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.

Thanksgiving Thrice

I had more formal opportunities to give thanks in Uganda than at any time previously thus far in my life. On Thanksgiving Eve, the USAID Mission Director for Uganda very graciously had a group of us over for a quite proper American Thanksgiving meal with thanks to our friend Mitra for help organizing.

Pumpkin pie, turkey, mashed potatoes, cheese galore, we ate a fantastic dinner that left me in a tryptophan coma by the end of the evening (tryptophan comas are apparently urban legends now according to evidence-based medicine, I’ve heard). My friend Jesper (Swedish – you know, those healthy, in-shape Europeans with the highest life expectancies) experienced American gluttony in its completely culturally-sanctioned form for the first time.

One of the guys at dinner, Andrew, started the following organization up near Gulu (see previous post on Gulu): http://freedomincreation.org/. Some of us finished the evening watching a video about his organization which deals with art therapy for child victims of the Lord’s Resistance Army conflict.

Thanksgiving #1 group photo:

Thanksgiving Eve post-prandial picture

I slept well on a full stomach nervous about Thanksgiving #2. On Thanksgiving Day, Sarah, Julie, and I headed to La Fontaine for another Thanksgiving feast at the place where we watched the election in November. Again, amazing fare – turkey, green bean casserole, pumpkin pie, stuffing, even cranberry sauce – filled our stomachs. I was starting to feel really, really full now by Thursday night.

But wait! Third time’s a charm. Saturday night, my coworker Dennis had his annual Thanksgiving event at his house. The stuffing and cornbread were particularly amazing. Julie, Sarah, and I had a great time mingling there, including with a woman who heads an organization supporting pediatric oncology patient families. (More on that in a later post.)

I never thought giving thanks so much could hurt one’s stomach. Now I know. But as far away from “home” as I was, home is where the stomach is just as much as it is where the heart is. I now know that Thanksgiving is quite reproducible even in far away lands. Feeling drowsy on a couch in a glucose-induced stupor with friends nearby is all it takes to make you smile and remember home (and be thankful that you don’t have to eat like that again for another year).

Rotaract at Ssese Islands

One of the first weekends of November, our friend Chris (a Rotary Ambassador scholar – see: Chris Deal’s blog link) invited some of us to come along on a Rotaract service trip. Rotaract, as described to me, is for younger Rotary members. Most of the Ugandan Rotoract members we met were in their upper 20s/young 30s. We took a lively bus ride with about 60 Ugandan members and 5 expats from Kampala down to a port near Entebbe to hop onto a ferry bound for the Ssese Islands.

The Ssese Islands are a group of 80-some odd islands in Lake Victoria. They are thought to have separated from the mainland 12,000 years ago. The largest island, Buggala, is also the most developed. The islands have a rich cultural and religious history and belonged to the Buganda kingdom.

We arrived on Buggala and walked to our lodging. We spent the first night getting to know each other and then dancing. Although I tried to go to bed around midnight or so, the music played all the way until breakfast at deafening volumes! Our leader came by with drums at 6AM to wake us all up for a morning run before a day of service work.

A group of us ran a hilly course before breakfast, all of us having had no/little sleep due to the music. The run served as a great way to see some more of the island and the vistas grew increasingly beautiful and wide as we ascended the island.

After breakfast, we hopped on rudimentary, large fishing boats for our journey to Serinya island, an island lacking electricity and plumbing. We met some community leaders and started the manual labor. We carried large stones in our hands, wheelbarrows, or in human chains to lay the floor for a school clinic being sponsored with Rotary Club funding from various Kampala chapters.

We then collected barrels/buckets of sand and cement after moving the stones. I tried balancing the barrels on my head (successfully) given that mode of carriage’s popularity in many African regions. Did we felt the heat as we transported these building materials! I can say we definitely had a fun time, though. I felt a tiny bit of what some manual laborers here may feel after a day of such work in the hot sun which is far removed from my usual daily activities.

We also saw the in-progress construction of a biolatrine being sponsored by the Rotary Club consortium. The premise being that human sewage collects in a tank and the methane gas will be used a source for cooking. Which brings me to lunch…

We had a fantastic lunch made by local women in HUGE iron/steel vats. I wish I had a picture of these vats! The fish and meat were excellent and the whole lot of us fed the hunger work created in us. The local people were extremely hospitable, and we even took some time to play soccer in a round with some local kids before leaving.

Before dark that night and after we boated back to Buggala, a local Ssese Island Peace Corps volunteer took us a tour of the Speke Fort in the jungle of the island. Not in either major guide book of Uganda, this fort came with colonialism on the island when John Speke came here in the mid/late-1800s. We reached the stone buildings after a short, nice jungle hike rife with monkeys. The site had been mostly swallowed up by the jungle, clearly rarely visited, as trees growing inside of the outposts and vines and moss covering the stones suggested. Our Peace Corps friend hadn’t visited it since three years ago when she started Peace Corps here.

Thoroughly exhausted, somewhat dehydrated and sun-exhausted, it made sense after dinner to dance again and stay up late. (Insert a tinge of sarcasm.) A few of us took a short night hike to see the stars in their magnificence sans the plaque of city lighting. I tried to go to bed early again, but the music kept me up all night again, but this time we awoke to find out only one person had stayed up that late! And he assumed the role of DJ, unfortunately for me.

Only 5 of us 60-some people went for the morning run after the drum call at 6AM, an event akin to a fraternity hazing event I decided. I ran in the jungle along the coast instead of the ascending run from the day before with the others and took in the sights and sounds on a quiet, cloudy Sunday morning on the island.

Arriving back in Kampala after a nice ferry ride bacy to Entebbe, I slept WELL that night! The service trip afforded a lot of great experiences and Rotary and Rotaract clubs do excellent and needed structural improvement work here. Sacrificing sleep every once in a while can be accompanied with rich, unforgettable experiences.

“Obama don’t leave us” and the Kampala Marathon

You may be wondering how these two topics in the title are related. You will know by the end of this post. I will start with the Kampala 1/2 marathon which I ran with my friends Jesper and Chris. We trained for a few weeks (literally 2-1/2 for Jesper and me) and then ran on Sunday, November 23 with thousands of other people divided among a 10K, 1/2 marathon, and full marathon (http://mtnkampalamarathon.com/).

Talk about hilly! Although one can only train on the hills, 13.1 miles of a hilly course at 1000m certainly challenges a flatlander’s body. There were few expats running it overall, we thought. I mean, c’mon, I was the 3rd American to finish the 1/2 marathon – that is not because I am fast! Many runners wore tattered shoes and untypical running clothes.  At the end there was a huge after party with sponsored tents all around. Ugandans won the top awards in all categories, especially exciting for them because of the famed success of the Kenyan runners. I had fun running the race and enjoyed the challenge and seeing different parts of Kampala, some new to me.

Now the link to Obama. As Ugandans cheered people the runners, I constantly had “Obama, yea!” yelled at me while I was running. Actually, it was astounding. I would smile back or high five the people, more just to be engaging. There was something celebrity-esque to it. Americans abroad in most places are undoubtedly experiencing celebrity status as the world celebrates Obama’s election — there were only 5 countries officially supporting McCain. Yet, there are many dimensions to this election.

I stopped counting after literally 2 dozen times people cheered me on with something related to president-elect Obama. There was a key moment, though. At one point, I passed 2 Ugandans running and they said to me, Obama don’t leave us.

Obama don’t leave us, indeed. This line summarizes something in the air here. Since I arrived in August, Obama has been on the lips of everyone. No, I mean that literally. On the bus to Kigali, Rwanda someone was reading The Audacity of Hope in front of me. On the street DAILY pre-election, Obama’s name would appear in conversation. Many cars here have bumper stickers like “Obama/Biden ’08”. People wore Obama t-shirts. My co-workers would talk about it with me almost daily. One of my neighbors had a “Ugandans for Obama” bumper sticker. Boda boda drivers still say OBAMA! as a greeting to me on the street. Catholic, Muslim, Pentecostal – Obama! everywhere. While some people were using the word “elitist” to make Obama look unaccessible or different to Americans in the US, some of the most nonelite people in the world cheered him on from here.

I would speak with drivers, people on the street, and others who would have an analysis of the US election beyond some Americans I knew, including myself at times. One of the drivers at the project for example – I don’t think he has secondary level education – stayed up all night for all the debates and offered analysis of all the candidates that often left me amazed because of its comprehensiveness and thoughtfulness, all coming from a non-American.  Did I know that much about Ugandan politics?

At dinner one night, my Dutch roommates and I went out with some Ugandan adult friends. We talked American politics and Obama most of the time – definitely not by my choice. Even when I tried to veer the conversation away from Obama, it always came back to Obama and Bush and passionately so. (My European friends often had to deal with Obama conversations that started when someone saw me as an American. They graciously allowed them to continue, even when I knew it wasn’t as important to them as we later discussed.) More than Obama, the broader vision of America the Ugandans I have spoken with has opened my eyes to some new foreign interpretations and ideals of what America stands for to them.

Celebrity status indeed. But as with many things there is a Janus-face to such popularity.

The reasons Obama is so liked here are plentiful. He has a lineage relationship with Luo tribespeople who are present in Kenya and Uganda, for example. He is part African and a leader and example by extension to many in the African diaspora of countries around the world, a diaspora with a horrific history and endless struggle globally. He offered a new type of international relations method, not original, but unseen for many years by the world. He has the potential to challenge African leaders in a way a non-African may not be able to do, and there is hope (where there is not pessimism) that many African leaders are feeling precarious at the very least. Obama, many here believe, will not pat “democratic” or otherwise undemocratic dictators on the back like predecessors have. But what else?

The local papers wrote ad nauseum about what an Obama presidency may or may not mean for Ugandans. I will summarize the obsession in three points from what I can surmise, though there are more: (1) his obvious roots in East Africa; (2) the potential challenge he’ll be to East African dictator democracies; (3) and unfortunately because of how they experience politics, some people think America is going to throw all sorts of “goodies” to this region now. Open the Treasury floodgates.

Let me unpack (3) a bit. I have spoke with Ugandans and expats alike about this one. Because of his relationship with the region, some people think/thought Obama will/would provide Deliverance…in the form of aid and direct structural improvements. Some people wrote about it in the papers, while others warned against such a belief.

The economic crisis in the USA does not seem (as far as I can tell) to translate here in Uganda, so its obvious priority to Americans is not really appreciated. While Uganda is rising economically (and with increasing wealth disparities at the same time), many people here are always in some way in an economic crisis like every other country in this region, crisis meaning inadequate employment and weak political/social/economic/legal/health rights and nonexistent safety nets. So in one way they understand the economic crisis more than most Americans ever will. But at the same time an economic crisis is not conceivable or accessible here when American media exports show and inculcate a far more glamorous depiction of America. I am occasionally telling people that all of the US is not California or NYC wealth.

In a country where politics is intertwined with corruption and corruption translates into “goodies” for friends of a corrupt politician, I offer one lens of many at play that makes the expectation for “goodies” understandable. Some regional authors discussed this in op-ed pieces. Kenyans were happy for many reasons, but in some regions some people were especially happy because of the expectation for goodies. Obama’s constituents, to some here, are the world’s left behind. Talk about a populist spin on corruption! Simply put.

Hopefully, Obama will show the world that the corruption-handouts/goodies relationship is not the status quo; he is not Robinhood. Relatedly, Illinois Governor Blagoyevich’s resignation would be another beacon of democracy, one to inspire hope that the world is what we make it and that corruption is not always hopeless or tolerated.

Obama don’t leave us. Whether or not they should say it, that line is palpable in the air: among Americans losing jobs and watching benefits drop in the media I read from here, among those in neglected conflict areas of the world, among the disenfranchised in Uganda. Such immense pressure on our country and one person makes me nervous, despite my personal sense of immense hopefulness and change this election can bring. My precariousness aside, my time here at this point in time has humbled me given my affiliation as an American. And while trite, I continue to realize all those great things most of us realize we take for granted at some point as Americans. Yet, I know we can be ever more the beacon. It continues abroad, but it will need to be restarted at home. Ahem, health care reform for example. But I digress!

So in summary to a potentially much longer post, it’ll be interesting to watch the new dawn of international relations…. and expectations.

Picture from Chris Deal at our expat all night election viewing party: http://2.bp.blogspot.com/_z5E_4idIFXI/SRxYUFjDQ8I/AAAAAAAACZE/qkWH6LTOYAA/s1600-h/11-10-08+251.jpg. (The concession/acceptance speeches occurred slightly before 8AM local time.)

“The Big Get Down” and other tales of rafting the Nile (aka THE SOURCE)

I am terribly behind on my posts, so I am trying to catch up. This post refers to a trip taken to Jinja, Uganda (the “Source of the Nile”) in mid-October.

The night before a group of us (mostly Yale residents and medical students) went to Jinja, we visited a popular Irish pub here, Bubbles. The crowd was quite interesting, diverse, and as the night went on, we joked from the terrace part of the bar where we settled that the inside was becoming “the room of bad decisions” as we guessed who in the indoors crowd would make bad decisions. The funnier part of the dialogue occurred when one of our friends decided she and others going to the bar to get another drink would carve through as “the wave of innocence” in the “room of bad decisions.”

The next morning we departed for Jinja by matatu. We arrived and walked through the town a bit. The main street’s architecture felt reminiscent of parts of New Orleans and Latin America.

One side of Main Street, Jinja

We enjoyed a leisurely stroll before getting to The Source Cafe, the namesake of esoteric jokes my friend Rachelle and me would commence shortly thereafter. The Source was the source — of wonderful coffee, the elixir of energy and the life force (or source).

Michiel getting some coffee beans at The Source Cafe

 

The Source of coffee and friends

We headed to a resort-type place for the afternoon and after checking in we took a boat ride to the Source of the Nile.

Kingfisher Resort Jinja

 

Roof of vines at Kingfisher

Well, the Source is quite arbitrary so we saw many hypothetical sources.

The touristy Source that's not the Source

 The ride was nice though, and we enjoyed watching the fishermen. 

Idle boat on Lake Victoria

In fact at night, Lake Victoria at the mouth of the Nile was awash with lights from men fishing at night. I didn’t capture it well on digital, but it reminded me of pictures I have seen of lakes and rivers in China lit up at night by hundreds of laterns.

Hundreds of fishermen on Lake Victoria at night

In the morning we checked out and a group of us set off for rafting on the Nile.

Team Tutu pre-rafting

And wow. In all of the amateur rafting I’ve done around the world, this experience was by far the most exhilarating and perhaps unpredictable. We had one particular flip on a rapid where my helmet somehow got caught in the rope after the flip thus preventing my ascent to the top of the river. I simultaneously freaked out and then remained calm as I started to gulp water. I finally unfastened my helmet after a struggle and surfaced after going through a bit more of the rapid, coughing up the Source water engulfing me. I saw the others downstream now reunited with the raft and a safety kayaker collected me. The fall there was called “The Big Get Down” but I am certain it should be renamed to “The Great Fall Out.”

Rafting the Nile 1

 

Rafting the Nile 2

Yikes

Yes please

Needless to say, I approached each subsequent rapid with a little bit of anxiety! We had ample time to float and wade in the immensity of the Nile along the way, and sun we did absorb. We even saw some river otters, which we were told is a rather rare sighting for rafters. There are class VI rapids on this stretch of the Nile, but we didn’t run beyond class V. I was fine with that.

We finished with Nile Special beers and soda from the rafting company at the end of a full day of rafting. The motto of Nile Special as depicted on the bottle is: “True Reward from the Source”. But why have beer brewed from the Nile River water when you can just swallow it yourself during a day of rafting? Nonetheless, the reward mellowed out a day of fun, sun, and exhilaration.

Tuberculosis medication shortage

As I continue to learn more details, I am realizing that I should have written this post a while ago and have to no reason to delay it further. For the past few weeks, there has been a shortage of anti-tuberculosis medications in Uganda. As I learn more stories, I am getting a better sense of the impact of this shortage. Of note, the shortage is not making headlines, for which reasons I have no clue, though \”corruption,\” the common response to most problems, is being uttered on the lips of health professionals.

Right now, patients who come to the National Tuberculosis & Leprosy Programme (hospital ward across from my office) with tuberculosis have to pay 80,000 Ugandan shillings (~$41 USD) to a private pharmacy to receive a month\’s worth of treatment including isoniazid, rifampin, and pyrazinamide – 3 of the 4 necessary medications in a tuberculosis treatment cocktail. That is, if even the private pharmacies have it. The NTLP only has ethambutol, the fourth medication, in stock. In order to receive it, the pharmacist needs to see the purchase of a month\’s supply of the other three drugs before he gives out ethambutol to a patient to complete the tetrad.

Previously, the patients would receive all drugs at no charge through the international funding of the NTLP. Now, the poorest people (the ones who experience active Tb more often) cannot afford or obtain the medication given that it is likely much more than their monthly salary.

There are the obvious risks of death, especially in HIV+ co-infected persons, increased transmission to others, and people who in some way will get incomplete treatment regimens. This in turn, may lead to increasing drug-resistant strains of Tb, the last thing needed to be exacerbated here.

Forebodingly, Nicholas Kristoff in a recent NY Times article (07 December 2008) talks about the global concern needed and the action we must take with the continued growth of multi-drug (MDR) and extrememly-drug resistant forms (XDR) of Tb: http://www.nytimes.com/2008/12/07/opinion/07kristof.html. He relays this grossly underreported health issue that continues to accelerate, an issue global powers need to address with the fervor HIV/AIDS has received.

One of the doctors working in the NTLP told me patients have cried when they realize they cannot receive their medications. This doctor also told me that even 80,000 USh would be costly for him, to put price in context. At $41 per month for 8 months of treatment, it is easily seen how families making less than $300 USD/year equivalent would have a hard time paying for such medication for one person.

If that were not enough, a similar shortage is occurring with anti-malarial drugs right now. This is especially problematic because we remain in the rainy season when malaria infection is higher. Here is the latest I have found on this topic: http://www.monitor.co.ug/artman/publish/regional-special/Govt_hospitals_running_short_of_malaria_drugs_75510.shtml. I need to speak with a few more doctors on the current situation since I do not interact with malaria studies or clinics much. And recently, there was a shortage of anti-retrovial medication for HIV, though I have heard by word-of-mouth that this one has been improving.

You will note in the conclusion of the malaria news article that Global Fund money has not been forthcoming. I do not know the exact reason why but I have heard it has to do with the mismanagement of funds previously. Perhaps this article lends credence to this possibility: http://www.monitor.co.ug/artman/publish/news/We_are_using_Global_Fund_money_better-_PS_65626.shtml. Are funds being used better since three years ago? I am not sure, but for some reason, the needed dispersements have not been provided.

Research project participants in our collaboration continue to receive anti-Tb medications. Those that receive referrals to the NTLP through a research project are part of contigency plans to the best of my knowledge, including the study on which I spend the bulk of my time where patients were previously simply referred to the NTLP.

I am going to try and spend time in the NTLP on Friday and next week to gather individual stories and learn how doctors convey shortages to patients. It will make for a sobering prelude to Christmas, but for many here, it will be an even more difficult and possibly life-threatening Christmas for them.

It is particularly frustrating because Uganda, at least in this region is modern, growing, promising. (Some Ugandans would agree or disagree with this.) Maybe this could be \”expected\” (though unjustly so) in a less developed country, but because Uganda appears at face value to be one of the more modern African regions, I believe events such as  these should be all the less tolerable. I will amend this post as I receive updates and change the data/time of the post to make it appear \”new.\” Stay tuned…

Portrait of a team

Every morning at 8:15AM I meet the health home visitor team to crosscheck data collected from the previous day and to listen to how things are going in the field, among other tasks as needed. We meet at the “Brown House,” a place just outside Mulago hospital where research participants with tuberculosis come for care in various MU-CWRU research collaboration studies:

Part of the CF team: (L-R: Micheal Angel, Hassard, Esther, Kezron, Sheila, Joan)

Kezron and Sheila work on another study; the “CF” (the study on which I work) and “Alcohol” study teams meet every morning in the same room. Joseline, Joyce, and Godfrey, other CF HHVs, were not in the room when I took the picture. Micheal Angel is our data manager, and he crosschecks my crosscheck.

After I finish there, I head up a hill to the MU-CWRU office. This is where I spend a bit of time currently. (It is the Medical Officers’ office.) The doctors below are principal investigators or co-PIs on studies here. If I am not in here then, I am either shadowing physicians or in the field, though I will not be doing the latter now until I have ethics board approvals of the study I described in the pilot study blog post previously.

 MO’s office:

Medical Officers (L-R: Dr. Grace Muzanye and Dr. Phineas Gitta)

Beyond Juba and transitional justice

On October 30, I attended two events of the Peace Film Festival put on by the Transitional Justice Project at the Faculty of Law at Makerere University and other collaborators. The program flyer can be found at this link: http://www.beyondjuba.org/other_documents/filmfestival.pdf.

You may be thinking, “what is transitional justice?” So was I. Here is a working definition from International Center for Transitional Justice (http://www.ictj.org/en/tj/):

“Transitional justice is a response to systematic or widespread violations of human rights. It seeks recognition for the victims and to promote possibilities for peace, reconciliation and democracy. Transitional justice is not a special form of justice but justice adapted to societies transforming themselves after a period of pervasive human rights abuse. In some cases, these transformations happen suddenly; in others, they may take place over many decades.”

Here is a bit about the project (http://www.beyondjuba.org/project_info.php):

“The project builds on the participating organisations’ work on peace and conflict related issues in Uganda, and in particular reflects the outcome of a three day stakeholders dialogue under the same title which was hosted in Kampala by the three collaborating partners in December 2006.

Uganda’s post colonial history has been characterised by division and conflict.  One of the most violent and protracted of the conflicts is the 21 year war in northern Uganda waged by the Lord’s Resistance Army/Movement (LRA/M).  The current peace talks between the Government of Uganda (GoU) and the LRA/M, which are mediated by the Government of Southern Sudan (GoSS), are welcomed as a solution to attain sustainable peace in Uganda.  However, there are reservations about how the peace consultations are proceeding, and some stakeholders feel that the discussions around accountability and reconciliation may not result in process that is sufficiently comprehensive in ensuring sustainable peace in northern Uganda or in the country as a whole. For reconciliation to be effective, the northern Uganda conflict must be placed within a wider national context.

In the past there have been attempts to establish transitional justice mechanisms for Uganda. They have not related to broader political dynamics like decentralisation or gender, however. Another challenge is that current reconciliation initiatives like the Peace Recovery and Development Plan (PRDP) view reconciliation in a localised fashion and therefore only allocate a small part of their budget to it. If the Juba Peace Talks offer hope for sustained peace and create opportunities for meaningful national reconciliation in Uganda, then considerable efforts to create a climate conducive to change should be made.

One such effort is the Beyond Juba Project, a three year project funded by SIDA and NORAD. The project constitutes of three pillars: (1) In-depth consultation and training with key stakeholders including different branches of government, (2) research on critical legal, and psychosocial issues for inclusion in the national reconciliation process and (3) a multi-layered public information campaign that reaches all sectors of society.”

I caught the end of a panel, but I was able to view the movie “Uganda Rising” which finished the day’s events on 30 October 2008. Despite all the stories I have heard here about the LRA, nothing to date has given me more historical context, narrative from victims, and political explanations than this video. Although I knew of horrific LRA crimes and briefly encountered a post-internally-displaced persons camp in Gulu (see Gulu post), the magnitude and brutality (and yet hope somehow) relayed through the interviews of survivors made me realize how much work remains in terms of educational, political, legal, health and infrastructure improvements, and mental health care needs for northern Ugandans. Everyone talks about the long road and improvments that have been made since the LRA left the region. The amount of work to be done remains large. I STRONGLY encourage you to view the video if you can get it. Visit: http://www.ugandarising.com/home.html. I will definitely buy a copy to bring home or get while at home and have a showing. I am thankful that my friend Sheena here, whose roommates, recent graduates of Yale College, helped organize this, alerted us to the festival. Groups such as Invisible Children, World Vision, Rotary International, Save the Children, and others (including one I will describe in my Thanksgiving Day post) need our continued support to do the important work up north.