Reflections on Uganda

Originally written June 11, 2008

Every time I leave the United States, I think I come back changed.  I find more of myself each time I go, each time I push the envelope, each time I take chance. Otherwise, I am restless and trapped, and it’s over. Otherwise, I become dead on the inside.

When I landed in Kampala, I felt happiness, but mostly I felt relief – to be in Africa again. It’s an odd thing to say – but it felt like I’d come home even though I’ve never lived here.  I arrived at Entebbe airport, into a well-lit, white-tiled, high-ceilinged terminal with bathrooms that put the Boston airport to shame.

However, Kampala itself is about as half as developed as Chennai (Madras) from 20 years ago. A city of two million people, Kampala has narrow roads, horrendous traffic, heavy air pollution, and a lot of dust. There are rarely any electricity cuts – I was told this has to do with the fact that Uganda provides electricity to the neighboring countries of the Great Lakes region. However, juxtaposed against that is the terrible state of the roads. It seems that no one has repaved them since the British left.  Outside of the city, it is even worse.

There are potholes everywhere, which causes stagnant water, which in turn causes malarial mosquitoes. Malaria is a real, debilitating concern in Uganda. One of my colleagues commented that one could live with HIV; however, malaria can sweep you right under your feet and can be immediately fatal.

The economy of Uganda is mostly agriculturally based. It is a fertile land, full of papayas, maize, watermelon and plantains, plantains, and plantains. I never knew there were so many ways to eat a plantain. You can have it as chips, sliced and sautéed, roasted, mashed (“matoke”) with meat sauce, and cook meat within the leaves itself.

One of our site visits included a rural HIV clinic in the northeast Kayunga district. Services included antenatal care, PMTCT (prevention of mother to child transmission), and HIV testing/counseling to community patients. The clinic had an operating theatre, but no doctor – not even a visiting one. The nearest hospital was not too far away but had only two doctors. An old, painted pick-up truck functioned as the ambulance. There were no resources for patient meals. The health workers did not have goggles. The midwives were warm, extraordinary, sharp, and they were doing the best they could with what they had. It was relatively clean; as in, there were no open drains or anything unhygienic to the eye.

The pharmacy was the size of my medicine cabinet at home and contained nevirapine and anti-retroviral therapy drugs. The nurses said they did not usually have shortages of medication despite the small quantities, except for one of the recent second-line drugs, due to the cost. Patients retain their own charts here.

The visit grounded everything for me. It was sobering and remarkable.

Medical site visits in Kampala included the PMTCT department at the Johns Hopkins/Makerere University collaboration at the main hospital in Kampala (Mulago). A recurring theme was the challenge of getting fathers or male partners involved in testing, counseling, etc. – this is not always because they don’t want to be involved, but they often feel isolated from maternal and pediatric care. The physician who was at the rural clinic told us that up until recently that all maternity wards in Uganda had a sign on it saying “All men keep out” (the rural clinic discussed earlier did). Another major issue was food insecurity. Food prices were escalating, making it harder for patients to purchase the nutrition necessary for adherence to HIV medications. Food aid for patients in most cases was unavailable or grants had run out.

We also visited Mama’s Club, a community-based organization founded by Dr. Lydia Mungherera. The organization is a support network for HIV positive mothers, a safe haven for them to come with their kids, socialize with and support each other, and also engage in crafts-making for economic support. We listened to the testimonials of the mothers – how many of them found themselves in situations of economic hardship and emotional despair, abandoned by partners and families, and how they had found Mamas’ Club.  One of the women noted that it helped to hear the other women’s problems, as it emboldened her to take on her own.  Some of the mothers had children who were HIV positive and suffered stigmatization by teachers and students at school. Some of those children were there.

Everywhere we went in Uganda on the site visits, it was PEPFAR, PEPFAR, PEPFAR providing the funding for HIV/AIDS treatment . . . and sometimes The Global Fund.  I believe this is the only good thing that the Bush administration did (full stop). There is no health insurance in Uganda. If you are wealthy you are required to pay. If you are poor, you do not pay. That’s it.  In Rwanda there is at least the “mutuelle” and the government is very serious about providing universal healthcare. (Just wait and see – my prediction is that Rwanda is going to move into middle-income status in the next 20 years).

Uganda is on the rich side of poor. In fact, it makes the medium category in the UNDP (United Nations Development Program) Human Development Index. If this is almost middle-income, we have to do better . . . so much better. The inequality is nowhere near as pronounced as it is in South Africa, but it is there. You see shacks and tin houses on the edge of the road, with tiny plots of maize and maybe a few plantain trees, and by contrast you see gorgeous orange-tiled houses on the hills. There is a robust Indian middle class of both those who have lived in Uganda for generations as well as recent transplants from India. In fact, all of the management at the hotel where I was staying was Indian.

Going to Uganda was the first time I’d really been back to a developing country context since I had lived in India.  I was two days in Kampala before I was running all over town, giving directions, shopping and meeting up with friends. Kampala is a city that I could move in. Unlike the paranoia and insecurity of Pretoria, Durban, and Johannesburg, Kampala is a relatively safe place. People are awake and moving at all hours and I felt comfortable having drinks late night at a bar with friends.

On a side note, I have touched the waters of Lake Victoria at the mouth of the Nile, where the river eddies and bubbles as it channels outward. Although my Rwandese colleagues assert that this is crazy, and the real source of the Nile is in Rwanda.

See here for additional photos.

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