Newborns professor's journey of service at UoN

Prof. Rachel Musoke.

Prof. Rachel Musoke has been a lecturer at the University of Nairobi, Department of Paediatrics for more than 40 years. Get to know how her teaching experience has been in the interview with her following her retirement.

You have been teaching in the Department of Paediatrics for more than 40 years, tell us how your teaching journey been.

I joined the Department of Paediatrics as a young person, with little teaching experience. Of course, when you are a resident or a senior house officer, as we used to call ourselves those days, you still taught junior colleagues. But as a lecturer, I had not done a lot of teaching before and the experience I have got has certainly been with the University of Nairobi. 

When I started, I had a different view, I wanted to do it the way we were taught. Partly the way we were taught, as a student you had to do the homework yourself, you clerked a patient, went back and read so that when you came to the ward round, you would be able to answer questions. So, my expectations at the time were exactly that. Because that is what we went through. We used to say that anybody who was not ready to do the work, “he/she wanted to be spoon-fed”, which should not be case at the university. You cannot say, I have not been taught because you taught yourself, came and presented, and then the experienced person adds on whatever you had. So those were the expectations that I had when I was starting this journey.

Our teachers were very strict, both in undergraduate and postgraduate training. I guess one also gets the impression that this is how things were. They were very strict, and you had to know your patient, read around the patient, and as we know “no patient ever-presents as in the textbook” then you had to go and be able to answer any question about that patient. 

As time goes on and I am not too sure whether it is the 8-4-4 system that changed people especially the undergraduate students, I suspect that there is too much pumping of information into the students such that they don’t learn how to get the information themselves. Expecting to be taught like you are in a classroom setting, which as far as I am concerned university should not be like that, you are supposed to search the information, put it together, and then you are guided. One finds that the undergraduate students now compared to earlier on, when you are for example expecting a discussion you do not get as much participation. Earlier on everyone would read on their own then we share the information in a tutorial. A tutorial is a tutorial, you do not expect the lecturer to give you the information. This is something that has changed quite a bit over the years.

Postgraduate is slightly different. When people join like in Year 1, some have been out of the academic period for quite some time, and currently, this period is becoming longer and longer. People used to come back after about 2 years of work as a Medical officer, currently, this period is longer for many individuals. And quite often when you have been out of the academic environment for a long period, it takes a bit of time to reacclimatize yourself to being a student. I think this affects some of the students in the postgraduate students.

An example, going outside the university, I have been carrying out different training sessions mostly on breastfeeding and nutrition, when you go out there, you ask people what they were reading, and you are shocked. In one training in Homabay, I asked participants, what do you people read? The reply came, “We read The Nation”. Currently, the times are even different, there is easy accessibility to the internet and computers, but those days, information was from your undergraduate textbooks, if you had not sold them already, and CMEs (Continuous Medical Education Sessions) were very rare. Now you have even had online CMEs where people log in wherever they are. So those years, people would come in with different backgrounds from different settings, and of course, by then it was the only University of Nairobi that was training medicine within the country for a while until Moi University came into the picture. Nearly everyone who was coming back for postgraduate had done undergraduate in the University of Nairobi, except a few who had trained abroad.

Of course, what has changed also is that the Ministry of Health used to pay for Postgraduates, a salary and I think their tuition fees. So, the numbers were no more than about 10 students per year, which meant that the patient load has changed a bit. When I joined the department, we used to be about 3 consultants in the Newborn Unit (NBU) and only about 2 registrars. When I started asking for more registrars, people were surprised, asking “what are they going to do?” Not understanding that there is a lot of work within the NBU. 

What used to happen then, because NBU admits every single day, it meant that one was on call every other day. And you can imagine you are doing 24 hours every other day; this was a lot of work. Besides this, the admissions were more than 100 babies per month a number that has not changed a lot comparing to current admissions, and you still had to cover labor ward, maternity, and post-natal ward. Eventually, they started giving us more registrars. At that time we did not have a NICU until about 2008, but there was still a lot of work. Before that, without a NICU, all our babies used to go to the Main ICU, and for some time there was a tug of war between the anesthetist and the neonatologists on who takes primary care of the neonates. You would arrive there, and the incubators are next to an open window, fluid management were not specific for the neonatal period. So, we started fighting for our NICU within the NBU. Eventually, we had a donation for ventilators for our NICU.

After this there was another tug of war with the anesthetists as again, unfortunately, the belief in this country was like, only anesthetists could ventilate, the same fight that Dr. Kumar and Dr. Reel found with the pediatric patients in ICU. Because until they came, there were no pediatricians in the ICU. The training of anesthetists is very different from ours, especially in the newborn area. So, when we started the NICU in NBU, the assistant director of clinical services wanted to post an anesthetist. We informed him of the fact that when we go abroad for our fellowship training, we are the ones who do the ventilation, we are all trained. Hence, we resisted this move. 

Currently, the NICU is run by neonatologists. And even though the clamor for starting fellowship training in neonatology has been there since the ’90s, I am very happy that it is starting this year 2020. At the time we did not have a proper set up for a fellowship program we would have functioned as a level 2 Neonatal unit but not as a level 3 which we have now. And even now there are several things yet to be put in place to run as a full level 3 unit including the use of central lines among others which we have struggled for. Currently, the residents struggle to look for peripheral intravenous lines, and you can guess the little veins of a newborn, within a week’s admission you exhaust all the veins pricking the baby every time for IV fluids and IV medications. A central line can take you longer hoping they do not get infections. But those are things that, now that we have a fellowship program, KNH will provide them. But we have been asking for them. 

I have worked on the curriculum quite a bit and my extension of stay was partly to see the fellowship program begin and am glad that it has started. I may not be fully part of it as I would have wanted but I am glad it has started. Though many things are yet to be setup.

Teamwork is also very crucial for patient care; we have had very experienced nurses though some of them have retired, unfortunately. Earlier on we had a little more teamwork than now, I do not know when we drifted. But in the neonatal unit, one of the main things has been the shortage of nurses. Sometimes in a room, there are more doctors than nurses and this should be the other way round. For a level 3 neonatal unit, the nurse: patient ratio should be 1:1 or at least 1:2. The nurse is expected to know more about the patient than the doctor because they are there all the time. The NBU now has more than 100 babies, and you can have one nurse taking care of about 30 babies in some rooms. This limits our efficiency a lot.

Having acknowledged the role of a cadre of nurses called neonatal nurses, we started the Neonatal Nursing Course within the hospital around 1983 with Dr. Kungu, first as an in-service course for nurses within the Unit. We designed to run for about 3 months initially, but the first group of trainees gave feedback and reported that this was very short. We gradually revised the curriculum brought it up to 6 months then later to a year. But all this time it was an in-service program and members of the department of pediatrics used to give the lectures to the nurses for several years. Also having acknowledged that doctors training nurses had its challenges, we still told the nurses in training that we had to get nurses to teach them the way training in nursing work is done. 

Later, the KNH staff education and nursing council came in. KNH staff education took over the program, of course as the department we used to come in and give lectures, but one can say that it was also a departmental program because most of the work we used in the training were coming from the department. Eventually, the nursing council took it up, reviewed the curriculum. We were able to send four nurses to Monash University  in Melbourne, Australia for them to see how the proper neonatal unit looks like and how it runs. Then when they came back, they spearheaded the revision of the curriculum. Right now, I am not sure, but there neonatal nursing courses offered in other places including Nairobi Hospital and Aga Khan University Hospital.  But as far as I remember we were the pioneers. 

Furthermore, for a very long time, the department has also contributed a lot to the training of the Diploma in Pediatrics for Clinical officers in Kenya Medical Training College (KMTC). We used to give the lectures in this training. We used to give the lectures and even when they come to the wards we would assist in their supervision and clinical training.

When I finished my Master of Medicine in Pediatrics and Child health, I was posted to the department and the then head of the department and having acknowledged my interest in nutrition and a newborn, asked me where I wanted to be.  I chose the Special Care Unit in Mulago Hospital, Kampala, Uganda. I already had a love for the Newborn, I enjoyed working with babies, so I worked there until I left for the UK for other specialization in Newborn care with the hope that I was going back. But political instability in Uganda prevented me going back to Uganda. And when I was coming over, Prof Bwibo, having been our lecturer in Makerere and having shifted to Nairobi as well due to the same reasons, I wrote to him and I told him that I was coming over to Nairobi. He asked me to apply and the rest is history, since then I have been here.

However, I did not do a Ph.D., as is the requirement now, to be promoted. Those days it was not mandatory. For you to be promoted, it was about publishing. If you had enough publications in peer-reviewed journals and of course you have done your number of years, you could be promoted on those grounds. So, there was no insistence to have a Ph.D. to be promoted. I still think it's wrong for the health sciences to insist on a Ph.D. Why do I think so? Our training is so long, Undergraduate was 5 years, now its 6 years, did an internship for 1 year, worked for 2 years before joining the MMed program, and these are already 10 years. Somebody who did a 3-year BSc or BA in those 10 years has already done their Ph.D. and they are professors. Then you finish your MMed, work for some time and go for another 2 years to do a fellowship, and most of us are like this, this is 18 years plus. To ask me to do a Ph.D. for a promotion from a lecturer to an associate professor is absurd. Insisting on a Ph.D. is not appropriate for the health sciences. Ph.D. is good, but it’s a narrow field, in terms of clinical medicine, Ph.D. doesn’t make you a clinician, whereas a fellowship makes you a clinician. For us as neonatologists we are a juggle everything, we span across all the disciplines, you are a cardiologist, pulmonologist, gastroenterologist, etc. within the neonatal period. But anyway, even though the school of medicine had fought this battle about the necessity of a Ph.D. for promotions, I sincerely hope that in the future that people will look back and say “you were right”.

What have you enjoyed most about your work?

I have enjoyed nearly everything. I have enjoyed interacting with people, undergraduates, postgraduates, and off course faculty. The mentorship program has also made me focus on specific individuals, many of whom have become my friends and we continued being friends. The joy of looking after the babies and seeing them grow. Quite often you meet somebody on the road, and they say “Daktari, do you remember me?” sometimes of course you do not even remember. 

To relate you to a very interesting encounter I had, I was in our follow up clinic and one of the mothers came and said “Daktari, please come” at the time, my feeling was, maybe her baby was unwell, but she needed help because the clerks used to only allow those who had a booking. So my reply was “Let me finish with this patient I have then I come. So, I go out there and this mum had carried a big Kiondo full of maize and beans, and she told me “Daktari, my baby was 1000gms at birth, I didn’t think he was going to survive, now I have been home, and the baby is 1 year old now, so, I have to thank you.”  

When you get things like this you feel happy that you did something that somebody appreciated, and many mothers remember you especially in KNH even though you see so many babies on and off, the parents do remember you. The joy of seeing them grow, after taking care of them; they were just fitting in your hands, now they become bigger and bigger, you feel so happy. Of course, sometimes when you lose, you feel bad. Bu the joy of seeing so many come through is something that keeps the memory going. 

Having been the oldest member of faculty at the department, and knowing that you have even overseen the training of many younger faculty members at the department, how do you describe this atmosphere?

If you are a teacher, to take you back to my high school, my class we were among the first students to do science subjects at O-level. The teacher who taught us chemistry and physics was from the UK, she used to say, “If you all fail, I will pack my things and go back to England.” So, she took a real interest in us, and her passion was palpable. If you are teaching and the people you are teaching do not come up, you feel a failure. But if you teach someone, it gives you the pride to know he/she was your student when you see them progressing. 

In fact, within the department right now, other than the people who did not train in the University of Nairobi, and other than people like Dr. Njai who I found in the department, all the rest have been my students at one point. When I joined the Department Prof Wafula and Dr. Onyango were doing their MMed Program. I feel proud all the time, that the people I mentored were back as faculty. And sometimes when I signed up for courses like ETAT+, Pediatric HIV, they were my teachers now. I remember when I turned up to attend the Pediatric HIV course, some of the people who were running it were my ex-students, I was asked “are you sure you want us to teach you?” I said yes, HIV was then more of a new disease and I wanted to learn. When ETAT came, of course, we had done many of the things in the course, even then I still had to go back and learn in the same setting. 

What somebody learns is to humble oneself and know that somebody who is more junior to you can teach you. And I think this also came through when we were both undergraduates and postgraduates, our teachers encouraged us to shine above them. You clerked a patient and you had your diagnosis, even though the senior person says it is not correct you were allowed to dig deep and investigate, and sometimes you would turn out to be right. One time a Professor of surgery lost his bet to a student, when the diagnosis given by the student was right, so the good professor had to give the student the money. 

So, we were encouraged that anybody can have more information than you. I remember another incident when I joined the in Mulago Hospital, the head of the department mentioned that “it's up to you young colleagues to come and teach us what is new” because, especially when doing your postgraduate, you may read more than your professors, because you want to pass your exams. But yes, someone must acknowledge that information can come from anybody, it could be an undergraduate or postgraduate student or the most senior professor, but knowledge is knowledge. You might have read something that I did not read, and you have evidence, then it becomes part of my knowledge as well. Nobody can have all the knowledge, and it can come from anyone no matter how junior he/she may be. 

You can still be senior, but you must value the people below you. And this helps us to grow. If you always say “I am the boss” things do not run. As the head of the neonatal unit for several years, everyone would make suggestions in our meetings, then we would come out with the best way forward together. Ideas come from many angles. You put the institution or patient care forward, making sure that whatever decision is made is for the interest of the party intended. Other than Prof Meme who took over as chair of the department after Prof Bwibo, the successive chairs have been my students, but life goes on.

And to talk about what has been your passion for a big part of your life up to now, the newborn infant, tells us about your love for neonatology and its role in the world of pediatrics.

My love has been two things, Neonatology, and Nutrition. Nutrition is another thing that spans across all disciplines, one may say it is the backbone of everything that we do. Without proper nutrition, many of the other things we do cannot be achieved. 

I became interested in breastfeeding when I had my first baby, he is now a big man. For us in Africa breastfeeding is taken as the norm for newborns and infants, relatives and friends pushed you through this period. When my son was about 6 weeks, I felt like milk was insufficient, and with the panic of wanting to give something else, I consulted a cousin who connected me to a lactation consultant. Helen Armstrong, the lactation consultant, not knowing that am a pediatrician kept giving me ideas, advice and followed up on how it was all going. Eventually, she asked me what work I was doing, I hesitated but I said, “I am a pediatrician.” She almost collapsed, “you mean I was telling you these things when….” She responded.

We were taught and knew that breastfeeding was natural among other things, but we were never taught that if things do not go as expected this is what could you could do. So, she invited me to be part of the breastfeeding information group, and that is how my knowledge in breastfeeding gradually flourished including nutrition. 

In the neonatal period, and another pediatrician mentioned that “Neonatal nutrition is an additional emergency to ventilation, etc.” After you pump in the oxygen, intravenous antibiotics, and the rest, if you do not feed that baby, it will not survive. And sometimes I feel that most of the babies we lose in the NICU have underlying malnutrition. We ventilate them for days and we do not pay keen attention to the appropriate amino acids, lipids, among other nutrients, and after a few days, the baby goes into a total collapse because we have not handled the nutrition. And this applies to older children as well.

When we started the Breastfeeding Information Group (BIG), we eventually formulated a curriculum and started training health care workers within the country; this was later taken up by the ministry. By this time WHO was formulating the breastfeeding course. Then we started the lactation center in KNH in 1992 as a joint venture between the University of Nairobi Department of Paediatrics, KNH, and the Ministry of Health. We started training within KNH with some participants from outside KNH, thinking these would go out and disseminate the information or start training centers across the country. 

Later, around 1995, the Commonwealth Secretariat in Arusha came out with an idea that the preservice curriculum should include breastfeeding management. So, through a workshop, universities in East, Central, and Southern Africa drew up a program to see what they will teach in this regard. After this, all Pediatric Postgraduate students were to go through the Breastfeeding course and later after reviews we included all aspects of pediatric nutrition including the national programs in this regard. From 1997 up to now, this course has been mandatory in this training. We have tried to involve the obstetricians, initially, some did but it was not as a mandatory course, but I still wish that the obstetricians would benefit a lot from the course at least the antenatal section of it. 

And with the immense work you have done in the care of a neonate in this country, from teaching to developing guidelines, guiding protocols of care, and on top of that supporting the NBU in KNH, don’t you think you are leaving a big irreplaceable position with your retirement at this time?

My view is nobody is irreplaceable. People may do it differently, but you cannot say anyone is irreplaceable. The newborn unit now has a good team which I am sure is going to go very far. In the ministry, yes, I have been part and parcel of the infant and young child technical working group, way back from the ’80s. I have also been part of child health and at one point in reproductive health sections in the ministry. I have assisted in the development of newborn guidelines together with Dr. Murila especially and once newborn health was pulled out of reproductive health it gave us more space to do this. In terms of Child Nutrition, several people have taken an interest, especially Dr. Beatrice Mutai who is taking over from me. 

Another place where I have been involved in taking care of children is Nyumbani Children’s home and Lea Toto program. I have worked with them since 1996. We have a home in Karen and have clinics. This has been my community activity. And many of the residents have helped in the reviews for these children and was able to supervise one dissertation using the data from this program. When I started working there, we did not have ARVs and we used to lose a lot of children, but now I can boast we have so many adults who have passed through the program and some even have families with children. 

And for the medical doctors reading this, am sure you have some thoughts you want to share with them.

What one would say when you chose to go into medicine, it becomes part of your life; Learning to balance between work and family is very crucial. Many of us forget that you are also a person, with personal needs and you need time to think about you as a person other than you as a doctor who is taking care of this or that patient. Sometimes coming home and you are still worried about that patient whom you did not make a diagnosis, is not easy. But we must try to achieve a balance. 

Furthermore, remember that when someone comes to you as a doctor, they are looking for help. Put yourself in their situation, being empathic. For example, sometimes one can get angry and this gets reflected in the patient or parent you are interacting with. This may at times because of exhaustion, especially with 24-hour duties, sometimes even without a chance to find something to eat in between. It is not easy, but one must learn to say that “yes, am tired but this person has come to me, he doesn’t even know that I have been up for such and such a long period, but he/she need help.” Learning to control yourself  becomes very important. But now that there are more shift duties, when you are off duty, make sure that you do something else that has nothing to do with your work. 

This could be anything, church, recreation, sports, and looking after your body is so crucial. I have been singing for so many years, I have been part of the Music Society ever since I have been out of school. Have a hobby, whatever it is, something that has nothing to do with health care so that one can balance in what one does. 

What message would you pass on to your residents in the department of paediatrics?

Sometimes, it may feel as if the faculty are pushing you too much. But quite often we do that because we want you to succeed. If I comment on whatever you have done, am not criticizing you as a person, but I want you to improve in whatever area I feel needs working on. There are many good things that residents are doing, which may not always reflect in the way we interact with you, because quite often, I do not know whether it is because of our medical training, but we seem to be looking for faults. But there are many good things that people are doing, which you may not get a compliment or may not be registered as “so and so you are doing a good job” So as we push you, it's because we want you to excel. 

The Department of Paediatrics all through the years has been one that nurtures students probably more than other departments in the College of Health Sciences, I do not know whether it's because we are paediatricians, but our residents have received compliments from people from other departments on this. But do not be put off with whatever we say, it is because we care, we want you to be excellent. And let us face it, you are the future, long after many of us are no longer there, you will be the one holding the mantle and you will be glad that you were pushed as a postgraduate because this period also shapes who you become as an individual, a doctor, a person worth your name. 

As young people aim to do as much as you can. Team up, each one of us has different strengths, but when you come together as a team, those strengths are going to bond together and collectively you will come up with something very big. The health sector right now is suffering, sometimes the bigger bosses do not listen to you. But when as a team, you can collectively say “we are being bullied, we are being harassed, but despite all that, we will do what we can.”

Is there a message you want to share with the whole team in the Paediatric Department from Residents to the Faculty?

I keep saying that I will be part of the team because Kampala is not far. As faculty and together with our students, we should continue working together as a team. Teamwork is very crucial. We learn from each other and let’s continue this. Let us not lose the family aspect of us. The department is one big family, when one of us a student or faculty has some concerns, we have teamed up together to find solutions, and I would like this to continue. We should continue supporting one another, be academic or social. The roots of a family always go deeper and deeper. 

It has been a good period of my stay in Kenya, when I came, I never thought I was going to stay for this long. I know more about Kenya than my home country. And it is a joy as I move around the country. 

Prof. Rachel Musoke has been a lecturer at the University of Nairobi, Department of Paediatrics for more than 40 years. Those who worked or have been trained by her will remember her soft, gentle, motherly, and patient approach to the care of newborn infants. Her great work within the department of pediatrics, the KNH newborn unit, and the Ministry of Health inspired this initiative. As residents within the department of pediatrics, we have witnessed her work face to face, and it was a great privilege to have worked with her. Her work has impacted many and will do so for many years. She has left a wonderful legacy. We wish her a blessed retirement period. 

Authors: Dr. Allan Kayiza and  Dr. Chifor Teresa Mfu

Edited by: Dennis Omido