Thoughts on Mali 4 years later

After a post-night shift slumber, I awoke thinking about Mali this afternoon. For the first time since leaving Uganda, I re-read my 2009 blog posts from Mali (https://healingnumenor.wordpress.com/category/mali/).

In 2012, Mali underwent significant strife with Tuareg separatists rebels returning from Libya with weapons from the conflict in Libya (http://www.nytimes.com/2012/02/06/world/africa/tuaregs-use-qaddafis-arms-for-rebellion-in-mali.html). In March 2012, a coup occurred in the capital (http://www.nytimes.com/2012/03/23/world/africa/mali-coup-france-calls-for-elections.html). As if things couldn’t get worse, Al Qaeda in the Islamic Maghreb (AQIM) in effect overtook the Tuareg separatists and imposed their version of sharia law (http://www.nytimes.com/2012/06/03/world/africa/in-timbuktu-mali-rebels-and-islamists-impose-harsh-rule.html) and continue to dismantle the public cultural way of life in northern Mali.

The AQIM rebels have destroyed holy and historical sites (http://www.nytimes.com/2012/07/03/world/africa/mali-islamists-exert-control-with-attacks-on-mosques.html). In terms of safety it is impossible for non-regional people, such as Americans, to travel to Timbuktu. The Festival au Desert, one of the most powerful travel experiences I’ve had, has been “exiled” to Burkina Faso. Now, the AQIM stones people, amputates limbs, punishes people for listening to music, all while previous poverty soars and the infrastructure in northern Mali crumbles (http://www.nytimes.com/2012/07/31/world/africa/couple-stoned-to-death-by-islamists-in-mali.html & http://www.nytimes.com/2012/08/05/arts/design/african-art-is-under-threat-in-djenne-djenno.html).

Whenever I’ve read one of these articles over the past year, I sigh, then SMS my friend Jess who arranged our trip to Mali, and pause to think about the Tuareg family that hosted us in Timbuktu and Essakane. Vaguely knowing the answer to this question — it was unfolding as we decided to go to northern Mali for the Festival au Desert against State Department recommendations in 2009 — I still ask, how did it come to this? While driving to the hospital the other day, I came upon Terry Gross’ interview with New York Times reporter Adam Nossiter on NPR’s Fresh Air (http://m.npr.org/news/front/168483341). He laid out the timeline of events succinctly in a useful interview. If you are at all interested, I recommend you read it or listen to the podcast.

My father asks me on the phone about my experiences with Tuaregs when he reads/hears these news reports. I smile to myself recalling how warm, friendly, proud, musical, and above all, hospitable and peaceful they were with me. I remember how they waxed poetically about the desert and about their love for their way of life amidst the economic hardships. The news reports do not explain who the Tuaregs are or always relate their everyday stories or history. Of course, they are not a monolithic group. Now, we only hear about the separatist faction, which apparently, itself has been overrun by the competing AQIM. As I was told while in Mali, the vast majority of Tuaregs are not separatist rebels and now they have been victimized twice over — poverty and neglect by the government based in Bamako and AQIM oppression as we read about day after day. In one of my posts, I write about their poverty and its origins and the Bamako government’s treatment of Tuaregs.

The Timbuktu in 2012 news reports is not the same place of 2009. I only hope a concerted effort is made by ours and other governments to rid northern Mali of AQIM so that the cross-cultural exchange/interface my friends and I experienced can be renewed, that the Tuareg families I met flourish in the ways they have often struggled to do so for centuries in the Sahara. If you want a glimpse into some of the cultural richness we experienced, download music by Ali Farka Toure, play it, dim your lights, sip a glass of tea, and picture yourself huddling with people around a bonfire in the middle of the desert.

The Liberian Correctional Palace

Yesterday, I went with Dr. Kerry to the “Liberian Correctional Palace” just outside Zwedru – the Grand Gedeh County main prison. Not knowing what to expect in a Liberian prison, the road there gave a quick sense of its remoteness. A UN driver took Kerry, a nurse named Ernest, and me along the dirt mud road running through the bush outside town.

Kerry started doing a weekly clinic at the prison after she kept seeing a number of prisoners present at Martha Tubman Memorial Hospital in Zwedru where she predominantly works. Many had signs of malnourishment and with protracted courses of various health problems. She ended up writing a report that helped change feeding and other policies at the prisoner. The County Health Team should have been seeing the patients but they were not doing so with any regularity. Now, Kerry sees patients once a week at the “palace” (this is what the prison is called here) and refers those that need further care to the hospital within the next few days.

When we arrived, Kerry talked briefly with UN-POL and UN-MIL UN troops/officers who are helping teach how to run the prison. The India UN-MIL unit is now stationed here for that purpose. We checked in at the prison gate and signed the prison visitor book. Family members and pastors appeared to be the main visitors but not with much frequency. On a piece of paper sitting atop the desk, there were 4 crimes listed on the slip and nothing else: rape, murder, attempted kidnapping, and robbery. We headed into the prison, met some friendly guards, and stopped at the clinic, basically a set of 2 rooms with a desk in one and some benches in both. Outside the clinic window facing inside the prison, I saw the concrete compound where the prisoners could exercise all surrounded with the standard barbed wire rings.

The prison houses 115 persons, 111 of them being men. Of those 111, 35 presented to clinic yesterday with afflictions such as typhoid, dysentary, malaria, hernia, fungal skin infections (secondary to hygiene and the hot, humid weather here), constipation. Ernest employed top-notch efficiency in a crowded, hot room. Formerly from Sierra Leone, he worked with Doctors Without Borders there before coming to Liberia to work as a nurse. Kerry finds that he performs at a level higher than most physician assistants. With 35 patients in just under 2 hours, we all had to be efficient, though I was the weakest link. Ernest was both triage/intake staff and pharmacist. Kerry saw each patient in the interim. If she thought the patient had malaria, I did the Paracheck malaria test. A simple test, I used a lancet to prick the inmates’ fingers and then used a rapid diagnostic tool using some reagent drops to look for a certain strain of malaria endemic here. None of patients tested positive, but Kerry was concerned about the integrity of the particular kit box we had for the day. So she’ll keep tabs on their symptoms for next time.

The guys were pretty jovial the whole time. I didn’t know their crimes, but many were those listed on that little white slip of paper at the entrance I suspect. Some probably ask to come to clinic weekly just to see Kerry, and it was clear that they like what she is doing and the care she provides them. A 78-year old frail man was particularly memorable. As a term of respect Kerry and the other inmate who helped him called him “papa.” He had what appeared to be a Tinea fungal infection on the back of his neck. I couldn’t help but think what this man has seen in terms of Liberia’s history. The younger inmate’s affection towards him was endearing.

He wasn’t the oldest inmate. Of the 4 women here, 2 are 89 and 98 years old (the oldest people by far that I have heard of here). Why are they in? Up to 3 of the 4 were accused of witchcraft. Kerry didn’t have time to tell me the full story, but for all the anti-witchcraft accusation signs in the country, it seems some women are still getting jailed for it. Fighting on behalf of those women’s rights might be a good project for the nascent group Zwedru Women United for Change being run by Agatha Toure in TH, and we intend to pass that message on. Just the first day I was in Zwedru, Agatha said a few women had been jailed for witchcraft accusations.

Just after we packed up the remaining drugs, kits, and forms (let’s just say the lab work wasn’t the most hygienic of situations given the rapidity and lack of safe disposal equipment), I stood by the interior bars facing the exercise compound surrounded by cells. I had my camera, but I didn’t take what I thought was a powerful picture: a young man, Nubian in skin tone, hands clasped as in prayer intertwined with the fence, and alone, kneeling on the concrete. Bright sun in his face, barbed wire above and below him with the fading yellow-painted, decrepit walls around me. There wasn’t any particular “message” I saw in this image, but it captured some facet of prison life that only a photo might do.

As we left, Kerry showed me a set of gardens just outside the prison walls. Inmates now get some of their food from it. I didn’t know what to expect for the day, but the generally upbeat spirit of the prisoners was not something I would have expected. I tried to lighten up the finger jab by having them guess their malaria status first. Men are often the biggest babies when it comes to being a patient. I should know as one of them. So in a rural prison in Liberia or a hospital in Illinois, I know at least that transcends cultural boundaries and that honoring prisoner health rights is not only a professional ethical requirement but can be a meaningful one at that. Thanks to Kerry for taking me along and for standing up for her patients. I look forward to hearing if TH health accompanier supervisor Alphonso Mouwon’s idea to start TH health talks for the prisoners takes shape soon.

Traveling around Ohio is slightly different

Liberia is about the size of Ohio. Let me assure the reader that it takes much longer to travel around Liberia than Ohio. I’ll take a small tangent at this point. The infrastructure here relates to the country’s post-conflict environment, evidenced by the deficiencies in infrastructure. Take roads. Many African nations have poor roads – this is true in Uganda and Liberia, less so in Rwanda. Whereas Uganda has a well-developed road network – albeit with many roads in dire need of update – Liberia has neither adequate roads to get around the country nor well-paved roads. Most African nations have taxi/motorbus/bus services to get around the country at locally affordable rates. Liberia has none – that really made an impression upon me. Not only is private transport expensive, it is often difficult to arrange timely. In order to get to the southeastern towns and villages in Liberia, one has to go on the road to Zwedru from Monrovia. This is completely out of the way, but no roads exist connecting Monrovia to other coastal towns of the southeast.

The drive was often beautiful. Amos, a TH driver, provided much entertainment. He is affectionately known as “the director of smiles.” Occasionally we’d see what I thought might be primary rainforest but mostly we saw secondary rainforest growth. Rubber trees are an important crop here, and we could easily see where they had been harvested and replanted from the road side. Less village/town activity appeared the closer we came to Zwedru. In one town, an impaled monkey sat atop a stick at the road check. At another road check, a live monkey attached to a rope hung out with market vendors. No other animals crossed our path. The bumps, the dust, the unpredictable events of the day kept my excitement up, but the womb-like lull of the bumps put me to sleep for a bit of the 10 hours. That is, of course, until a big bump threw me off the bench into the aisle of the back of the vehicle!

We passed a number of UN bases along the way organized by country. Bangladesh, India, others. Of the many sights and smells we came across two struck me: the river separating Nimba and Grand Gedeh counties and a gleaming, large Chinese-funded hospital under construction. I plan to take a picture of the river on the way back. To make a simplistic generalization, when China wants to exploit another country’s resources, it usually pays in part with road development and infrastructure improvements. China won’t staff the hospital, and most likely won’t supply it, but the building itself definitely contains potential for area people. Given the health worker shortage in Liberia, the hospital has a lot of work ahead of it once it is completed. I noticed one more thing of note: a church named the “Lovable Lutheran Church.” Those Liberian Lutherans – they’re so lovable.

Chinese hospital in Nimba county

We arrived late afternoon to Zwedru with a number of TH people awaiting our arrival. We met some of the security guards, some of whom I’ll write about in more details later. We settled and went into “town” with Ana and Kerry.

Zwedru has an interesting history. The home town of former president Samuel Doe, he paved some of the main roads in the town when running for president back in the 1980s. His abandoned palace, now inhabited by squatters, sits near the entrance of the town. Road lights dot the roadside, and there is even a water tower. A city of 20,000 some plus people, it has a small town feel. But only this town which appears as a town may be more similar to a village. There is no grid electricity in the town – only generators for those who have the luxury of having one. There is no running water in the entire town. Not only no running water, one cannot buy bottled water here either. Well water or bust. But let me tell you what we can – and did – get: pizza.

One of the only 3 bar/restaurants in town – Florida – recently started serving pizza recently. And it is decent. So Ana, Kerry, Roona, and I headed there for informal orientation over pizza and drinks. Ana ran into a woman, who I will call “Dee” for the sake of privacy, that she met when she was here in January. Dee offered hilarious company for a little bit during dinner. Her story is interesting. She came to the US with her family during Liberia’s civil war. She’s hopped around a number of US cities. And hopped into a bit of trouble as well. She ended up in jail a number of times for crimes related to sex work, drug use/dealing, and other things. She stood out among local Liberians, mainly for her American English (versus Liberian English), her level of gregariousness, and because she was well-nourished (not overweight, but not as skinny as most Liberian women are). Dee didn’t really meet any stereotypes I could have thought up about a deported Liberian national from the U.S. She told us how she’s moved on, about her boyfriend on the flight of deported people, her business aspirations, and a little bit about her religious beliefs. I found out that she lived in Chicago in a pretty rough Westside neighborhood. Her father is ill and in Evanston, IL so I intend to bring back a letter from her to him. She also gave Ana a phone to give me since my mobile phone wasn’t working. Not something I was expecting, a mobile phone to borrow from a deported Liberian woman from Chicago who is now in rural Liberia. (The phone ended up not working either, but the gesture was very gracious.)

Roona and I went back to the guesthouse and got ready to call it a night. Until las cucarachas. The cockroaches. Yes, they are big and plentiful. In terms of yuck factor, mine was the lowest among Raj and Roona. It is not because I’m tough – it is just that they were in my otherwise very clean Ugandan apartment, and I just had to get used to them. Even the occasion when a large one crawled on my neck while I was on the phone, I was surprisingly calm. (Subsequently I ended its life and it was my Facebook profile picture for a while back in 2008.) All this brings me to the TH guesthouse…

(More pictures to be posted when I come across better bandwidth.)

Did you contact the OIC and CHO after reading the MOU with the MOH but before checking with CHT for input from the TTMs? OK. TTYL. LOL.

And so the non-governmental language of Liberia quickly needed to be added our vocabulary as we sat in on meetings with the following NGOs on Monday, April 5: Merlin, Action Aid, Clinton Foundation Health Access Initiative, and the External Aid Coordinator’s Unit. (Don’t worry, they all have acronyms, too.) Each partner listed has some exciting partnership with TH which we discussed during each meeting. Action Aid will be working with TH’s women’s group as mentioned a few posts back with PhotoVoice. Clinton Foundation’s work particularly interested me – they provide technical and consulting assistance to the Ministry of Health in a capacity-building manner. I’m sure that entails its own frustrations, but also provides interesting opportunities to strengthen the ministry’s capability to improve on its health commitments to Liberians. They have an office right in the corridors of the Ministry of Health.

Lunch entailed some fufu, a West African cassava-based product that looks like the blob (I can’t think of a better reference for comparison.) I had it in Ghana many years ago, but I don’t think my body remembered. I’ll leave it at that – gastrointestinal stories become less entertaining over time. What was entertaining, however, was the construction worker who was being teased by a fellow construction worker moments after I started feeling impacted by fufu. In with fitful anger, he said “I’m going to go pee-pee on you.” I think the threat was real. After some rest mid-afternoon, I reconnected with Roona and Raj when they returned from their last meeting. We did some grocery shopping for our wonderful processed dinner, last in Monrovia for a while – Laughing Cow cheese (it doesn’t need to be refrigerated), canned pears, canned chicken spread product, canned baba ghanoush, canned soda, and some bread. Essentials in a country that imports so much of its food, be it in the market or Western-style grocery store. Well-satiated, we packed it up and prepared to get up for our 6:30AM departure for Zwedru.

For Liberian recipes see: http://www.foodbycountry.com/Kazakhstan-to-South-Africa/Liberia.html

Easter in Monrovia

A year ago I spent Easter Sunday in Bujumbura, Burundi as detailed elsewhere on this blog. My friends and I went to a mass in the main cathedral led in French. The children’s choir truly had angelic voices. Although I don’t speak French, there was an unmistakable, familiar rhythm to the service. A memorable day during a memorable trip. That was a year ago.

This year I fought jet lag and slept the latest I think I have ever slept – just before before 1PM – in Monrovia, Liberia. Not so memorable. We had intentions to attend an African service at a Lutheran church somewhere in town; however, our contact we met on the plane didn’t get back to us. Needless to say, the added rest expedited the jet lag recovery.

I’m writing this short post days after Easter. Since then I have begun to hear stories of the trials, tribulations, and hopes of the Liberians with whom I have met through TH. Each time I find myself on the African continent, I find myself struggling with how I talk about my experiences, but more importantly, conveying their experiences. I want to capture the oppression but not at the expense of the strength of the human spirit in a world with far less material comforts, essentials, and social recognitions of human dignity than in high-income countries, where there it is not perfect either. It’s an ongoing discussion for me, one that continues to be shaped by experience, discussion, and reflection.

I brought a number of books with me: The Roads of Man by Ted Conover, Checklist Manifesto by Atul Gawande, This Child Will Be Great by Ellen Sirleaf-Johnson, The Birth of the Clinic by Michel Foucault, and A Hidden Wholeness by Parker Palmer. I also brought a stack of magazines, among them The Christian Century, a mainline theological magazine, which I have enjoyed for years. An article I read the night before Easter speaks to some of my thoughts on human expression in many of my African continent experiences. I’m excerpted a little bit below. Although it comes from the perspective of the Christian tradition, I think the theological dimensions apply widely for all readers regardless of any/no religious tradition.

“…On two mission trips to Haiti with undergrads, there was widespread agreement that the most disarming thing about the country was the laughter of the children, along with their raucous singing. How dare they sing when their life expectancy is so horribly short? Was their laughter an escapist respite from the tragedy of their lives, or a smart rebuke to our assumption that their lives were trapped in tragedy?…The insufferably earnest releases from our church agency presume that the morally attuned among us, the truly courageous, are the ones with the guts to admit how bad things are in this terribly flawed, fallen world… But those singing-through-their-tears Haitians make me wonder: a truly theological analysis suggests that we may be meant by God for music, destined for joy. Maybe our fitful good deeds are not the end of story. The church’s relief bulletins rarely include that theology along with its lists of sins and disasters. This is what you get when anthropology over takes Christology – it’s always Good Friday. What’s dead stays that way…” From “Now can we sing?” by William H. Willimon

There is singing. There is joy. Everyone should know. I’m not here to report on that solely, to downplay or overinflate it. Everyone deserves a lifetime to spend with their friends and families, to pursue their interests, to be treated with dignity. And by all indicators some societies are doing markedly better jobs healing and promoting health than others for a number of complicated reasons, including access to health care, health services, medical supplies, etc. That’s a reality, front and center with joy. But for this Easter in a country with dismal (but improving) health indicators, a country where in a report I read today that an infant mortality rate of 110 per 1000 births is “showing significant improvements,” if I’m honest to myself, I have to say “amen” to character and spirit of Willimon’s reflection after 6 years of experiences on the African continent. The needs don’t dissipate because of joy, but song in part reminds us of who we are and what we are to do.

Monrovia April 2-3, 2010

When I step back for a moment to contemplate it, I find the stark infrastructure and economic contrasts between capital cities truly remarkable. On my way home from Uganda last year, the acute contrast I saw within 24 hours was between Kampala and Reykjavik. On Friday, April 2 I spent 2 hours in downtown Brussels during a layover in the morning and then the evening in Monrovia, Liberia. One city with guilded exteriors, prolific chocolate shops (stereotypically true), and immaculately clean compared to another city with bombed out buildings from its country’s civil war, a few very well paved roads (a positive sign of improvement), and one not to be walked around at night. The rhetorical, perennial question lingering (when one brackets national sovereignty and history, of course): why do these stark contrasts persist?

In Brussels shortly before departure, we talked with Kimmie Weeks, a Liberian guy who has repatriated to Liberia after being in the US during Liberia’s civil war. He has been a significant child rights activist (http://www.youthactioninternational.org/yai/), and people at the airport from different countries came up to him given his past media presence and work. We all boarded, and Roona, Raj, and I landed in Monrovia later on April 2. As we descended in the air, I viewed the dense, verdant foliage meet up with the ocean with eagerness. The air appeared steamy – I knew what to anticipate weather-wise. We disembarked from the plane into 95F air with near 100% humidity. The familiar exhaust smelling air I’ve experienced on the airport tarmac in African and Latin American countries brought a flood of memories, reinforcing the power of the olfactory system in memory recollection. We waited in a chaotic line to have our visas stamped. Thankfully, my luggage arrived though Raj’s did not. We met a very kind Tiyatien Health staff member, Ben, after leaving the airport. We bought some delectable, simple bread at the roadside and started the 45 mile journey to Monrovia.

The Monrovia airport was built by the US military during WWII to facilitate exportation of rubber tires for the Allied forces in Europe. The location so far outside the city was chosen because Firestone has a nearby rubber plant. (Firestone has been in the country since around 1920). We passed many families on a very paved road as we left the airport. Rudimentary mud dwellings dotted the roadside, dense jungle-like foliage ended behind the homes, and a beautiful steamy sunset welcomed us as we drew closer to Monrovia.

The most memorable part of this road trip was Ben’s story during Liberia’s civil war. Trained as a physician’s assistant, he ended up provided care to the warring factions at different points in the war. One particular day, rebels had come near the school where his 2 children were attended. He found out that his kids were bused away safely, but rumors abounded that children were being abducted, adopted, and killed. He described the environment at the time, the fear, and the hopes for the future. As I felt in Rwanda and Burundi last year, the ramifications of such stories on a society and its individuals were rather unfathomable to me in the context of stable upbringing. We capped off a great conversation with a discussion about President Ellen Johnson-Sirleaf, the current president and the African continent’s first woman president. There’s an upcoming election, next year I believe, and we spoke about her and her competition.

We met up with Kerry Dierberg and Ana Weil, the former a Massachusetts General Hospital (Harvard) Durant fellow who agreed to work for Tiyatien Health in Zwedru during the fellowship. They were eating dinner at Golden Beach, a restaurant on the beach in Monrovia. Monrovia’s beaches are dangerous for expats in terms of security and undertow, and so being able to enjoy it at this restaurant was a great venue for us. We listened to Kerry and had some good introductory conversations about health in Liberia and TH operations in Zwedru. The connections among Raj, Ana, Kerry, and Roona are fun to trace. All of them except me have affiliations with Harvard and/or Johns Hopkins and had other contacts related to those institutions in Monrovia that they were not expecting. I enjoyed watching the energy of rekindled relationships.

Saturday April 3, we started the meetings en masse, which as I write this are ongoing through April 5 evening. We started on Saturday meeting with a senior leader in the National AIDS Control Program about an upcoming shared grant roll-out in Zwedru where we will be heading in a few days. (Zwedru, a southeastern Liberian town 20 miles from the border with Côte d’Ivoire, is TH’s main headquarters in Liberia.) We grabbed some street food and then headed to downtown Monrovia.

We bought some odds and ends on the main drag, Randall Rd. Events included a good falalel sandwich at a Lebanese eatery, stocking up on groceries and supplies before heading to Zwedru (all expensive because almost everything in this country is imported), and I thwarted an attempt of someone opening my backpack (I guess I learned some street smarts in Uganda). I should emphasize how friendly I find Monrovia overall right now! We then headed back to our air-conditioned guest house, a seductive luxury that we will quickly need to be accustomed to being without in Zwedru. As we were about to nap, we received a call from a programs officer at UNHCR-Liberia (United Nations High Commissioner for Refugees). A gracious man, we met with him and another UNHCR staff woman to talk about further building UNHCR’s relationship with TH. We also showed him a PhotoVoice project that took place in Zwedru with some former US TH volunteers. PhotoVoice (http://www.photovoice.org/) is an educational modality with a mission statement “to bring positive social change for marginalised communities through providing them with photographic training with which they can advocate, express themselves and generate income.” When that TH video gets posted on the internet, I will definitely post the link and provide more explanation.

We spent the rest of the day at the cafe of a nice hotel overlooking the ocean in order to discuss some issues in development work, goals for the upcoming weeks, and to enjoy the internet. All sorts of expat personalities shared the tables around us. Some military, some business, and most doing activities I can only imagine at this point. The stories here are undoubtedly plentiful and outside the type of my daily conversations in Chicagoland. The acronyms and vocab remind me again of my year in Uganda and some its excitement, success, frustrations, and failures. The evening finished with the appearance of one of Raj and Roona’s friends – Ranu – who is a medical resident in the Global Health Equity program at Harvard’s Brigham hospital and who is here independently consulting the Liberian Ministry of Health. His story is an entirely different post…

For now, listening to the delightful dialect of Liberian English spoken, re-immersing in the energy of change and all the complexities it entails, and working with an organization committed to community-driven solutions to problems keeps me revved. I leave this post with one comment by Kerry that I found inspiring that I will summarize and not do justice to in its eloquence: “some level of despair is what helps keep me motivated in advocating for my patients.”

Tiyatien Health/Liberia: A pre-departure introduction

A longer introduction to come, but today, April 1, I leave for Liberia to work with the organization “Tiyatien Health.” (http://www.tiyatienhealth.com) “Tiyatien” means “justice in health” in the Kwa-dialect spoken among some people in Liberia. Liberia has a rich, complex, and often turbulent history. Many simply associate Charles Taylor and child soldiers with Liberia when they hear its name. I will write more about those events along the way and hope to relay a fuller picture of daily life, the problems of the past, and Liberians’ hopes for the future.

Briefly, I will be working on a few projects for the organizations including using a tool to evaluate community health worker attitudes and ideas to improve patient care and the organization, surveying patients who are loss-to-follow-up and assessing side effects of medications they may be taking for depression, and working on issues related to distinguishing between demoralization and depression as well as clarifying some wording and data issues with a tool already in use for depression screening. I am very excited to be part of the TH team on this trip, and I am traveling with the organization’s co-founder – Raj Panjabi and 2 other medical students, Ana Weil and Roona Ray.

A few statistics until I have time to write more:

-There are estimated to be 122 doctors for 3.5 million people (http://www.mg.co.za/article/2009-01-14-liberia-battles-crippling-shortage-in-health-workers) in Liberia.

-In a multi-stage random cluster survey around Liberia (http://jama.ama-assn.org/cgi/content/full/300/6/676), researchers found 40% of Liberians surveyed met the criteria for major depressive disorder and 44% met the criteria for post-traumatic stress disorder (PTSD).

Stay tuned for more stories and statistics, history, and a travel adventure or ten.

T minus 7 days

The exodus of my expat friends from this place continues, and I will join their ranks soon enough. One week from today I leave Uganda. I intend to spend time updating my blog now and throughout June detailing experiences and trips. So very many to share.

In the meantime, I continue to work on SAS analysis of a data set looking at TB recurrence and alcohol use in preparation for a scientific poster, drafting portions of the paper based on study results of the trial on which I have been coordinator, and organizing myself for re-entry to the U.S. Goodbye parties and last minute shopping dot the calendar as well.

As after many experiences in life, I think “home” and time will show me how this year has changed me. Suffice it to say, I think a substantial change occurred.

SEHC Week of Action – Makerere University

I had the chance to participate in 2 of the 6 days of the Makerere University Students for Equity in Health Care (SEHC) chapters’ Week of Action. Its main objective was “to pass on the knowledge and skills acquired from the East Africa Health and Human Rights Leadership Institute to the health professional students under training.”

Speakers spoke about health & human rights connections on Monday and Tuesday. I presented “Advocacy: Successes and Challenges” on Wednesday, May 6 using the 10 Steps of Advocacy template Physician for Human Rights (PHR) taught me and then mapping each step to my recent involvement with the anti-TB medication stock-out campaign.

On Thursday, I attended AGHA (Action Group for Health, Human Rights, and HIV/AIDS) advocacy officer Roselyn Davina Vusia’s presentation “Health and Human Rights Status Quo, Gaps, and Way Forward in Uganda. She discussed relevant international and national law to capture the scope of the legal right to health. She then gave an overview on the elements of a right to health: Availability, Accessibility, Acceptability, and Quality (AAAQ). At the end of her talk, SEHC leadership demonstrated “equity” as they put it. The SEHC Medical chapter distributed medical supply donations from U.S. PHR Leadership Institute participants Neil Chalwa and Mona Singh to the 3 health professional schools, Anatomy Department, and Microbiology Department.

Medical, nursing, and paramedical students went to Katanga BEUPA school on Friday afternoon for a tour and to give some school supplies. Saturday night SEHC held a fundraiser dinner at the Jeliza Hotel. A few local officials from Katanga were invited as well as the teachers. I left to do some work in Kenya on Friday, so I had to miss Friday and Saturday events unfortunately. Hopefully, Herbert Kayonga, out-going SEHC medical president can write a comment to this post on how Friday and Saturday went. Stay tuned…

As PHR-Loyola chapter president in 2007, I had no idea that I would be able to one day see the SEHC Week of Action at some point, a cause our chapter fundraised for that year during our own AIDS Week of Action.

BEUPA Katanga School Project

After my daily morning research study team meeting on Friday, I met some Makerere University medical student leaders from the Students in Equity for Health Care (SEHC) chapter. The chapter has its Week of Action coming up on May 4-9, 2009, and I have been attending some of their organizing meetings.

The SEHC Week of Action is similar to the ones put together in the U.S. from the student chapters of Physicians for Human Rights. In fact, when I was chapter president of PHR in 2006-2007, we sent some money we fundraised to PHR explicitly for the SEHC chapter in Uganda. The week will consist of lunch time hours talks around advocacy and health & human rights issues in Uganda and community volunteer time in Katanga on Friday, May 8.

I went with SEHC members Herbert, Juliet, and Diana to visit a school in the Katanga settlement, a slum literally across the street from Mulago hospital. The SEHC students sponsor a weekly Friday porridge meal for the children and are looking to increase their involvement in the community even more with this year’s Week of Action focused on the children of Katanga. The experience reminded us once again of the immense poverty and challenges of the poorest Ugandans.

Here is a concise background of BEUPA and this particular BEUPA school, which is one of about 75 in Kampala District. This information comes from a proposal/protocol prepared by SEHC for Bucknell University’s undergraduate Globemed chapter:

Background of BEUPA

BEUPA is a learning centre found in Katanga providing basic education to direly indigent children. The centre was started by Kampala City Council (KCC) in conjunction with GTZ, a German Development Cooperation in 2000.  However, this GTZ – KCC venture was only a five 5 year program ending in 2005.  After the end of the venture, the BEUPA project was handed over to the community in Katanga.  Katanga being a slum, it is inhabited by majority of people living below the poverty line (living on less than US$ 1 a day).  The people therefore are in continuous socioeconomic crisis and could not maintain the project. From 2006 to date, the BEUPA is being run by a volunteer family, which is also at the moment almost giving it up.

 

From the inception of BEUPA to date, they have been providing basic education in Mathematics, English and literacy with an aim of imparting basic knowledge to the children. The children are divided into three groups depending on the age groups, and more so, how knowledgeable they are when they report to BEUPA.  These groups are in three classes.  Class I is a beginners class, Class II for intermediates, and Class III for those portraying an above average literacy potential.      

 

Background on the children at BEUPA

The total number of children at BEUPA varies from 50 – 100 pupils aged between 5 and 17 years of age.  Due to their poor socio-economic background, these children cannot afford the Universal Primary Education (UPE) that is not apparently free as it was stipulated to be in Uganda. 

 

Majority of these children are orphaned by or are living with HIV/AIDS, with some of them being the eldest children at their homes thereby having to head or take care of their families. Most of them are casual labourers, working part of the day, to supplement income for their families. The average child starts to work at the tender age of 8, being involved various activities jobs like collecting scrap metal for sell or selling foodstuffs on the street.

Receiving a single meal in a week at BEUPA, the highest attendance at BEUPA is noted that day.  The children come with firewood to cook the porridge.  The maximum attendance is noted that day a cup of porridge is served for the children at BEUPA.  This is because majority of the children live on only one meal a day (usually supper), and the day they are served with porridge is the only day of at least two meals.  The meal served is just, made of just 3kgs of maize flour to feed the entire population of the children attending that day at BEUPA.

The centre is run by three volunteer teachers from the community.  The volunteer teachers open the centre in the morning and close at noon, particularly because majority of the children come to school when hungry and cannot stay till evening on an empty stomach.

The story runs a bit deeper. GTZ pulled out in 2005 because KCC misused the aid money. The city council then became the sponsor of Katanga BEUPA school. At first KCC distributed a 50,000/= (~25) monthly “allowance” to the school but that ceased in 2006. Since then the teachers have been essentially volunteers. They have been promised to be put on a government payroll; however, this payment has not come to fruition. Unsurprisingly, KCC has not been able to find any outside donors.

The teachers in part credit Joseph, a previous SEHC president, and SEHC writ large as two of the reasons why they are still there. He came across the Katanga school and mobilized more Makerere health professional students to get involved with activities like soup kitchens and distribution of clothes donations to the children. Subsequently, the SEHC chapter formally committed to the community.

We met two teachers, Janet and “Hajjit,” who are volunteer teachers. They said the biggest challenges  for them come from kids from the poorest families in Katanga. These children typically eat one meal per day at 6PM, if that. Since they do not eat in the morning, they often fall asleep during class and have short attention spans because they are hungry. The children study up till noon and then go home for the day. Normally, they would be going home for lunch and then return, but since many do not get lunch and because the school has no funding, the day is only 1/2 day long.

The class used to be 60-80 students in size but after the necessity to introduce a quarterly fee of 5,000/= (~$2.50) per student the class size dwindled to the current 40 children. Yes, even $2.50 was too much for some children’s families or school was not enough of a priority in light of another needs or uses of money.

During our meeting with Janet and Hajjit, we met a Katanga resident, “Hajj” (a common nickname given to Muslim men here), who had generously donated the land on which the school was built. He has kept the land free as long as the school continues to be productive in light of its constraints. A kind, slight man, we all thanked him for his generosity and he thanked the SEHC students for their work.

The school technically can teach students 5-18 years old but most of them are at the younger end of the spectrum. Janet and Hajjit were explaining to us how the adolescents do not come, in part because they feel shame for not being able to read and write at their ages. Additionally, children need to find work at a young age as you read in the background, often collecting metal scraps for money in some rough parishes and zones of Kampala.

Originally, one of the long term goals for these children was to streamline them into vocational technical work. The teachers even had apprenticeships lined up for that segment of education after school years 1-3. But BEUPA Katanga did not have funds to pay the vo-tech trainers, so this idea went unrealized and the kids have since had to fend from themselves.

Some children when they finish the BEUPA school graduated into P5 of the UPE (the supposedly “free” education) and move upwards, but they are few. As we walked to the school, children who should have been in school were running all around having a fun time with friends. Many live with relatives who came to Kampala with parents living in the villages. Others are orphans. Most are low priorities in terms of access to family support.

Micronutrient deficiences, lack of access to funded education, and non-ideal family situations are among the barriers these children face. At one point I saw a likely drunk/high adolescent girl swaying outside a window of the school, eyes staring me glazed with an awkward smile. The kids in the class were joyful but a bit restless. These teachers and kids deserve more resources.

SEHC has the following objectives in its proposal:

Broad objective

To improve the functionality of the BEUPA project

Specific Objectives

1.       To improve the delivery of basic education at BEUPA, by providing material support, and intellectual support

2.       To regularize the attendance of children at BEUPA, by providing at least a daily cup of porridge

3.       To improve the health status of the children at BEUPA through VCT, de-worming, and provision of basic diagnosis and medication

4.       To pave way for a constructive exit strategy for the children at BEUPA

Walking around Katanga, I kept seeing an all too familiar scenario. Immense poverty, raw sewage, children running around, overcrowding and a muddy landscape that rain storms probably wreak havoc upon every time. And like in Nairobi or in major cities in Brazil, India, etc., these slums are minutes away from the opposite end of the economic spectrum. Garden City mall is 2 minutes drive down the road bordering Katanga and Mulago Hospital. I go to the gym there, watch movies at the cinema, and often eat and shop. Traveling from Katanga to Garden City the road is flanked by the two wealthiest parishes of Kampala, Nakasero and Kololo. Poverty may hide sometimes, but it is not far away.

BEUPA Katanga relies on the generosity of others. I myself believe in the power and place of civic action and the work of groups like SEHC in the poorest places. But the honest truth is that SEHC should not need to exist if the public sector worked more equitably in the health and education realms. Educated and healthy people would be more likely to succeed and have a chance to be upwardly mobile in the business, service, and manufacturing sectors. This realization of the common good in these areas (and I say this as the debate continues in my own country) has not yet been actualized and corruption and avoidable inefficiencies are partly to blame for the present situation in Katanga.

Thankfully, SEHC does exist in light of reality. If you are interested in helping SEHC’s work financially or gifts-in-kind (chalk, crayons, basic English and math workbooks) let me know and I can get you in touch with AGHA (Action Group for Health, Human Rights, and HIV/AIDS) for coordination, a Ugandan partner with Physicians for Human Rights that I have worked with on medication stock-out campaign and leadership training institute, the latter which I will blog about soon. I can also forward on SEHC’s proposal. I hope to go back to this Katanga school before I leave Uganda this time, and if so, I will take pictures.