African Massage

When the KIHEFO staff picked us up from the airport, they explained to us that the roads here have what they call an “African massage”, aka dirt roads with lots of bumps. We have been experiencing these roads throughout our time here, but especially the past few days during our outreach visits. For the past two days, several of the other interns and I have been surveying the residents of Rubira, a village within Kabale district, about nutrition for the benefit of our nutrition clinic. I have been struck by how humble these people are, and by how welcoming they were. Each one of them welcomed us into their homes with open arms, genuinely happy to see us and talk to us. At the end of each visit, they conveyed, through a translator, their thanks to us for what we were doing for them. I felt as if we should be the ones thanking them for taking the time out of their day to participate in our study, but our translator explained to us that the villagers are hopeful that the results of the surveys that KIHEFO does in the villages will be helpful to them in the future, which is why they are so glad to see us. Below are some pictures of the Health Centre II (see my previous post about healthcare in Uganda) in Rubira where KIHEFO will be holding an outreach camp next Friday!

the clinic's entire stock of medicine

Rubira Health Centre II

PS: I am leaving at 6AM tomorrow morning (11PM on Thursday in New York) for a three day safari with some of the other interns to celebrate my halfway point here in Kabale. I can’t believe it has already been two weeks—the time is flying by. The drive is 7 hours to Queen Elizabeth Park, so I am expecting lots of “African massage” along the way. Look out for pictures coming your way early next week!

The Blue Sweater

If you haven’t realized by now,  I read a lot, and I am currently reading The Blue Sweater: Bridging the Gap Between Rich and Poor in an Interconnected World, a fascinating read about microfinance and banking for the poor in the developing and the developed world, and I came across a quote at the beginning of a chapter that I think describes the mission of the organization I am working with here in Uganda extremely well:

Go to the people: 

live with them, 

learn from them 

love them 

start with what they know 

build with what they have. 

But of the best leaders, 

when the job is done, 

the task acccomplished, 

the people will say: 

“We have done it ourselves.”. –Lao Tzu

The Kigezi Healthcare Foundation, a really amazing organization, is run by Dr. Geoffrey Anguyo, a doctor here in Kabale who strives to fight ignorance, disease, and poverty, which are local problems, with local solutions. The organization is so deeply integrated in the community here, and all of the programs they have started aim to be sustainable within the community. Plus, the vast majority of the KIHEFO staff (99%) is Ugandan. This model is something that has allowed collaboration and trust throughout the community here to support the health of community members. Church leaders and traditional healers even refer serious cases of many illnesses to KIHEFO because of the trust and the respect that the groups hold for each other. Below are some pictures of the clinic.

HIV Clinic

General and Dental Clinic

Nutrition Clinic

KIHEFO ambulance

I have spent the past few days revising a nutrition survey with some of the other interns, and tomorrow and Thursday we will be taking day trips out into Rubira to complete surveys with residents of the village so we can collect some data for the KIHEFO nutrition clinic. It should be lots of fun!

Makanga Hill

I realized that while I have been here for a week already, I haven’t uploaded any pictures of the KIHEFO compound or clinic. The apartments we are staying in are located on Makanga Hill, one of the nicest places to live in Kabale. Other people living on the hill include professors, diplomats, expats, and similar types. It is beautiful for early morning runs, which my friend Adrien and I have done once, although the altitude makes running uphill more difficult here. At the top of the hill are the central offices for Kabale district (the court, administrative offices, etc) and some hotels, along with a golf course. The most well known hotel, the White Horse Inn, has been around since the early 1900s, when Uganda was a British colony. It claims to have free wi-fi, although the only time we tried to test that out it wasn’t working. It does have beautiful gardens and a nice view of the rest of Kabale town, however. Below are some pictures of the KIHEFO compound and me with some of the other KIHEFO interns at the White Horse Inn.

Our living room

My bedroom

The outdoor pavilion where we eat

a typical meal at the compound: chapatti, rice, beans,
avocado, mango, and pineapple

Amanda, Casie, Lauren, and me at the White Horse Inn

Too Many Muzungus

On one of my first days here, the other KIHEFO interns and I were walking back to the KIHEFO apartments when we saw a little boy staring at us. We waved at him, and he ran towards his mother shouting, “I have sean too many muzungus!”. Muzungu is the Swahili word for foreigner that has been adopted in all the local languages throughout Uganda, including the two local languages in Kabale: Rukiga and Runkanyole. By now I have gotten used to the fact that when walking through town or driving through villages, I will here children, and even adults, shouting “muzungu, muzungu!” when they see me. The children usually wave and smile, as they are excited to see new people; the adults in town who say it are often boda drivers (bodas, or boda bodas, are the motorcycle taxis that are a very common form of transportation here).

On Thursday, we went to a village nearby to take a tour of a fish farm and learn about sustainable agriculture here in Kabale. Of course, along the drive there, children who were walking home from school waved excitedly at our van shouting “muzungu!”. As I mentioned in a previous post, protein deficiency is the most common form of malnourishment in southwestern Uganda. KIHEFO has started a rabbit breeding project to promote an easy, affordable solution to this problem, and there is a local man who has spent the last seven years fish farming to promote a sustainable form of protein for the community. We visited him yesterday, and through one of KIHEFO’s translators Lillian, learned a lot about what this man does. He built all of his ponds by hand, and moves the fish from the breeding grounds to other ponds in small buckets by running up the mountain when it is time for them to leave the breeding grounds. He breeds tilapia, milacarp, and catfish. Below are some pictures.

On Friday, we went to Rubira Primary School. Rubira is a village within Kabale district. There we taught the P7 children (the equivalent of 7^th or 8^th grade in the US) about the benefits of using organic soil over traditional, sandy soil, and taught them how to make layered compost that would be useable soil within 30 days. We also got to learn some traditional dances and songs from the children. Below are some pictures.

Healthcare in Uganda

Yesterday we had a seminar about the healthcare system and public health in Uganda, so I thought I’d share some of it with all of you so you can learn a little bit about what it is like here. I apologize for the length of this post but I hope some of you will be interested enough to stick with it! I will break down the system; then I want to talk briefly about the many problems with Ugandan healthcare.

These are the different levels of healthcare facilities and capacities:

•  At the village level, there are Village Health Teams (VHTs): provide anti-malarials and pre-natal care (here it is called antenatal care).
• At the parish level, there are Health Centre IIs: they provide antenatal care and sometimes other types of care. These centers are supposed to be staffed by a nurse, but the nurses often do not show up, and the clinics often are unstocked.
• At the sub-county level, there are Health Centre IIIs: they provide some in-patient care, along with the ability to deliver babies.
• At the county level, there are Health Centre IVs: they have small operating theatres (operating rooms) for minor injuries and procedures, and are staffed by medical officers, the Ugandan equivalent of an American physician’s assistant.
• At the district level, there are hospitals: these are the only government funded health centers that are staffed by doctors, but even at hospitals absenteeism is a large problem. This problem is talked about more in depth below.
• At the national level, the highest level of Ugandan healthcare, is the Mulago Government Hospital in Kampala, the capital of Uganda. Even here, it is reported that around 60% of physicians do not report to work for shifts.

Medical Absenteeism

In Uganda, it is quite common for doctors to be placed at government hospitals, but to also have their own private clinics on the side. Private clinics in Uganda are much nicer than the government-run facilities, because they are usually better staffed. The people who go to private clinics are also more well off than those who go to the government facilities, and can afford to pay more for services (some of them have health insurance through their jobs). The government health facilities are supposed to provide free healthcare (as far as I understand), but there is a good deal of corruption both on the personal end and higher up in the system, which means that patients often have to pay fees they shouldn’t have to pay for a doctor to see them. Because the government hospitals are poorly funded and do not have nearly enough resources or staff, and because the doctors assigned to them make more money working at their private clinics, many simply do not show up for their shifts at the hospital. For the most part, there are no consequences for this, which means that the hospitals are left in the hands of doctors-in-training who cannot handle the number of patients or the types of problems they have. Nurses staff Health Centre IIs (mentioned above), as well as all of the other higher orders of government run facilities. However the government doesn’t always pay the nurses when they are supposed to be payed, so the nurses stop coming to work.

Traditional Healers

Traditional medicine, and especially traditional healers, are a very important part of Ugandan medicine. While it has become somewhat taboo to admit one goes to a healer, roughly 80% of Ugandans still do use healers. There are many reasons for this, one being that the ration of healers to people in a certain region is much higher than the ratio of doctors to residents of the region. Secondly, healers accept many more types of payment other than the form of money; for example, sometimes a family will give a daughter as a bride—many healers have multiple wives, as polygamy is still fairly widely practiced here. In addition, often healers are able to offer spiritual counseling to a client; many who seek out the help of a healer are searching for explanations: why so many relatives are dying or why a daughter is not married yet. I will go more into the culture of traditional medicine here in Uganda after we visit a healer at Lake Bunyonyi next week.

The Bread Basket Paradox

Malnutrition is a huge problem in Uganda. One in three deaths in children under five is caused by chronic malnutrition. I have seen some of this firsthand at the KIHEFO Nutrition and Rehabilitation Clinic, where severely malnourished children and a caretaker can come to stay while the child is treated. The work they do at the clinic is incredible, and they have over an 80% success rate (with children staying nourished after they leave), while most nutrition rehabilitation programs in Uganda have a 20% success rate. What is fascinating to me about the malnutrition in southwestern Uganda, is that this part of the country produces vast amounts of food because there are lush farm lands in the mountains. This area is called the bread basket, however it has the highest number of malnourished children in the country. This is referred to as the “bread basket paradox”. There are a few reasons this is true. First, there is a lack of education for parents about proper nutrition for their children. So while the children are actually getting enough food, they are not getting enough nutrients. There are a lot of sweet potato farms here, and often poorer families will feed the children only raw sweet potatoes, as the mother is responsible for farming, taking care of the children, and doing all of the other household work (this is still hard for me to fathom, as the average number of children per family here is around 6 or 8). The most common form of malnutrition here is protein malnutrition, which, in its extreme form is known as kwashiorkor.

Public Health and Development in Uganda

Uganda’s human development index (HDI), a measure that ranks countries using several variables including life expectancy, places it in the “low human development” category, coming it at 161 out of 187 countries. However, while Uganda clearly has some work to do, the country has been making great strides in recent years. It ranked highest in East Africa on progress towards the Millenium Development Goals (MDGS), which were goals set by the United Nations to be reached by 2015 to help eradicate extreme poverty. Of these eight goals, Uganda struggles most with maternal and child health targets, but has done well with primary education improvement.

One thing that is really neat is that here mental health is not a taboo topic. There are resources and medications readily available, which is rare in a country with such a different culture of medicine than the one in the US.

Some of the things that cause continued public health challenges in Uganda are lack of access to:

1.     clean drinking water

2.     agricultural support

3.     education & training

4.     alternative employment

5.     contraceptives & family planning

Social Determinants of Health in Uganda:

• systematic corruption
• low income level (30-40% of people living in poverty)
• gender (domestic responsibilities/gender violence)
• alcohol consumption
• poor nutrition

Thanks for sticking with it, I know it was a long post!

Mountains Beyond Mountains

The walk up the hill to the KIHEFO compound

The past few days have been beautiful. Kabale is located in the mountains of southwestern Uganda, about a mile above sea level. The town is very hilly, with larger houses and hotels located higher on the hills overlooking the town center. The KIHEFO compound is about halfway up Makanga Hill, one of the nicest parts of the city. Right above the compound is a golf course and a very nice hotel called the White Horse Inn—the oldest hotel in Kabale—which were both brought into existence when Uganda was a British colony.  I love looking into all the hills here; earlier this evening a lot of us went up to the Inn and got a drink and looked out at the hills. I already love it here in Kabale, and have seen and learned so many new things in the past few days. 

Another picture of the walk up the hill

African Time

We got tentative schedules on the first day, but we’ve slowly been learning that everything here works on a much slower pace than it does back home. For example, breakfast at 8:15 really means breakfast at 8:45. While at first this was hard to get used to, I’m starting to appreciate how nice it actually is. Everyone here is so relaxed, and no one seems to be in any hurry to get anything done. While this was frustrating when things weren’t working when we first got here, I’ve started to realize that there is rarely anything that needs to be done right away, and have started to enjoy just being here and taking everything in. (Side note: the internet here also seems to run on what the KIHEFO staff call “African time”, so my blog posts may be a bit sporadic).

Now that we have finally completed our orientation, we officially begin working at the clinics tomorrow, starting with grand rounds at 7:30AM (before breakfast). Then in the morning I will be working in the general clinic and the HIV/AIDS clinic, and in the afternoon will be going to the nutrition wing of a missionary hospital with one of KIHEFO’s social workers to see how the hospital is different from the KIHEFO clinic. However, every day has gone differently than planned so far, so we’ll see what happens!

Getting Here

After three long days of traveling, I  finally made it to Kabale, Uganda. I left Connecticut at 8:45am on Friday morning, and arrived in Kabale at around 4pm local time—9am in New York— on Sunday afternoon. The trip, while long and exhausting, was straight forward and uneventful. While I wish I could say I’d gotten to see the cities of Montréal and Amsterdam during my layovers there, people-watching in the airport was almost as good. It has always amazed me to see so many people who you may never again encounter, but who happened to be in the same airport, at the same time, going to the same place, for vastly different reasons.

The tarmac at KGL

This trip for me was different in that it was the first time that instead of feeling nothing but excited as I got closer to my destination, I felt more and more terrrified. So after some serious waves of self-doubt on my last 9 hour flight, I landed at Kigali International Airport (quick side note: here in Southwestern Uganda, “ki” sounds are pronounced as a hard “ch”, so Kigali is actualy pronounced Chigali).  As I was waiting in line at passport control,  I had my first direct encounter with the lack of resources in a developing country—the power went out. Everyone continued to go about their business—this is a normal occurrence here—and the generator soon kicked in, but it made me realize that energy is not consistently available even for necessary institutions or for those who can afford it.

View from the hostel in Kigale, Rwanda

Once I cleared customs,  I walked outside and was met by one of KIHEFO’s drivers, Enock, the CFHI program coordinator, Trina, Lillian, a social worker and tour guide for KIHEFO, and the two other participants who flew into Kigali: Marti and Marni. At this point any of the fear I had been feeling for the past several hours disappeared. The city looked beautiful, everyone was so welcoming, and I had completed the difficult part of the journey on my own. We went back to the hostel for the night, took some much needed showers, and went to sleep. I woke up completely awake at 5am, so I just listened to the birds chirping until the others got up. There was a beautiful view from the hostel.

We had breakfast at the hostel, which consisted of eggs, rolls with butter and jam, coffee, and delicious bananas grown right in Rwanda. After breakfast, we packed our things and went to the Kigali Genocide Memorial. It was surreal to think that 20 years ago, on April 6^th, 1994, the president’s plane was shot down flying into the very airport I had just flown into the night before. Yet while the story of the genocide is tragic, and the trip to the museum was emotional, but I am glad I got to learn about the country’s history in  the short time I was there. Below are some pictures of the museum.

After we left the memorial, we made a quick stop for lunch at a shopping mall, where I got some strawberry yoghurt made in Rwanda (pasturized, of course) and a bottle of water for 800 Rwandan francs, around $1.30. We then left for Kabale, which is only two hours away from Kigali. The drive was beautiful, with lots of mountains, farms, and cattle grazing. When we got to the border, we had to get out of the car and cross on foot.  After walking across “no-man’s land” we got our passports stamped at the Ugandan immigration office and officially entered the country, although it is worth noting that I was officially country-less for about 20 minutes. About 20 minutes after we crossed the border, we made it to Kabale. We settled into the apartments and have started getting

oriented here in Uganda.