinical clerkships there. In addition, 79 Yale faculty members have spent time at Mulago Hospital.
The program launched at a serendipitous moment for the medical school at Makerere, Mayanja-Kizza recalled. While there were many other partnerships with universities around the world, most focused on research. Mayanja-Kizza said another need remained unmet.
“Our main need was for people to be trained in subspecialties,” said Mayanja-Kizza, who is now the co-director in Uganda of the Makerere University-Yale University (MUYU) collaboration. “Around that time we had started reorganizing our wards from general admission wards to subspecialty wards. Before that we would admit patients on different wards every day. That meant that any one doctor would treat everybody. There were no specialists. We realized it was better for a patient with kidney disease to be managed by a doctor who was expert in kidney disease.”
Since the collaboration began, Ugandan physicians have trained at Yale in cardiology, nephrology, pulmonology, endocrinology, emergency medicine, neurology, intensive care, gastroenterology, rheumatology, and pediatric surgery. And their training has had benefits throughout the hospital and medical school in Kampala. “Now we have people who come back and work in a given specialty and continue training in that area,” Mayanja-Kizza said. Those newly minted specialists have gone on to form societies that encourage others to seek such specialty training. And departments beyond internal medicine have realized, Mayanja-Kizza said, that with subspecialty training, patient care improves.
“When we interview the people who are selected to come, the question is, what are the concrete skills you want to learn? What’s missing from your practice at home? And then let’s figure out how to put together a curriculum that will allow you to meet those goals,” said Tracy Rabin, M.D., HS ’10, assistant professor of medicine, assistant director in the Office of Global Health, associate program director for global and community health in the Primary Care Residency Program, and co-director of MUYU in the United States.
Gidio Agaba, M.D., came to Yale for training in endocrinology in 2016. In Uganda he had started out in emergency medicine, before joining the endocrine unit in 2013.
“In Uganda we don’t have fellowships,” he said in an email from Kampala. “You start doing what you like to do, and you train and learn from others as you treat patients. I knew the most likely place I would get an opportunity to train would be at Yale.”
He was accepted for a six-month fellowship in endocrinology and worked with a team led by Silvio Inzucchi, M.D., professor of medicine (endocrinology).
Since his return to the endocrine unit in Kampala, Agaba has been treating patients, training residents and medical students, and providing medical education to other doctors and nurses.
For students, residents, and faculty at Yale, the benefits are different. First, they learn how to function in a low-resource setting. That means seeing diseases and disease progressions not often seen in the United States, like malaria or advanced cases of AIDS. It also means working with limited tools.
“What does it mean to do this without a CT scan? What happens if you can’t get immediate blood test results, or it takes 48 hours?” said Rabin. “Now you’re in this setting and it is frustrating to you. How can you make sure you are learning from this and not being overwhelmed by the frustration?”
The most important benefit, Rabin said, is gaining perspective.
“Skills are important, but there are systems that are different than ours,” she said. “Our system is broken in its own way, and other systems are challenged in their own ways. To have a perspective on your own work and your own system, it really helps to be outside looking at another way of doing things.”
That was the lesson medical student Kathleen Yan learned during her six-week rotation in early 2016. She divided her time between the infectious disease ward and the gastrointestinal ward, where she rounded with a team that included two Ugandan medical students, three interns, three residents, and an attending physician.
“It was quite a change, to say the least,” Yan said. “I had never seen medical care other than in the sterile halls of Yale New Haven Hospital. It was very informative in that I saw different cultural aspects of medicine, how medicine is practiced in a resource-poor setting.”
At internal medicine grand rounds on Sept. 29, Rabin, Mayanja-Kizza, and Rastegar traced the history of the program and described its future goals. “Our collaboration focused directly on improving patient care in the Mulago Hospital,” Rastegar said of the beginning of the MUYU partnership. “The goal was to improve care of the patients through education, training, and applied research.”
The focus of the collaboration, said Rabin, is now on faculty development at Makerere, postgraduate medical education capacity building, management of non-communicable diseases, and applied research into patient-centered care.
Since the summer of 2006, when Sadigh and two residents first went to Uganda to work in the Mulago Hospital, the situation in Kampala has improved, said Mayanja-Kizza. Mulago Hospital is undergoing renovations and will reopen as a specialty hospital. Two new district hospitals have been built in Kampala, including one near Mulago. A mother/child hospital focusing on obstetrics is being built on the Mulago campus.
“The plan is that we are going to have three district hospitals, plus the maternal hospital,” she said. “Mulago will be a super specialized hospital for liver disease, kidney disease, etc. Therefore, the training of our physicians at Yale was just in time. They will continue to train other people in each specialty.”