Transforming women’s urological health in Uganda

Dr Namugga Martha Monicah is one of four female urologists in Uganda.

She recently completed the Fellowship of the College of Surgeons (FCS) exam at the College of Surgeons East and Central and Southern Africa (COSECSA) exams, finishing top of her class. She was supported with a sponsorship from Newson Health.

This episode of the podcast, released on the eve of International Women’s Day which this year centres around equity for all, looks at women’s health and access to care in Africa.

Dr Monicah tells Dr Louise Newson about the barriers to women’s health in Africa, the shame surrounding it and the international support making a difference.

She also addresses the stigma around the menopause and the need to move past a ‘suffer in silence’ approach.

Martha’s three tips:

 1. Anyone in the world who listens to the podcast, know that there is somewhere where menopause doesn’t have to be taken on humbly and that something can be done to improve your quality of life.

2. To the African girl child, know that despite all the challenges, the hurdles, you can still do it, you can still emerge victorious.

3. In whatever small way, any individual can do something to improve the life of another.

For more about Dr Namugga Martha Monciah, visit https://www.baus.org.uk/professionals/urolink/urolink_home.aspx.

Episode transcript:

Dr Louise Newson [00:00:09] Hello, I’m Dr. Louise Newson and welcome to my podcast. I’m a GP and menopause specialist and I run the Newson Health Menopause and Wellbeing Centre here in Stratford upon Avon. I’m also the founder of The Menopause Charity and the menopause support app called balance. On the podcast, I will be joined each week by an exciting guest to help provide evidence-based information and advice about both the perimenopause and the menopause. On the podcast today I’ve got somebody who’s not in the UK and someone in a country that I have not spoken to before on my podcast. Someone called Martha, who’s a urologist in Uganda. And some of you might know that my husband has done some work in Africa. He’s a urologist, but he doesn’t specialise in women, actually he specialises in men and male reconstructive surgery. So Martha was introduced to me recently and as a company we sponsored her for her final exams and we’ll talk about how well she did in a minute. So welcome, Martha, to this podcast.

Dr Namugga Martha Monicah [00:01:21] Thank you, Dr. Newson. Great to be here.

Dr Louise Newson [00:01:24] Oh, no it’s brilliant. So, you are incredibly inspirational. There aren’t many female urologists over where you are. So, can you just tell me a bit about you and why you decided to do urology?

Dr Namugga Martha Monicah [00:01:39] My name is Martha Namugga Monicah, I’m 34 years old. I’m a wife and a mother of two sons. And I was general surgeon first before I ventured into urology. There’s nothing special, I didn’t have any touching story behind my choice of urology, it just happened to be one of the rotations that I enjoyed fully, and I found the urologist quite inspiring. And then I also had a dream of helping women with fistula in Uganda. So, urology was a means to that, so ended up choosing urology after my general surgery and that’s what I did my fellowship in.

Dr Louise Newson [00:02:19] Which is great. In fact, my husband was similar. He didn’t set out to be a urologist initially, but then he started to meet people like Steve Payne, who’s also been part of Urolink, and found it so inspirational and really enjoyed the people that he worked with. So,  tell me about, for those people who are listening who don’t know what a fistula is. Do you mind explaining what a fistula is, Martha?

Dr Namugga Martha Monicah [00:02:42] So a fistula is any abnormal connection between two surfaces that have a mucous membrane. So, in Uganda, obstetric fistula is something that is not rare for a lot of women who cannot afford timely care when they go to deliver babies, so they end up getting an abnormal connection between their vaginal canal and their rectum or vaginal canal and the bladder, and then they become ostracised or neglected from society because they have, you know, this stench and it becomes complicated with family, they usually lose their families. A lot of them stay like that for some time because maybe they don’t know that there is somewhere where they can get help. But once those women are identified and investigated, surgery can be done to make the situation better. So, we have a lot of people who come over to Uganda and do sort of like a surgical camp.

Dr Louise Newson [00:03:39] So when people have fistulas that go into their bladder, so they have urinary symptoms, they have leakage and incontinence.

Dr Namugga Martha Monicah [00:03:47] Yes. So they have continuous incontinence.

Dr Louise Newson [00:03:51] And that can often lead to them being completely ostracised from the community can’t it, when they have urinary incontinence.

Dr Namugga Martha Monicah [00:03:57] Right. So, most times they lose their husbands. There was a lady who was especially touching, she’s a Christian, she really loved to go to church, but the most complicated thing about the fistula for her was that she wasn’t able to go to church because then kids would laugh at her because she smelled like urine like a baby. So, just to see the women get better and get their life back, that makes my day. It’s wonderful.

Dr Louise Newson [00:04:26] Absolutely. I mean, it’s transformational surgery. And certainly, I mean, over here, fistulas do occur, but they don’t occur as commonly because obviously care when people are in labour is better. But we don’t have that same sort of stigma really from incontinence. And incontinence of urine can be very common, especially as you know, in the menopause, but people still often can carry on with their lives and it was only when my husband came back from Africa the first time and told me that people couldn’t go to church or they were not able to be part of the family and community, it makes you realise actually what a big problem it is. Certainly in the UK, women don’t like to talk about urinary symptoms, they certainly get very embarrassed talking about incontinence. Do people over there find it hard to talk about?

Dr Namugga Martha Monicah [00:05:17] Yes. Yes. Generally, things to do with reproductive health are topics which are seen as immodest. A lot of people keep quiet with the problem, some of the women have stayed incontinent for over 10, 20 years, and yet they didn’t come to hospital to seek help. It’s something they are shy to talk about a lot of the time, a lot of people suffer silently.

Dr Louise Newson [00:05:44] Gosh, so how do you educate them. How do you let them know that there is treatment available?

Dr Namugga Martha Monicah [00:05:49] We pass around, not me in particular, but what I’ve seen being done. My work with a fistula is more at the hospital level when they come to get reconstructed and maybe in the post-operative period. However, the efforts by the Ugandan government include sensitising people over social media and radio, which is the commonest thing that goes around here, and in churches and our hospitals that keep calling out to these women and having regular campaigns throughout the year for years now to try and capture some of these women. And there’s some NGOs which actually go down to the communities and go house by house looking for any women who might be affected by these situations. Some women also get referred by their other colleagues who might have had a similar problem in the past that got rehabilitated.

Dr Louise Newson [00:06:43] So the more people are aware that there is treatment available, the better, isn’t it? But how many surgeons are there over there doing your sort of surgery, Martha?

Dr Namugga Martha Monicah [00:06:54] So let’s see, maybe less than ten. There may be two surgeons distributed in the west, some in the east, some in the north, but most of them are actually gynaecologists. That’s their main speciality. We have a urologist who has done quite a bit of work with women who have fistula, he’s published a couple of books, he’s a urologist. And then we have another urologist in the east. But most of the other people are gynaecologists. There are not more than 20 people doing reconstruction in Uganda. They usually get support teams from the UK or from Ireland. Most times people come in to work with some organisations that are volunteers that come in and work together with the doctors and their local team to try and reconstruct that lady.

Dr Louise Newson [00:07:48] Which is so important. And so how many female urologists are there in Uganda?

Dr Namugga Martha Monicah [00:07:55] Oh female urologists, there are not so many in Uganda. Let’s see, maybe it’s the four of us at the moment. We have our retired senior consultant, Rosemary Nassanga, and we have Dr Hope Kibansha, who qualified three years ago. Then just recently we have myself and Dr Annah Tinka. Just us four ladies who are urologists, it’s not a field that a lot of women take on in Uganda. For now, maybe the situation would be different in future.

Dr Louise Newson [00:08:30] Well, I hope so. Certainly, you’re a fantastic role model. And amazing that you’ve done so well… you’ve done actually incredibly well. So, do you mind saying what you did in the exam and what your result was?

Dr Namugga Martha Monicah [00:08:43] So we had our exam in Namibia in December, and I emerged on top of my class. It was under the College of Surgeons for East Central and Southern Africa, so country members or member countries take turns every year in hosting the exam and a big conference after. We had candidates from different parts of Africa that have to sit the exam and I managed best in my class. So wonderful. It was good for me.

Dr Louise Newson [00:09:18] It’s amazing. Amazing. So does that mean you got a medal?

Dr Namugga Martha Monicah [00:09:22] I did get a medal, yes.

Dr Louise Newson [00:09:23] Yeah, well, you need to be very, very proud. I mean, to get the highest marks, to be the best in the exam is absolutely phenomenal. My husband actually got the gold medal when he did the exam many years ago and it was something he always wanted to do, but he thought he might not be able to. My two children, I had two children then I’ve now got three, but I had two and they were I think one was two and one was one when he was revising for the exam. It was a very hard time because he was working and revising as well as obviously being a full-time surgeon, but when he got the gold medal it all just seemed worthwhile and when I saw the photo of you with a massive grin on your face, deservedly so, when you had the results, it reminded me of how happy my husband was and it’s phenomenal, actually. And no one will ever take that away from you. I mean, once you have an award, an achievement, that’s there for life and your family must be really proud of you, aren’t they?

Dr Namugga Martha Monicah [00:10:24] Yes, I can relate to what your husband was going through. I have two little children, four and one and I’m a wife and my husband is also very busy, so I had to juggle a lot of things. I had to work two jobs and two babies and a husband and a home to run. It was quite hectic. Lots of late nights, lots of time invested, so it was it was beautiful that it paid off in such a way, truly.

Dr Louise Newson [00:10:53] Oh, totally. And so, obviously, as I said at the beginning, we sponsored you. But how did the sponsorship help you then?

Dr Namugga Martha Monicah [00:11:02] Well, the sponsorship gave me an opportunity to go to Namibia and stay comfortably and do my exam comfortably. And also knowing that I had a sponsorship, it meant that I didn’t have to work so hard at my jobs. I would take a bit of time off and concentrate on reading for my exam and preparing better. It was a wonderful, wonderful opportunity. The girl child in Africa has a lot of challenges growing up and just going through school and completing school. The few of us that have gotten the opportunity we don’t take for granted. So, the good performance, I think, could also in some way be related to the fact that I didn’t have to worry about the funds and the exam fee and the travel fee and the stay, and so on and so forth. I could get batter done and read. And while I was there, I didn’t have to worry much really, everything was taken care of, so I’m really grateful to you Dr Newson and your organisation for supporting the girl child in Africa.

Dr Louise Newson [00:12:06] Well, you know, we’re so pleased and as you know, my husband’s part of Urolink and he goes out to Africa usually twice a year and he comes back very humbled. The first time he came back he was absolutely exhausted, and sadly he’d had his computer stolen and his money stolen, and he had come back with awful diarrhoea, so he wasn’t feeling very well. But he still said Louise, this is the most amazing week of my life actually, and I’ve learnt so much and I feel so humbled by the people, everybody is so friendly and so grateful. And each time he’s gone he’s learned more and more and you know, I think for us we forget how privileged we are over here and it’s so important to be able to give and share because helping people is why we went into medicine in the first place, isn’t it?

Dr Namugga Martha Monicah [00:12:57] Right.

Dr Louise Newson [00:12:57] I feel very strongly that everybody deserves access to treatment that’s going to help improve their lives, but also the quality of their lives. But actually, the work you’re doing is not just improving the individual, it’s all those people around them as well, and I think that’s why working in women’s health can be really transformational for families and communities, probably more than men’s health in some ways.

Dr Namugga Martha Monicah [00:13:24] Yes, because I think women play a big role in society, no doubt in any society, and in the African society especially. It’s very important to have a healthy population, but a healthy population of women especially. Yes.

Dr Louise Newson [00:13:39] Absolutely. And I know when we spoke before, Martha, you were saying that your education about the menopause has been a bit like mine at medical school, and I didn’t really get any education. People don’t think about the menopause in a way that perhaps they should. Would you agree with that?

Dr Namugga Martha Monicah [00:13:57] Yes, absolutely. When I saw you’re a menopause specialist, I was like, well, what is that? In Africa it’s like the women have to accept that the menopause is just something that happens, you know, part of life. So, don’t complain, take it gracefully. But I’ve taken some time to read about your work, it seems like really, really important work. And you’re helping a lot of women. Down here, a lot of women won’t come to hospital and complain about the post-menopausal syndrome and the symptoms and all the nasty things that happen because they feel that it’s just part of growth. It’s just something that you have to go through, so they suffer in silence.

Dr Louise Newson [00:14:43] Certainly over the last 20 years, women globally have done that, even in the UK as well, because we’ve always been told, well it’s a natural process, all women go through it so we can just battle on and carry on. But actually, for a lot of women, and I’m sure it must be the same over there than it is over here, that they have a lot of psychological symptoms. A lot of women feel very low, they feel very demotivated, they have feelings of reduced self-worth and really find it very difficult to function. And also, quite a few women have physical symptoms, including muscle and joint pains and headaches. Although some women will obviously soldier on, it can be really, really difficult and it means that you can’t be the best version of yourselves. The other thing that worries me is the health risks as well. So, you know, the risks of heart disease and obesity and diabetes, which can affect all communities, and then the other thing is the urinary symptoms that can be involved. Women who’ve had fistulas, once they become menopausal, the tissues in the perineum can become very thin, they can lose their collagen, they can lose the vasculature. So urinary symptoms can really become so much worse during the menopause, can’t they?

Dr Namugga Martha Monicah [00:16:08] Yeah, the mucosa or the vaginal lining, the perineal lining becomes quite thin, so that complicates the fistulas further. Some women have fistulas during their child reproductive age, but hit menopause with fistulas unattended to, I’ve seen a few of those.  In the space of menopause here in Africa, there’s a lot of work that needs to be done, a lot of education, a lot of advocacy.

Dr Louise Newson [00:16:36] Yeah, absolutely, and one of the things also is thinking about how we can enable vaginal estrogen to be given to women who are menopausal, especially with those women who have symptoms, because we know the majority of women have some localised symptoms, whether it’s related to vaginal dryness or urinary symptoms. We know that vaginal estrogen treatment is very cheap, but it’s not available is it, in Africa?

Dr Namugga Martha Monicah [00:17:02] No, no, not necessarily, I think that some estrogen creams are available in some of the pharmacies, but they are quite costly and a lot of women cannot afford it.

Dr Louise Newson [00:17:13] Certainly when I’ve been trying to find out about it, some of it comes from America and it is a lot more expensive. But in the UK it is a lot cheaper and there must be ways of being able to get it out over to you and that’s something that I’m really keen to try and explore, how we can do that, because certainly even if people have surgery, we know that wound healing can be so much better when they have vaginal estrogen and some women might not need the same type of surgery if they have vaginal treatment at the right time, you know, when their symptoms first start to be a problem, rather than waiting until they’re more severe.

Dr Namugga Martha Monicah [00:17:48] Right.

Dr Louise Newson [00:17:49] So there’s a lot of work that’s needed to be done, isn’t there?

Dr Namugga Martha Monicah [00:17:52] There’s a lot of work that needs to be done, there’s a lot of work that needs to be done. Absolutely. Well, that would be very helpful, making available estrogen to women that need it would be very, very helpful.

Dr Louise Newson [00:18:04] Well there’s lots of hurdles but I’m quite determined… and I think we need to keep getting the conversation over… I know that Urolink, some of the surgeons, including Suzie Venn who you know, are coming out again soon to try and really assess female urology, because in the past they’ve been focused more on men with Urolink and now they’re focusing, quite rightly so on women as well. It’ll be very interesting to see what they can do and the changes that they make and I know that they’re going to come and visit us in the clinic as well, which will be really good.

Dr Namugga Martha Monicah [00:18:41] Yes, Dr Susie has, I think, a vast experience in travelling to Africa, I think to Tanzania, and I think she does quite a number of fistula surgeries as well over there. So, I’m sure she has some contacts already. I’ll also put you in touch with another doctor, who also has some contacts already of the people who keep visiting and helping us with the surgical camps from the UK and Wales. They could also be a link. Maybe one day you’ll come out and meet some of the women when there is a camp, it would be a really nice thing. I’ll send over the contacts and see what you can do.

Dr Louise Newson [00:19:22] Yes, I would love to. Actually, for many years I thought how wonderful to be able to do charity work like my husband does. but then I’ve always thought, I don’t have a skill, I’m not a surgeon, I can’t sew people up, I can’t do anything. But actually, knowing indirectly from my company over here in the UK, we can help people, it’s really important. You might know we’ve done quite a lot with a HIV charity, Sophia Forum, where we’ve written information about women living with HIV because we know many women with HIV are more likely to have menopausal symptoms and less likely to have treatment. We’re also now doing some work in the UK, but we hope it will be given elsewhere, for women who have had FGM, female genital mutilation, because a lot of these women really suffer when they’re menopausal but they don’t understand why. So, we’re working with some communities to get the right information so people can understand what’s going on with their bodies.

Dr Namugga Martha Monicah [00:20:24] Right. It sounds like very good work, Dr. Newson.

Dr Louise Newson [00:20:28] Well, it’s so important to note what you were saying at the beginning, it’s about how we educate people so they understand what’s happening and understand if there is treatment, because it’s the same in any area of medicine, if you don’t know what’s happening, it can be very frightening and isolating can’t it.

Dr Namugga Martha Monicah [00:20:47] That is true, especially here. I think there’s a lot to do in the education space and sensitisation space… one community at a time. I think a lot can still be achieved.

Dr Louise Newson [00:21:00] Yes, absolutely. So, now you’ve been introduced to the menopause, you’re not going to be able to ignore it. I think there’s some really exciting times ahead and I really want to be able to improve the health of future generations as well.

Dr Namugga Martha Monicah [00:21:18] That is very, very beautiful.

Dr Louise Newson [00:21:21] So, before we finish Martha, I always ask people for three take home tips, so three things that they might learn from after listening to the podcast. I’m really keen to ask you three things that people in Africa might be able to learn or benefit from, just from having you as now a trained urologist.

Dr Namugga Martha Monicah [00:21:48] Okay. So, just two from the podcast. Of course, you’re doing some work with menopause…if anybody hears or to listen to the podcast, they will know that there is somewhere out there in the world where menopause doesn’t have to be taken on humbly and embraced, that something can actually be done to improve their quality of life.

To the African girl child, know that despite all the challenges, despite all the hurdles, you can still do it, you can still emerge victorious. And lastly, in whatever small way any individual can actually do something to improve the life of another. 

Dr Louise Newson [00:22:35] Absolutely brilliant, and I think the more we connect, the more we can speak, the more we can help each other. That’s going to really make big changes going forward. I’m very, very appreciative of your time and I just want to publicly, once more, say congratulations, because I know the work that you did was so hard, but so well-deserved that you got the gold medal. So well done, Martha.

Dr Namugga Martha Monicah [00:22:55] Thank you, Dr. Newson, and thank you for making it possible.

Dr Louise Newson [00:23:02] For more information about the perimenopause and menopause, please visit my web site balance-menopause.com or you can download the free balance app, which is available to download from the App Store or from Google Play.

END.