Archive for October, 2008

Jazz, soccer, and Ugandan birthday cake

October 20, 2008

Independence Day falls on October 9th here in Uganda. Not everyone celebrates it depending on their political leanings as I came to find out. But most had the day off from work. Sarah and I tried to go to the celebration at the Kololo airstrip. When we arrived we had to pass through metal detectors set up on the street. Right before we entered, a man told me I had to leave my camera or I could go no further. He then told me he liked it, asked where I bought it, and starting playing with it.

Quickly calculating what to do, I asked him, “Well, who would I give it to?” “Oh, it will be safe with one of the police.” To which I replied looking him straight in the eyes, “Will it really be safe?” He said with a smile, “It will be safe.” And then I said gently, “No it won’t.” We both knew that was the reality. So Sarah and I left. Apparently, we could have had our cell phones confiscated as well.

When the president goes somewhere, phones and cameras are technically prohibited. I did not know this beforehand unfortunately. As we were walking home, Sarah grabbed a quick shot of the airstrip. And then a police officer approached us. We left after that, suffice it to say, after an interesting conversation.

Independence Day - Kololo Airstrip (downtown Kampala in background)

Independence Day - Kololo Airstrip (downtown Kampala in background)

The next day, I awoke to my roommates Willem and Michiel coming in my room with a lit birthday cake while I was sleeping. They strung up balloons around the apartment and had party kazoos in their mouths. Very kind of them! 

Tasty frosting

Tasty frosting

That night a group of the Yalies and Willem, Michiel, Sarah and me then headed to the Kampala International Jazz Festival – the first one here ever. Held at the fancy Speke Resort on Lake Victoria for 2 days, we were excited about the venue. Three great groups performed, but hands-down Miriam Makeba’s performance was the best. 

Miriam Makeba performing

Miriam Makeba performing

She had a rich, sultry voice, even at age 76. She is perhaps the most famous African artist internationally. I found a duet of her and Simon & Garfunkel on my iPod when I checked back at my place afterwards. Quite the entertainer, storyteller, and singer. She completely captured the crowd. At 76 years old, it was amazing how energetic she was.

The Jazz Festival was not too crowded, perhaps a little surprisingly. There were many foreigners (about 50% of the crowd). The prohibitive price may have been a reason why more Ugandans were not there or the distance from the city itself at a fancy resort. Hopefully, they’ll continue the tradition annually and make it a bit more accessible. It was a great way to spend a birthday night in Uganda!

Sunday a larger group of us went to the Uganda versus Benin World Cup/Africa Cup qualifier game at Mandela National Stadium. Sidenote, on the scoreboard it read “Benin vs Udanda” for the first half of the game, but then later someone noticed the spelling error.

Benin v Udanda

Benin v Udanda

 Benin appeared to have the game in their hands. Uganda had good offence but couldn’t deliver and had many offsides violations. But then they did deliver and scored two goals within minutes of each other and won the game. People started spraying water all over the crowd, and an eruption of noise filled the stadium.

Benin v Uganda

Benin v Uganda

The stadium was only 2/3 full at its height. Make no mistake, it did not mean it was less crazy. As at all sporting events, people tend to drink a little bit much. And by the end of the game, that led to some interesting situations such as the following.

At the very end, people in our section started throwing trash at the police on the field. Well, let’s be honest. That is not going to go over well in any setting. So the police aimed their tear gas guns at our section and everyone started running. Except us. We had no clue what was going on.

Dawn before the threat

Dawn before the threat

But then someone yelled, “Mzungu run!” We started to and then realized why. Now the police did not launch the tear gas at us, probably because our group of about 18 people was the only one left by the end of the exodus.

The matatu ride back took a long time, and a lack of agreed upon price created a mildly tense situation with the driver and conductor before we exited the vehicle. Nonetheless, we had a great time overall throughout the day. Waving my Ugandan flag around in celebration, people honked horns and boda-boda drivers cheered. Uganda won. We had a fun time watching it.

Gulu and LRA history

October 11, 2008

After leaving Murchison Falls on Sunday, we traveled next to Gulu. Gulu is the second largest town in northern Uganda. The Acholi people are the predominant ethnic group, and I saw dances from their region at Ndere Centre as noted in an earlier post. Refugee movement into Gulu largely accounts for its large size.

Before going into my trip, let me recount some history of the Lord’s Resistance Army and its impact on the region. All historical information following comes from Ian Leggett’s “Uganda” Oxfam Country Profile series book that my brother gave me before I came here.

In 1987, Alice Lakwena (a woman without military experience who had a vision) became the leader of an armed opposition group called the Holy Spirit Movement, a movement against the current NRM party headed by the current president, President Museveni. The movement integrated elements of Christianity and traditional belief systems and drew people through the use of a sort of “Prosperity Gospel” message. The Movement was quickly stifled by the NRM’s army (the NRA – National Resistance Army), and the NRM offered amnesty to the rebels. Gulu and Kitgum were focal points of the HSM.

Around the same time, warriors from a neighboring region, Karamoja, started attacking cattle in Gulu and Kitgum, thereby destroying and cultural and economic liabilities for the Acholi. Enter Josephy Kony. He brought together a cohort of rebel groups under the umbrella of the “Lord’s Resistance Army.” Similar to Lakwena, Kony claimed to be possessed by religious powers enabling him to be a medium. Having no known agenda or direction, the violent, unpredictable, and impulsive LRA movement began terrorizing the Acholi people.

The LRA would abduct children, maim people in grotesque ways, and raid schools, health centers day and night. The descriptions of the crimes need no introduction here. Suffice it to say, they constitute some of the most vile ways of treating fellow humans, not unlike what is currently going on in eastern Democratic Republic of Congo (DRC) in North and South Kivu regions at this very moment. Ironically, the LRA claimed to be protecting the Acholi people as it terrorized them. Northern Sudan began giving aid to Kony and his followers for its own short-term strategic reasons against the southern Sudanese group Sudanese People’s Liberation Army (SPLA). (Southern Sudan now suffers from LRA actions, as the LRA has relocated to the forests of southwestern Sudan/northeastern DRC).

Estimated abductees exceed 20,000 people, with over 2000 in 1995 alone according to Amnesty International. Children killed children under LRA direction; children wielded weapons brainwashed to kill indiscriminately; children were sexually abused, and childred were forced into mind-altering drug use. I use the past tense, but it still occurs in the LRA areas.

According to a 1999 Amnesty International report, over 400,000 persons were internally displaced in Uganda in Gulu and Kitgum. We were told by our doctor hosting us in Gulu, Dr. Croule, that the refugee (internally displaced persons) IPD camps ranged in size from a few thousand to 60,000.

We arrived in Gulu, again seeing green but drier land compared to Kampala area. It felt hotter here than in Kampala as well (and my neck showed it). Non-governmental organization (NGO) signs appeared on EVERY corner. Over 200 NGOs have been doing work in Gulu over the past 2 decades. World Vision, CARE, Save the Children, UN [insert the name of any branch of the UN], Rotary, and the list continues… I wish I would have taken a picture of one particular intersection that probably had 30 organizational signs alone.

On Sunday afternoon we walked about the city, visiting mostly local markets and stores. Nothing was tourist-oriented whatsoever. We still had fun, but unless one was a worker here, one only needs 24 hours to experience the town itself. After guys and gals both tried on some clothes at different street side shops, we had a rendezvous back at Jojo’s Palace, our guesthouse (quasi-motel).

View out of my Jojo's Palace bedroom

Jojo's Palace

 We had a dinner – buffet style – of Ugandan food with Dr. Croule at a local restaurant. We barraged Dr. Croule with questions about Gulu, the IDP camps, infectious disease issues and resource constraints at the hospitals in town. Good conversation continued, and we discussed end-of-life issues in general given the research one of the Yale medical students had done comparing Holland and USA. It made me miss my graduate school days in ethics.

Then a brilliant walk home. The number of stars we saw – utterly breathtaking. The Milky Way rode the sky and constellations glittered, pulsed, and gave me pause to step back for a moment. We arrived at the hotel and Jesper, Brendan, and I continued excellent conversation about our being akin in some ways to a type of minority group in the country, infrastructure and efficiency issues, and the next day’s visit to Unyama.

Monday morning we had breakfast at Kope Cafe.

Kope Cafe - Jesper and Brendan

Kope Cafe - Jesper and Brendan

 The cafe is colorfully painted, and its profits go to an arts therapy program for children affected by displacement.

The crew enjoying breakfast and GOOD coffee

The crew enjoying breakfast and GOOD coffee

Dr. Croule picked us up around noon and 6 of us traveled with him to Unyama, a former IDP camp that recently lost official camp status, but continues to house people and receive some aid. During the drive from Gulu (around 7km), I was amazed by the gregarious friendliness shown by people we passed. Uganda is incredibly friendly, but in Gulu it was even friendlier. Brendan, Jesper, and I were squished in the back of the truck bed, but waving to kids and adults ameliorated the awkward positioning pains!

Unyama housed thousands of people, but Dr. Croule did not know the exact number. A series of constructed huts surrounded by barbed wire, except for entrances, dotted the landscape. The camp is now about 2/3 emptied at this point. People here generally speak Luo, so we could not communicate in either English or Luganda. Our driver, Richard, did translating for us, and we walked through the camp a bit. The little kids called us the equivalent of “mzungu” in Luo: it sounded liked the Spanish word “mono.” I asked what the biggest problems are in the camps.

Unyama IDP Camp (latrine foreground)

Unyama IDP Camp (latrine foreground)

 Dr. Croule said sanitation is the biggest problem, followed by domestic violence and drinking. Guards would patrol the camp’s border when it was official. The children and adults we saw wore very dirty and tattered clothing and generally beamed bright smiles at us.

Unyama IDP Camp

Unyama IDP Camp

Mental health issues, not surprisingly, are paramount concerns here along with infectious disease. (There is an ongoing hepatitis E outbreak in the region, much malaria, wild polio virus north of Gulu coming in from a Congolese outbreak currently, nearby Ebola outbreak last December, and an unknown ailment causing very distended bellies in children featured in a national paper the day we were there.) As to mental health, a psychotrauma unit recently opened at one of the hospitals. Post-traumatic stress disorder, anxiety, and depression afflict many here. The unit is not enough, but it is part of a more comprehensive program that is being rolled out currently. Mental health parity is not present in most resource-constrained settings. I see it in Kampala. In Gulu, it’s starting to become more addressed thankfully.

It is a fair assessment from one angle to say we were “disaster tourists,” something about which I am not particularly comfortable. When I was in the squatter settlements of Nairobi, I often felt like I did not belong there. Conducting needs assessment with the aim of raising awareness, interventions, and programmatic development made my rationalizing easier at the time, however. After going to Unyama, a place I will not return to, a place I provided no clinical care (side note: Jeremy, Tracey, and Jesper stayed to work in hospitals there for a few days) or research, the only rationalizing I can do is bring awareness to the reader and provide links to organizations that serve those affected by the LRA’s madness.

I am thankful for the opportunity to visit Unyama and Gulu. I was surprised with how organized it seemed (knowing there’s always a Janus face to what you see and experience in a setting like this) and even more surprised how generously accepted our presence seemed to be. It’s hard to paint a picture meaningfully having not talked with the residents of Unyama or knowing its history more. I pondered these things and others with Brendan as he, Sadia, and me rode the 5 hour bus ride from Gulu to Kampala that evening. Chalk another group of people to keep in your thoughts and/or prayers with the burden of knowledge hopefully to guide awareness and advocacy.

Here are some links to organizations below:

Invisible Children Project: http://www.invisiblechildren.com/theMovement/ (you can use Google video to watch a near one-hour film from the creators of the project) [My knowledge of ICP courtesy of friend Andrew Thomas, high school teacher, Crystal Lake IL]

CARE, World Vision, Save the Children, Rotary International, Oxfam and many others all have field stations in Gulu if you are interested in supporting a broader organization doing work there.

Link to NGO Forum in Gulu: http://www.humanrightsuganda.org/ngo_forum/index.php?page=86&expand=69 

"Pray for Us" - Unyama IDP Camp

Murchison Falls National Park (includes vehicles stuck in mud and a lion)

October 9, 2008
This past weekend I had an opportunity to go to the most popular national park here – Murchison Falls National Park. The Fogarty scholar in the program’s first year, Jeremy Schwartz, is now a third-year Med-Peds resident at Yale currently on a 6-week rotation at Mulago. He invited  me to come along with the Yale & friends team he had put together. We went to bed rather soon after I arrived since we had to be up at 4:30AM to hit the road at 5AM.
 

5AM people. Most of the "Yale & Friends" crew.

5AM "Yale & Friends" crew

 

 

The trip to Murchison Falls National Park on Saturday and Sunday went by quickly but not too quickly as to not feel like a trip of adventure with the requisite expected “unexpected” things of such journeys. We left the city and started the journey north in a privately rented matutu driven by one of the drivers Jeremy knows, Bunjero, from the Infectious Disease Institute at Mulago. We numbered 11 passengers including a lovely physician couple from England.

 

We stopped for food at one point alongside the road during our 6 hour journey, and I had my first “rolex,” a delectable food consisting of a simple omelet wrapped with chapatti.

Jesper waiting in line for roadside rolex

Jesper waiting in line for roadside rolex

 

You can spice these things up, but the basic one I had was superb. The salt-engorged diet of the US is lacking here, but not in this particular rolex! We also ate some goat-on-a-stick, passing up the liver-on-a stick. I mean seriously, I cannot eat liver-on-a-stick at six in the morning. At any rate, after the stop we continued on. One of the strangest parts of the journey was a track of about 20 minutes of speed bumps literally in the middle of nowhere. It severely slowed us down, and we were begging for a satisfactory rationale for them. We arrived at none, Bunjero included. Oh well.

 

 

 

As we traveled north, we noticed beautiful landscape and increasing differences in the infrastructure, housing, and development of the homes and stores. What would be described as “hut” became increasingly more common and stores fronts and electricity were less prolific compared to Kampala.

Near Arua on the way to Murchison entrance

Near Arua on the way to Murchison entrance

Clearly, we saw lower socioeconomic status. People waved and smiled often as we drove by and kids, like everywhere else, were fascinated with our presence. En route we stopped for a picture of Karuma falls the point where the Lord’s Resistance Army advanced to at its farthest attack from the north.

Karuma Falls

Karuma Falls

 

 

Murchison Falls National Park is Uganda’s largest protected area. Much of the game suffered poaching during the Idi Amin regime. Numbers have been gradually increasing since then.

 

We entered the park and took in the sweeping, classic picturesque Rift Valley savannah. For me, having accumulated a mental picture of Africa with experience and lore, some level of inculturated mystique that can be erroneous or romantic, the land, I could not help but feel one of those surreal moments the savannah can impart on a foreigner.

Park entrance

Park entrance

 

Brendan hilariously broke my pensive gaze when he said, “It looks a little bit like South Dakota.” True – South Dakota with giraffes.

 

 

 

You are probably not surprised to hear we found ourselves stuck in the mud at one point having to get out and push as a group to dislodge the vehicle. All part of the fun. We continued, seeing various animals such as Ugandan kob, impala, water buffalo, and warthogs. When we arrived at the Nile River, we were greeted by guards and extremely gregarious baboons.

Baboon - up close and personal

Baboon - up close and personal

And by gregarious, I mean one of them hopped into the front of a car next to us in the driver’s side, another one wrested food from a young British woman, and all the baboons present posed for us in a pathetic puppy-like way.

Seriously, I'll take your leftovers

Seriously, I'll take your leftovers.

 

 

The ferry to bring across the matatu arrived, which Bunjero and his vehicle took, while the rest of us hopped into a boat toward Murchison Falls. 

Ready, set, photograph a hippo!

Ready, set, photograph a hippo!

 The casual trip up the Nile showcased elephants,

This isn't the Mississippi River

This isn't the Mississippi River.

water buffalo, many species of birds, a hippopotamus splendor,

hippo and water buffalo

Two for one: hippo and water buffalo

crocodiles, and waterbuck.  Eddies and foam increased as we neared the Falls and then we saw the Falls from a distance,

From a distance...

From a distance...

and got out of the boat on a small set of rocks so that we could get our pictures taken with it in the background. Moms love those pictures!

 

 

 

We made our way back to the other side of the river to meet Bunjero. Menacing clouds appeared in the distance and our next decision was whether or not to go to the top of the falls. We did, just as it started raining. It was worth it, too. I have been fortunate enough to see many falls, but the power and landscape of this waterfall was simply breathtaking upon close view.  The sun had almost completely set by the time we arrived at the lovely solar-powered and extremely comfortable lodge Jeremy and his wife Tracey had scouted out beforehand. After a nice dinner, the rest retired while Jesper (Swedish medical student), Brendan (Yale resident), and Dr. Mo and his wife (name alluding me) discussed politics, international affairs, and economics. With so many perspectives, we had a rich, energizing discussion despite our fatigue. We had to cut it off at 10PM or so since we were again leaving

Jesper and Sheena braving the mist

Jesper and Sheena braving the mist

early to do a proper safari.

 

 

After breakfast at 5:30AM, we hit the road again back to the Nile ferry.

Our happy crew at 7AM river crossing

Our happy crew at 7AM river crossing

After our crossing and more interactions with the baboons, we picked up a guide and continued onward seeing a lion, giraffes, elephants, and many other animals and birds.

Lion

Lion

As we were tracking some giraffes we became stuck at one point in a serious way.

What are you doing here?

What are you doing here?

 Two vehicles stopped to help us. Some ingenuity with a jack helped us get out of the mess.

Jeremy pushing the matatu with all his might

Jeremy pushing the matatu with all his might

Being mesmerized with giraffes, I started off towards them. Giraffes on one side, Lake Albert in front of me with the green and dark blue mountains of Congo right there on the opposite shore.

Mountains in Congo in background

Mountains in Congo in background

Idyllic in some way, except for when the mud is flying, the ropes are breaking, and the matatu stays lodged in the deep rut!

 

 

 

We found a Land Rover stuck at one point and came out of the matatu to help as we continued. I went to use nature’s bathroom and noticed a pungent stench. I looked left and saw a completely stripped carcass (except for a completely intact head) of an impala. The vertebrae were completely exposed and the horns remained on the animal.

Speaks for itself

Speaks for itself

Meanwhile, the guide from the Land Rover shouted, you need to leave! There are lions nearby. (Oh, hence the carcass and vultures.) Well, I had to wait a moment, but Bunjero didn’t and he grabbed the carcass and dragged it to the road for all to see.

 

 

 

You’ll have that. We continued towards the exit, but not before we watched a rain storm sweep across the savannah, including a mass running of water buffalo. We enjoyed seeing the curtains of rain in the distance and so clearly.

"I bless the rains down in Africa." 

This 3-day trip provided a great way to see Uganda’s physical beauty. But perhaps just as important, the people in our group made wonderful travel company. Provocative, fun and thoughtful conversations filled our downtime or travel time. I am thankful for the new friendships that came out of it. I think this has been one of the hidden treasures of my time abroad so far – new friendships, new stories, new backgrounds, and new differences and commonalities to discuss. New energy. The trip continued after Murchison with a different tone, perhaps a reticent one of sorts. Next stop: Gulu, gateway to the refugee camps of northern Uganda…

Uganda-CWRU Research Collaboration 20th Anniversary Celebration

October 2, 2008

Yesterday I had a fortunate opportunity to get a broader sense of the important history and work occurring at my research site, a once in a decade opportunity in fact.  On Monday and Tuesday, scientific meetings were held at the Hotel Africana in celebration of the 20 years Case Western Reserve University has been in partnership with Makerere University/Mulago hospital. I was able to attend yesterday’s events.

 

Everyone affiliated with the collaboration was invited to yesterday’s events – literally everyone – including janitorial staff for the Case/Mulago offices. I think in a way I had unknowingly taken for granted this collaboration until I learned its uniqueness according to those who presented, last of which was the Vice President of Uganda. For example, you’ll see Dr. Christine Sizemore’s (chief of the Tuberculosis and other Mycobacterial Diseases Section in the NIAID Division of Microbiology and Infectious Diseases) name in my “NIH training” posts since she gave a tuberculosis lecture in Bethesda in July. I had the chance to meet her again yesterday after her presentation about the collaboration from an NIH perspective. She told me afterwards as we were walking that the Uganda-CWRU TBRU (Tuberculosis Research Unit) collaboration is one of the most unique in Africa for the NIH. She said the Ugandan leadership in general has been a gold standard. Whereas at many other NIH-funded research sites internationally the US researchers lead the majority of the research work, Uganda is a shining distinction in that the Ugandan researchers are exceptionally trained (they receive training here and in the US) and lead the majority of the research in the collaboration.

 

I had not realized this. I just assumed what was happening here, the type of partnership, hierarchies, and delineations of US/Ugandan divisions of responsibility, was the same elsewhere. Apparently, that is not the case. Dr. William MacKenzie from the US Centers for Disease Control (CDC) further emphasized the uniqueness and success of the Uganda TBRU. It is one of only 4 international sites funded by the CDC for the TBTC (Tb Trials Consortium) and one of 2 in Africa period. One of the US researchers presenting called it the “most efficient Tb research site internationally” with 90% of patients enrolled in one particular study being enrolled correctly to protocol and with Ugandan research participants accounting for 47% of the study patients from this multi-site international trial. That particular speaker summarized the Ugandan collaboration this way, “Good science, good clinical care.”

 

We heard presentations from a number of Ugandan professors and researchers as well as researchers from the USA.

Dr. Alphonse Okwera presenting

Dr. Alphonse Okwera presenting

 The speakers were not just from the biological sciences either. We had 3 presenters talk about the twenty years of social and behavioral studies in light of the collaboration’s funding of social science work surrounding HIV issues. One of the US researchers present at the formation of the collaboration, for example, researched Ugandan attitudes towards vaccinations in preparation for an AIDS vaccine trial. Combining social impacts and assessments of research is important to the collaboration.

 

 

 

 

The intersections of cancer, HIV, and Tb were discussed much yesterday. As HIV becomes more chronically managed here, issues of HIV-related malignancies become more and more relevant. Discussions of research mapping the intersections between infectious disease and oncology highlighted new directions in research. Implementation research is still needed for delivering quality HIV and Tb treatment to all, but the future will be in chronic disease research, as it currently is in the USA right now.

 

A number of well known researchers were present or referenced throughout the day. One of the speakers scheduled Dr. Peter Mugyeni, stood on the President Bush’s left when the PEPfAR bill was signed originally. One speaker referred to Dr. Sten Vermund, one of the directors of the program that brings my colleagues and me to our respective Fogarty sites around the world this year. The last speaker of the day was the Vice-President of Uganda, Dr. Gilbert Bukenya who was surrounded by security detail and all.

Uganda vice-president Bukenya

Uganda vice-president Bukenya

He emphasized the importance of the collaboration in light of its history which he was a part of from the outset. (The VP was a former dean and professor at Makerere University School of Medicine.) There was a lot of to-be-expected “patting oneself on the back” in the celebration, and as the day went on, it was clearly appropriate, to say the least, given the challenges, risks, and extremely hard work of the Ugandans and Americans over the past 2 decades. When the collaboration started back in the late 1980s Uganda was not in an ideal state politically or in terms of infrastructure – the collaboration was a risk, but one that has ultimately benefited study participants/patients, health care capacity building and research training for Ugandans, and the furthering of scientific knowledge, especially in Tb and HIV.

Ndere troupe performing in between speeches

Ndere troupe performing in between speeches

 

I have to say that the glue that holds the collaboration’s success together, from what I could tell from people’s comments and my short time here, is the Fogarty AITRP (AIDS International Training and Research Program) and state of the art laboratory facilities available through the NIH funding. To date this program has allowed 53 Ugandans to train at CWRU for masters and doctoral level programs in immunology, anthropology, epidemiology, microbiology, and virology. Fifty of the 53 have returned to Uganda. The relationship between the high caliber of research and those leading it, most who were part of the AITRIP training, could not have been clearer. My mentor, Dr. Chris Whalen, has been an instrumental and crucial part of that program. Today I learned that the risks have paid off thus far in the dividends of capacity building and quality research. This collaboration has “trained the trainer” and because of it, its productivity and sustainability (provided international funding continues) is strong. One of the Ugandan researchers call for more AITRP funding received resounding affirmations from the audience. The collaboration has resulted in AITRP trained individuals co-authoring over 389 peer-reviewed journal articles, 115 of which had AITRP trained Ugandans as first authors. There is always a tug of war actually and conceptually between clinical emphasis and research emphasis when working in resource-constrained settings. Yet, the research here has translated into better patient care at the very least.

 

What does this all mean? Well to me, capacity-building means more Ugandans caring for Ugandans with the state-of-the art arsenal of knowledge to do so in a resource-constrained environment. It means local approaches to research design and implementation and more of a truer sense of “collaboration.” And it turns challenges parental arguments from high-income countries that low-income countries cannot undertake such endeavors. Additional implementation methods of transparency and accountability further solidify this project’s success.

 

Uganda’s advancement during the past 20 years was noted in the same way. Twenty years ago the discussions were about “no care which to access” to present discussions of securing “access to care” for all Ugandans. I think the most important of the public recognition made on several occasions thanking the patients/participants. At the end of the day, for all the successes and markers of success, the event was patient-centered.