One in a Million
Sitting Down With… Gladys Atto, ophthalmologist at Moroto Regional Referral Hospital, Moroto, Uganda
Aleksandra Jones | | Interview
You’re one of only 45 ophthalmologists in Uganda – a country of over 45 million people – and the only one in your region, Karamoja. What are the reasons for this shortage and is the situation improving?
Ugandan students are not motivated enough to go into specialties like ophthalmology, otolaryngology or dermatology, as those are seen as focusing on very small parts of medicine. Money is a big driver and candidates imagine that these paths will not be profitable.
What I see as an even more pressing concern is the unequal distribution of ophthalmologists across Uganda, where we have around 14 reginal referral hospitals. If each one of them had an ophthalmologist, we would have an equitable distribution of eyecare experts, but many are concentrated in urban areas that attract most specialists. Getting ophthalmologists into rural areas like the one I work in is a huge issue. People feel that these parts of the country don’t have enough amenities and don’t provide opportunities to progress in their careers.
Why did you decide to practice in Karamoja?
The area where I grew up, around 450 km from Karamoja, only has one ophthalmologist, but for me, having even one specialist in a region makes such a big difference. When people know that there is a specialist in their regional hospital, even if it’s 100 km away, it gives them hope. But in Karamoja there were no ophthalmologists, and patients who needed eye care felt hopeless and helpless. I knew that the burden of disease was high in the region and yet there were no frequent ophthalmic surgeries taking place , except for those performed occasionally by visiting doctors, with no proper follow ups. Also, Trachoma is still endemic here and that tells you how high the need for eye care services is.
I could really see the potential of this place and the need for an ophthalmologist willing to practice here. When I was applying for a Sightsavers scholarship, interviewers asked me where I wanted to work. I replied that I wished to work in Karamoja and they thought I was only saying that to be guaranteed the sponsorship, but I had already got in touch with the local hospital director and had an agreement that this was where I would work after completing my education. Now, my mission is to make sure other ophthalmic specialists come to work here, so everywhere I go, I talk about how proud I am of my job, I wear the best local clothes, and really try to impress people and let them know how wonderful the region is. Karamoja is one of those remote places that you have to see for yourself to find out more about it and want to stay.
What is it like to practice in Karamoja?
There are times when I don’t feel like I’m making any impact, and I feel discouraged. I also get lonely as all my friends are in the cities, far away from me. People here are very reserved, so it’s hard to see if patients are happy with their treatment outcomes. Health-seeking behavior is poor, so healthcare professionals really have to make an additional effort to encourage patients to come to us. This often makes it seem like they are forced to access healthcare, but those who decide to come are always very appreciative. The first day after surgery always brings the nicest comments from my patients who can suddenly see facial features, colors, and other details. Most men in the area keep animals and they can’t wait to go home to see what color their animals are! Some patients suddenly notice how long their nails are and ask for nail clippers.
If I can improve someone’s chance of finishing school and getting proper education, it makes me very proud, but I also know that everyone needs their sight, whether it’s a farmer or a housewife. When after surgery they are able to get back to their normal chores, I feel my work has meaning. Manual workers are not as vocal as office workers when they lose their sight, but their work is equally valuable and important.
I perform a lot of surgeries – mainly cataract – at the hospital, and then my team goes out into the large region, which is sparsely populated, with huge distances between villages. We choose a district and stay there for around a week at a time, performing approximately 60 surgeries and doing follow ups, sometimes visiting people at home if they can’t come to us. I try to make sure that nobody is left behind, especially those with disabilities.
How did you get into medicine?
Becoming a doctor was my dream right from childhood. My primary school teachers used to say that I talked so much I would become a lawyer – like the great Ugandan role model, Julia Sebutinde, who serves on the International Court of Justice. I was adamant I would be a doctor instead! There was one big challenge: I wasn’t any good at mathematics, and in Uganda a good grasp of math is seen as essential to go into medicine. I struggled with it at every level of my education, but somehow, I managed to get the necessary credit in my final exams.
Getting into medical school in Uganda is extremely competitive and even the best-performing students often don’t get in. Those at the top of the list receive government sponsorship and the rest of the candidates fight for a few spots available for privately paying students. I didn’t manage to receive the government sponsorship, so I opted to get my medical education at a private university, known at the time as Kampala International University in Ishaka, Uganda, which was very expensive – the financial aspect discouraged many good candidates from applying. I knew that neither I nor my parents could afford the tuition fees, but I had this faith that things would work out. The first two semesters were very hard financially and my mother was telling me that perhaps I needed to give up, but I started looking for various sponsorships. Thankfully, I was granted a sponsorship from State House Uganda, and it really took away all my anxiety. That’s how I was able to finish medical school, but I know many others have not been as fortunate.
What made you choose ophthalmology?
When I was doing my internship in Uganda, it was a very rigorous process. What I found out was that I didn’t enjoy general medicine as much as I had previously. Seeing patients with chronic diseases that would not get better was really bringing me down. I realized that eye care gave me an opportunity to focus on a small part of the body, which really suited me. I’m generally a perfectionist and pay so much attention to detail and that is why ophthalmology – especially ophthalmic surgery – is so appealing to me!
Tell me about your mentors…
My first eye care mentor was John Onyango, who is now the Head of Department of Ophthalmology at Mbarara University of Science and Technology in Western Uganda. When he taught me at medical school, he would walk into the classroom without any notes or books – everything was in his head. The way he would talk about ophthalmology and the shortage of eye care specialists in the country was truly inspiring. When I was about to start my internship, he called me to remind me that I did so well in ophthalmology I should think about following this path – and offered to continue to teach me. I am very grateful that he did that. During my ophthalmology residency, my course coordinator was Simon Arunga. He was instrumental in teaching me not only surgical, but also diagnostic skills. Then, when I went to the London School of Hygiene and Tropical Medicine in the UK, my supervisor was Allen Foster. He had been an impressive figure with so many publications under his name, and yet there he was, calling me personally to talk about my research! He still checks on me regularly to make sure I’m applying the skills he taught me. There have been many other important people I have crossed paths with in my career so far – I feel very privileged.
You recently received Uganda Medical Association’s prestigious Women in Medicine Award named after Josephine Nambooze. What does this mean to you?
It is hugely significant to me. Working in a rural area, I sometimes find it hard to get motivated and I don’t always see much appreciation day to day. The award shows me that no matter where I am, people are noticing the work that I do. For my work to be considered outstanding is more than enough to encourage and motivate me to do more for my patients. It also means so much because of Josephine Nambooze’s name attached to it! She is the first female doctor in Uganda, and in the whole East Africa. She is known as “the Mother of Medicine” in Uganda. I have had patients call me after they read about the award – some of them had been quiet and reserved before but still reached out to congratulate me – and it has meant a lot to me.
Tell me about your work with Sighsavers.
Sighsavers sponsored my Master’s degree in ophthalmology. We had an agreement that in return I would work in Karamoja for at least three years, which was equal to the number of years that I studied for my degree, but I have already completed this period and I’m planning to stay. I think it was expected that I would move to the city right after I could, but I don’t want to leave the region without an ophthalmologist. The charity also sponsored other eye care workers, including two ophthalmic nurses, one ophthalmic clinical officer and an equipment technician I work with, as Karamoja didn’t have any personnel like this before. Sightsavers is now building a new, fully fledged eyecare unit for our team, which should be ready very soon. We have been working together to carry out community outreach projects, and a few months ago we conducted an audit for disability inclusion, where we checked eight health facilities in the Karamoja region for accessibility to people with disabilities.
What are you working on at the moment?
I’m working out a five-year strategic plan for eye care in Karamoja. It’s rare that a small department like mine would consider having a strategic plan for an entire region, as my employment is officially just with the Moroto Regional Referral Hospital, but – as the only ophthalmologist here – I see patients from all nine districts of Karamoja, so I feel that a comprehensive plan is necessary. I would like to focus more on glaucoma, refractive errors, diabetic retinopathy, and other diseases different than cataracts. The backlog of cataracts is not very high at the moment, but other disorders are still largely unaddressed. I have also been looking into eyecare at local health units that refer patients to me. I did a study to examine why referral numbers were low and I found that there was a lack of skill for using diagnostic equipment, and therefore personnel’s motivation was low. That’s why I want to include skill enhancement in my strategic plan. When there is a plan in place, it makes it much easier to advocate for the things that the region needs. I’m hoping that in time, we can have an annual eyecare review in Karamoja, with each district preparing a report, so we can assess progress and further needs. I think this would make local clinics accountable for the work they do. I would like political leaders of the districts to be present so that they are aware of the achievements and further requirements. I want Karamoja to be a model for other regions, to be looked up to. I would like ophthalmology residents to want to come and work here, and I think that this dream can be achieved; I just need to be patient. A strategic plan will be a great start and I hope that I can use it in the future to shout out about the things we need.
What is your typical week like?
I start work daily at 9 am. On Mondays my team and I see general patients in the outpatient walk-in clinic. We book patients in for surgery, we check their biometry and calculate the lens power for those who need cataract surgery. Our theater attendant deep cleans the OR on Mondays, so we don’t do surgery on that day. We educate patients who are waiting – a nurse talks to them about eyecare and they are encouraged to ask questions. On Tuesdays, Wednesdays and Thursdays after I get up, I go straight to the OR and perform around 10-12 surgeries. I try not to schedule any more surgeries for one day so I don’t get overwhelmed with work. If an emergency comes in, it doesn’t matter what day it is – we just go and see that patient straight away. If we receive referrals from other, faraway centers, we prioritize those patients so they are motivated to use the service again, and encourage their family and friends to come to us. They tell them, “They see you quickly if you come with a letter!” I also assess the referring personnel who sent them in and give them feedback on their initial diagnosis. I finish my work around 5 pm, and then an ophthalmic officer stays on call to see patients who come in after that time. If they can’t manage a particular case, they reach out to me.
Do you have any hobbies?
I love reading! Nigerian novelist Chinua Achebe and Ngũgĩ wa Thiong’o from Kenya are my favorites. Every time I read Achebe’s Things Fall Apart I learn something new. When I read other novels, I easily forget their authors, but whenever I read something with a medical theme, I understand and remember it so much better! I also do a bit of writing. If I get stressed at work or get a surgical complication, I tend to replay it in my head, asking myself if I did anything wrong, missed anything, or if I could have done things differently. As there are no other ophthalmologists, I don’t have anyone to discuss cases, so I sit down and write about it. It is therapeutic. Sometimes, I also write about life experiences. Moroto is a quiet place, great for walking or jogging, and I also do aerobics, listen to music or watch movies. Sometimes I think that my hobbies are very ordinary!