In Uganda, a Yale doctor helps train the first interventional radiologists at public hospitals

In early June, radiologist Eva Nabawanuka had a patient with a ruptured liver tumor. The patient was young but bleeding out — and urgently needed to be treated. 

Based out of Uganda’s largest public hospital and teaching facility, Mulago National Referral Hospital, Nabawanuka was able to stop the bleeding by performing an embolization, a common medical procedure within interventional radiology (IR), a subspecialty of radiology that uses image-guided, minimally invasive procedures.

Until recently, there wasn’t a single interventional radiologist in Uganda’s public hospitals. But Nabawanuka has spent the past two years training to become one through a program led by Fabian Laage Gaupp, assistant professor of radiology and biomedical imaging at Yale School of Medicine (YSM), and his collaborators at Road2IR, an international consortium of physicians, nurses, technologists, and trainees working together to bring minimally invasive, image-guided procedures to East Africa and beyond.

In August, Nabawanuka and her fellow trainees, Alex Mugisha and Sam Bugeza, graduated from the program at Mulago Hospital.

“That young man, prior to us being here, would have had no chance at all,” said Nabawanuka, now an interventional radiologist at Mulago Hospital. “He would have had to wait for surgery, and yet he was unstable for it. That’s a life saved because we are here.”

Surgery meets radiology 

Through outreach and education, Road2IR builds self-sustaining training programs to expand access to life-saving procedures in resource-limited settings. Launched in 2018, Road2IR started as a collaborative effort between Tanzania’s Muhimbili University of Health and Allied Sciences (MUHAS), YSM’s Department of Radiology and Biomedical Imaging, Emory University’s Department of Radiology and Imaging Sciences, and several other partner institutions.

Despite a population of nearly 60 million, Tanzania had no interventional radiologists until Road2IR started its pilot project in the country. IR provides image-guided, minimally invasive therapeutic and diagnostic procedures for countless medical conditions, from traumatic injuries and infections to cancer and vascular diseases.

“It’s kind of a mix of surgery and radiology,” said Laage Gaupp, one of the founding members of Road2IR and director of its program in Uganda. “We use imaging, including X-ray, ultrasound, and CT scans, to make procedures less invasive and use small needles and catheters to really get anywhere in the body. With that, we can make procedures a lot less risky, and we can allow patients to go home the same day and just make procedures safer and better.”

Many low- and middle-income countries still lack access to interventional procedures, despite the well-established benefits of IR, making essential, even lifesaving, treatment options unavailable to millions of people around the world.   

The Road2IR training program has helped to close that gap in Dar es Salaam, the largest city in Tanzania. The program was officially certified by the Tanzanian government in 2019, and MUHAS now offers a Master of Science (M.S.) in IR. 

The M.S. program is structured as a two-year-long training program with three trainees — all of whom have already completed a residency in diagnostic radiology — graduating per year. Participants both take part in in-person, hands-on training and undergo regular exams. The course is taught by volunteer teams of U.S.-based IR physicians, nurses, and technologists who train the fellows in two-week increments at least once per month. In addition to teaching fellows, visiting teams also train local nurses and technologists in IR. 

Since the launch of the pilot program in October 2018, 19 radiologists have graduated from the program in Tanzania, in addition to 11 nurses and technologists. More than 100 teaching teams have traveled to the country so far.

“When we started the program, the question was, essentially, do we try to bring people here to the U.S. to train, or do we do the training there?” said Laage Gaupp, also program director of YSM’s interventional radiology residency program and an affiliated faculty member with the Yale Institute for Global Health. “Both of these approaches have some advantages and disadvantages. But we felt overall that doing the training there would have a higher guarantee that we’re actually graduating people who stay there and serve their own population.”

From Tanzania to Uganda 

In 2011, Eva Nabawanuka participated in a student exchange program between Yale School of Medicine and Makerere University, the largest and oldest university in Uganda. While her rotation in New Haven was in internal medicine, she knew even then that she wanted to pursue radiology. When she went back to Uganda, Nabawanuka became a radiologist at Mulago National Referral Hospital, in the capital city of Kampala. 

But she thought she could do even more to save lives. Like Tanzania, Uganda — home to 50 million people — lacked widespread access to interventional radiology (IR), especially in its public hospitals. Nabawanuka had learned about the work of Road2IR and reached out to Laage Gaupp. 

“I was really, really excited about IR and the possibility of doing it here,” Nabawanuka said. “So I wrote Fabian and said, ‘Hey, I don’t feel qualified to do this, but I think I can if you help us.’”

Together, the two started developing a two-year local training curriculum for radiologists in Uganda. The program, which builds upon Road2IR’s existing work in Tanzania, is based out of Mulago Hospital, the largest public health referral center in Uganda, with an official bed capacity of 1,790 beds. It is also the teaching facility for Makerere University College of Health Sciences. 

“In places like Tanzania and Uganda, if we weren’t doing this, they would essentially not get treatment,” Laage Gaupp said. “You’re potentially saving someone’s life, or at least improving their life, and I think that’s very meaningful.”

Over the past two years, 24 volunteer teams have traveled to Kampala to teach Nabawanuka and her peers. That included hands-on training in the hospital, where the fellows would practice procedures alongside the visiting physicians, as well as weekly lectures on Zoom and written and oral exams. 

Before the Road2IR program in Uganda, image-guided biopsies were the only IR-related procedures available to patients in public hospitals, and patients would either wait to get surgery, travel abroad for care, or visit private hospitals where treatments are more expensive.

Now, interventional radiologists like Nabawanuka can perform many other procedures, from abscess drain placements, in which a doctor uses imaging guidance like an ultrasound to remove pus and infected fluid using a catheter, to central venous catheter placement, in which a doctor uses imaging guidance to insert a catheter into a large vein for medication administration, fluid delivery, or blood draws. Within the first year of the program, 1,890 patients were seen at Mulago Hospital’s IR clinic.

“I work for a public hospital where the average Ugandan seeks care,” Nabawanuka said. “For me to be able to offer services to that person is very, very, very impactful.”

Nabawanuka’s cohort, the first to graduate from the Road2IR program in Uganda, won’t be the last. Next year, three junior fellows — who just wrapped up their first year in the program — will graduate.

The Road2IR program has not only benefited Nabawanuka, her colleagues, and her patients in Uganda, said Laage Gaupp. It’s also had a big impact on the volunteer teams of IR physicians, nurses, and technologists from the U.S., including YSM faculty.

“For many people, this will be their first trip to Africa or even out of the country,” Laage Gaupp said. “They go to Tanzania or Uganda and see a completely different part of the world. So many people after that [trip] reach out to me and say this was really one of the best things they’ve ever done. For many people, it’s a life-changing experience, and they want to go back every year.”