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A Mighty Rain:
One student’s
ardent pursuit of
Family Medicine
training in rural
Uganda

by Dr. Anam Majeed, reporting from Mbarara Uganda

Profile Dr. Bulumba Njuki Festo: Family Medicine Resident at MUST

by Dr. Anam Majeed


There is a torrential downpour outside; Rivers are crashing from the
sky with ferocious intensity. The rain is so loud, it is difficult to
hear ourselves. I am sitting with Dr. Njuki Festo, the one and only
resident of the Family Medicine Program at the Mbarara University of
Science and Technology (MUST), in the restaurant of Mbarara’s Acacia
Hotel. I first met him at the Third Annual East African Family Medicine
Initiative conference, held a week earlier in Kampala. He stuck out to
me among many of the other doctors, residents, students, and other
medical professionals present. I found his comments to be very
insightful, and his genuine passion for Family Medicine was impossible
to miss.


That is why, in spite of the thunderous weather, after a busy night
working the wards at MUST that I am not entirely sure is over yet, he
comes to meet me at the restaurant. He is gracious, articulate, and
supremely polite; repeatedly declining my attempts to hand him a menu. I
wear him down eventually, and he places a genteel and minimalist order
of fries.


Dr.B. Njuki Festo is a rare and interesting breed of physician. Many
people go into medicine with the solid idea that they will have a finite
number of disciplines to choose from: Internal Medicine, Pediatrics,
Psychiatry, OB GYN, and so on. Family Medicine had been available to
MUST, but the last residents had graduated years ago, and it had since
been defunct until Dr. Festo applied for the position. It is not often
that a residency program is especially revived for one student, in fact,
it was the first time I had personally heard of such a thing happening.
After meeting Dr. Festo, however, it is abundantly clear that the man
was born to practice Family Medicine.


“Why did I choose Family Medicine? There are a number of reasons.
Initially, I started out as a clinical officer and I gradually upgraded-
going from a diploma certificate to a [MD] degree. Before I was a
medical officer, I had a lot of interaction with the community. I did a
lot of work that was community oriented and I was challenged in it, and
this pushed me to become a medical officer because I wanted to help. I
saw that there was a need and no one was actually addressing the need.”


‘Clinical officers’ and ‘medical officers’ can be mystifying concepts
for North American audiences; quaintly British sounding , vaguely
bringing to mind colonial outposts out of a Somerset Maugham short
story. We can think of them as something parallel to physicians: trained
in the medical model and licensed to practice medicine in partial
scope, but without a Medical Doctorate degree or approach. Whether in a
specialty or part of general medicine, clinical officers are able to
provide treatment that is outside of the capacity of nurses. In large
district hospitals, clinical officers are part of a medical team working
under senior physicians, and can superintend smaller district
hospitals.


“I became a medical officer to support the community,” he says. “I
still go there and do outreaches to support them. I interacted with so
many specialists working in the outpatient department. Many consultants
would send me to see their patients- obstetricians would send me to see a
baby, surgeons sent me medical cases. I got this feeling that if I
became a generalist I’d be more useful to the community. I have a
paternal uncle who had done Radiology, so when I was rotating with him I
asked whether there was a course that one could do which actually
encompassed everything.”


Seek and you shall find. Having worked in community hospitals
alongside physicians, Dr. Festo inherently felt there was a need for
Family Medicine- without knowing what it was called or if it even
existed at all.


He leans across the table. “My uncle said ‘Yes, there is something
called Family Medicine, but you know, it is not known. And you would be
alone.’ He said so many negative things about it, probably because he
wanted me to do Radiology like him. But I still insisted upon Family
Medicine, and I was fortunate in that I met many resourceful people. I
met Dr. Mugabi, who provided a lot of inspiration, Dr. Biseko who was
very supportive and wrote the recommendation letters to the university
and also Dr. Mubangizi.”


Dr. Francis Mugabi is a Family Physician and Head of the Outpatient
Department at Mbarara Regional Referral Hospital, Dr. Biseko is a
Mbarara University trained Paediatrician currently working at Mengo
Hospital as the head of department –Peadiatrics, and Dr. Vincent
Mubangizi is a lecturer and Acting Head of the Department of Family
Medicine and Community Practice at MUST. I, too, was lucky enough to
meet them both at the conferences in Kampala. “Dr. Mugabi told me all
about Family Medicine, and I got the idea that this is something I
should do. Initially, when I came to the department I wanted to be an
assistant lecturer, thinking I could eventually do Family Medicine, and
this is how I started interacting with Dr. Mubangizi. I came and asked
him ‘Dr. Mubangizi, I have this passion, I want to be a Family
Physician. But I also want to teach and I feel this is my calling. How
can I join?’”


The department recognized Dr. Festo’s abilities and his passion, and
asked him to write up papers to support his application, which he did.
He was then told that it wouldn’t be possible: MUST needed funds to
resuscitate the stagnant Family Medicine program and there weren’t any.
Where there is a will, there is a way, it is said, and that way came in
the form of a sponsor willing to provide the necessary resources to fund
Family Medicine. Dr. Festo came onboard.


I ask him what he planned on doing as a Family Physician once he had
finished his residency. “I have a number of issues, things I’m looking
at. One is that by the nature of my attachment with the department- my
scholarship entails me to remain with them for capacity building so it
involves recruiting more of the undergraduates to join. The two
semesters I have been in practice I have always been interacting with
students. They ask me what Family Medicine is and they are surprised
that there is a residency for it, because to them it was like a dead
end. But they have loved it.”


“Today I was in the theater talking with a fellow resident who is in
Surgery, and he told me I was lucky. That I was able to do the same
things that they are doing, but I don’t have to stop at that. I am able
to address other disciplines. I wasn’t expecting this from him because
people are always asking me ‘Why did you pick Family Medicine? You are
doing the same things as us, you should become a surgeon.’ God willing
that I will be able to actually recruit as much as I can, and interact
more with the undergraduates so I can bring them on board. And I hope to
practice in the community where I came from; even now I still go back
there. There is a bond between me and the community where I started
practicing from.”


The love of community is a recurrent theme with Dr. Festo. The
community he speaks of is a place called Kyanamukaka, one of the 3 sub
counties that make up Bukoto Central Constituency in Masaka District, a
deeply rural area about 35km off Masaka-Rakai –Mutukula tarmac road.
Home to roughly 80, 000 people, It borders Lake Victoria and has within
it 5 parishes and 59 villages. When he has time on the weekends, he goes
back by five-hour ride to provide medical care. Dr. Festo is not paid,
except for a small room which his patients insisted upon giving him so
he could have somewhere to stay comfortably during the night.


He doesn’t believe there is a lot needed to keep doctors practicing
in a rural area after there have finished their MD. “I have a strong
feeling that a Medical Officer that has been in an area for two years
will get attached to that community. We should come up with a policy
that if someone is sent to a rural area to manage a center after
something like 3 years they should be offered a free scholarship to do
post graduate studies. So there is an incentive: only give free
scholarships if you’re going to do Family Medicine.”


He grew up and went to school in the capital city of Kampala, but
expresses a fervent desire to practice rurally. There are many
challenges in the rural areas that aren’t part of city life, and I am
curious to know the differences he has observed.


“A main one is access to health,” he replies. “In the cities there
are a number of centers, either private or government, that you can
easily access. In Kyanamukaka Masaka, people are coming from the shores
of Lake Victoria, and have to travel nearly 60km before they reach the
unit. Patients come and sleep at the unit and are seen the next day
because their numbers are so large. It is very hard to buy medication.
There is no real infrastructure to travel so rurally, road-wise. A
vehicle takes me 20 km, and then I get a boda boda for 15 km, because
there is no other way to go on the road.” A ‘boda boda’ is a precarious
form of motorcycle taxi used in East Africa. It comes from the English
‘border-border’, having originated from a need to smuggle or be
smuggled, border to border.


“You get a lot referred cases- a patient needs to be referred, and
you can’t refer. You get a patient who needs a specialist, but many who
we refer end up going back to where they came from because they can’t
afford to go to town.’”


There is the expensive aspect to hospital upkeep to consider. “They
are prescribed drugs the government hospitals don’t have, so they have
to buy them. If they need sutures, they have to buy them. All their
meals, they have to buy themselves. That’s why I feel that Family
Medicine will give me the tools that I need to refer only when it is
really necessary. I can also do certain things myself, that specialists
do when it is needed. Family Medicine gives you that room, to refer when
you know you’re not supposed to do something yourself.”


It is important to note that figuring out what you don’t need to do
in Family Medicine is as important as figuring out what you need to do,
because you are constantly being asked to define the parameters. He says
there are many things he is exposed to in his Surgery rotation which he
feels are not necessary, and it is vital that the program is adjusted
to reflect this. Accordingly, there are things that a Family Physician
practicing in rural East Africa needs to know that one practicing in
North America wouldn’t, possibly a caesarean section, for example.


Dr. Festo is something of a trailblazer, ardently bushwhacking the
path for those who come after him. He is not merely content to finish
his residency, but wants to customize the program to suit the needs of
the rural Ugandan population. He mentions the need for inter-university
collaboration with other established Family Medicine Programs, the one
at Makerere, for example. He is also fervent advocate for research and
analysis.


“The government of Uganda has captured a lot of data. We don’t
analyze the data, which is our weakness. I will tell you a story about
malaria. From the health centre we had noticed that there were a lot of
malaria cases in the last two months and wanted to find out if all of
these patients were coming from the same localities, and whether we
could do an intervention? Surprisingly these cases were coming from
places where people had been given mosquito nets. When we went to one
particular village, we found bed nets acting as barriers for chickens
instead of being used properly. There was a government program to help
people with their income, so the local people were given chicks, but
they didn`t have money to construct cage like structures to keep in the
chicks, so they use bed nets as chicken coops. How do we stop this
pattern? It becomes our problem. They can improve their income by
raising local chickens, because they don’t need a lot of effort, but not
at the expense of their health. We need to come up with a plan on how
to take care of these chickens as part of our malaria initiative.”


You have understood the essence of Family Medicine in rural East
Africa if you have understood that sometimes it requires figuring out
how to raise cost effective chickens on the fly.


There are many challenges on the road to establishing effective
Family Medicine programs in Uganda. There are the obvious problems of
funds, of resources, of teachers and professors, and of training sites.
But the relationships and the visible outcomes make the challenges
worthwhile.


He is quick to point out that a close relationship is instrumental in
the successful practice of Family Medicine. “The mere fact that you
know this person’s name, you know they are the relative of so and so,
this makes them really open up to you. There is the medical component
and the social. I’m not given anything, but I go there to give back and
to change something that I feel is not being addressed. And they like
it. I have good relationships with people in that area. And whenever I’m
there they are happy to see me because I impart knowledge and involve
myself in a number of community projects.”


He leans back, having made a modest dent in his plate of fries.
Outside, the thunder has stopped, and the fading light is punctuated
with bird calls and buzzing insects. The sounds of rain have given way
to the sounds of life; there is only the vibrant greenery of Uganda all
around us.

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