South-West to Kabale

            Field Visit # 2

              During our second week of field visits, our team travelled to the far south district of Kabale, a destination approximately 20km from the boarder of Rwanda and about 70km to the border of the Democratic Republic of the Congo. Our first stop was the AMREF Kabale office where we were introduced to Nicodemus a Project Coordinator and Project Manager for AMREF and Nzaba, the District Health Educator of Kabale.

                The first item on the agenda for our team was to meet with the District Health Authorities and to share the objectives of our visit, the LVBIHI concept. We discussed that, although Kabale is not considered within the basin of Lake Victoria, it has been identified as a district with a disproportionately high burden of morbidity and mortality when compared to other district within Uganda. Again, we were interested in hearing about the strengths and challenges faced by the health centers in this district and the top priorities generated by these Health Authorities.

                Kabale is unique from the other districts due to the elevation of the land and the resulting climate. The average temperatures range from 20-24 degrees Celsius in the day and drop down to 14-18 degrees Celsius at night and can fall as low as 10 degrees during the rainy season. These are huge variations in comparison to other regions where the range is typically 28-32, with low's of 24 degreees Celsius. The relative humidity in Kabale in the morning is close to 100%- it feels like walking through a rain cloud, very low visibility and extremely damp.  As far as the eye can see, the hills are high and rolling between 2,000m and 2,500m above sea level. Homes tend to be very isolated from one another and from the conveniences and cares available in the town centre.  

 Lake Bunyongi, Kabale

View from the hilltops overlooking the village Nyarurambi

                During the meeting with the Health Authorities we heard about several of their accomplishments over the past few years; increased distribution of Insecticide Treated Net (ITN) to pregnant mothers and children five years old and under; increased childhood immunization, de-worming and routine vitamin A supplementation programs; and widespread implementation of a project initiated by AMREF titled “PHASE”, Personal Hygiene and Sanitation Education. Challenges in the area were largely related again to staffing (both the training and retention of); primary care and prevention of disease at the household level; and issues with maternal and neonatal health, which again of course, is one of the issues our team is most interested in learning about. 

                There are three key indicators considered internationally for determining the health of a nation: 1) Life expectancy; 2) Infant mortality rate; and 3) Maternal mortality rate. In any effect, each of these indicators is intricately linked to the others. Just for the sake of an example of these intertwined relationships, consider first how a mothers education level impacts her socioeconomic status (SES), her age of conception, birth spacing, her ability to judge health issues, her knowledge of the importance of antenatal care and her decision to deliver in the presence of a medically trained birth attendant. Her SES will impact her nutritional status and thus the healthy development of her fetus and will impact her body’s ability to endure pregnancy and delivery. The health of her infant will rely on the mothers’ access to resources such as post-natal care, childhood immunizations and the ability to provide safe feedings.

                 If we consider Uganda in a snapshot, the maternal mortality rate is about 600/100,000. The infant mortality rate currently stands at 88 deaths per 1,000 live births (which does NOT take into account the 18% of infants born still). This means that 1/11 infants die before their first birthday. Of those infants who survive the post-neonatal period, 69 out of 1,000 will die before reaching their fifth birthday- this implies that 1/7 babies born in Uganda will not reach their fifth birthday. These statistics make it is easier to grasp the life expectancy rate here in Uganda- 50 years for men and 52 years for women. Now consider life expectancy in Canada- 79 years for men and 84 years for women. The under-five mortality rate of 6/100,000 and the maternal mortality rate of 7/100,000. In Canada, essential health services are free and accessible. We have safety nets that ensure equity. We have highways and ambulances. We have food banks, community health centers and voucher systems. Although these are challenging numbers to realize, I hope it helps with understanding of the goals of this project, to learn how to best improve maternal, infant and pediatric health to improve nation-wide health outcomes.

                After our first meeting, again began travelling to several Health Centers within the region to develop a first hand perspective of maternal, neonatal and pediatric care available in the district. We met with Dr. Gilbert, the superintendent of the referral hospital, Rugarama. We visited a labor suite where 50-60 births occur monthly and also the new operating theatre for caesarean sections (and other surgical procedures) which is currently being built with support from DRI. Next we entered the neonatal and neonatal intensive care units, then finally the general pediatrics nutrition centre. After extensive discussions with Dr. Gilbert, he and I came up with a plan for me to come work within neonatal and pediatric nutrition centers come January. Previous to this experience, I trained as a pediatric clinical dietitian at the Hospital for Sick Children in Toronto. I am eager to learn more about the feeding practices within this hospital and hopefully, will be able to share some of the knowledge I have afforded throughout my training.   

Village Health Team members meeting at Nyaksaru Health Centre II

Obstetrics ward, Rugarama Health Centre IV

The future home of the Rugarama obstetrics ward,
neonatal intensive care unit and surgical centre

                While consulting with the team at Rugarama Hospital, we asked their perspective of the national health statistics generated by the government of Uganda. Our curiosity was based on the fact that these new statistics suggest decreases in maternal and infant mortality. We wanted to know first, if the staff at the hospital believed the validity of these statistics and if so, how these vast improvements were achieved. We never made it to the second question. The hospital superintendent, the District Health Officer and several others agreed that these national statistics are largely misrepresentative. Reason being that these statistics are generated using registered data only, which fail to capture the majority of morbidities and mortalities faced in many districts.

                Aside from the Kampala district, where many have means with which to reach health services, those living in less developed, rural areas remain to have poor access. To better understand the flaw of these government generated stats, consider the issuance of birth and death certificates which are used to identify the occurrence of each for national data. Neither document is legally required here. National figures demonstrate that just over 60% of birth deliveries occur within the home, without the assistance of skilled personnel. The majority of these births therefore go unrecorded, as do resultant deaths. In terms of death certificates, most do not have the means to support end of life care so death within the home is common place. The cost of transporting a dead body is over five-times the cost of providing end of life care in registered facilities, so if the first is unattainable, the registration of death is certainly out of reach. National statistics are dependent upon the availability and accessibility of data, the comprehensiveness of coverage and overall validity. Can you see the gaps?

                 From now on I am going to be living in Kabale. There is a lot of work here for me. In the next post, I will describe the household health survey that we will be conducting which will commence within the next two weeks. Of the 60 sub-districts within Kabale, 30 have been selected as a sample of the region. In total, the survey we are proposing will require the assistants of 900 VHT leaders within the districts, each who are responsible for approximately 25 homes in which the average household number is 8-10 people. Through this survey we will reach approximately 180,000 people in total. We will cross check these government generated statistics. With this representative sample, we will cross-check government generated numbers which will help us to become more capable of identifying key priorities for strengthening health systems within Kabale and the Lake Victoria Basin.

The Lake Victoria Basin Integrated Health Initiative (LVBIHI)

Field Visit #1: The Ssese islands

            First, I would like to introduce the team members that I have the privilege of working with on this fantastic initiative. Dr. Michael Marks, an obstetrician trained in UK who has dedicated the past 20 years of his life working to improve maternal health and well-being throughout Sub-Saharan Africa. Dr. Marks is the founder of the Bush Hospital Foundation, an NGO that advocates for and support primary health care in selected African countries. The bulk of their efforts are directed towards the supply of medical equipment and essential medicines to hospitals and clinics in remote areas. Dr. Mike is currently a medical advisor for another NGO, Direct Relief International and is the spear header of the LVBIHI. 

Dr. Mike with a Village Leader on Kitobo Island

                The second team member that I am working with on this initiative is Hilary Bowman, a supply chain logistician from GlaxoSmithKline (GSK) Inc. who is currently volunteering with AMREF under the compassionate branch of this large scale pharmaceutical firm. Now I can imagine what some readers are thinking-how can one suggest compassion and humanitarianism in the same sentence as the words large scale and pharmaceutical firm…? Guilty I am of the same question! If you’re interesting, I suggest you check out this pdf file and this youtube video to learn more about Andrew Whitty, the foreward-thinking CEO of GSK, as he professes his commitment to social responsibility by directing 20% of profits to strengthening health systems in developing countries.

Hilary outside of Rwendero Health Centre III
holding the nurse's 4-month old baby boy, Soloman

                To summarize the LVBIHI, it is a concept to deliver quality, affordable health care to reduce the high burden of disease in the Lake Victoria Basin. The Lake Victoria Basin includes all of the islands and districts surrounding Lake Victoria in Uganda, Kenya and Tanzania. This project is a partnership consortium between AMREF, Direct Relief International (DRI) and Marie Stopes International (MSI). The project aims to address the needs and gaps within current health systems which currently impede the delivery of quality healthcare to more than 30 million East Africans. By working with relevant Ministries, NGO’s and community based organizations, this project aspires to strengthen health care and promotional interventions focused particularly on sexual and reproductive health and rights, maternal, neonatal and child health, malaria, HIV/AIDS, TB, preventable communicable diseases and other water, sanitation and hygiene-related conditions (Millennium Developments Goals 4, 5, 6 and 7).

                I joined the team in the middle of their journey and just in time to travel to the Ssese islands, an archipelago consisting of 84 islands of which only 18 islands have a population greater than 2,000 inhabitants. The Ssese Islands represent one of the largest districts in Uganda covering 8,634 square kilometers, however less than 5% is land, the rest water. The total estimated population of all islands combined is approximately 54,000 and due to low population density, this district receives one of the smallest allocations in terms of health budgets. As such, the islands carry one of the highest burdens of disease. Health care is often difficult to access as is in many rural areas around the world. A mesmerizing three-quarters of current health issues are preventable at the household level, however, due to access to prevention interventions and an inability to access care in a timely manner morbidity and mortality are high. Care is severely impeded by wide-spread poverty and infrastructure issues such as access to affordable transport and a lack of provision to services by qualified health professionals.

From the mainland

                In total, we visited 6/11 of the health centers ranging from level II to level IV and 3/46 level I Village Health Teams. I was unfamiliar with this grading system are first, so a brief description of each: Level I refers to the village level in which village-elected representatives provide health education and are capable of treating conditions such as malaria and diarrheal disease; Level II refers to the parish level, this is the first point of contact with qualified health professionals such as a nurse and/or midwife; Level III refers to the sub-district centre which provides outpatient, inpatient, maternal services and HARRT (highly active anti-retroviral therapy); and Level IV refers to district level facilities, this is the point of contact with a qualified medical doctor and where surgeries take place. We also met with District Health Officers and several community leaders throughout the week.

Meeting with a Village Health Team under a wise old tree

                 Our interactions within these communities were simple, we would ask, “what do you think you need to improve health within your community”. Over and over again we heard the same response: Clean drinking water; improved maternal health services; retention of medical workers; transport whether it be by boat or land to ensure better access to tertiary care services; full-time supplies to medicines for treating malaria, bilharzias and HIV; full-stock of childhood immunizations; life jackets for fisherman; bed nets for all household members (current government allocations only ensure enough nets for children under five years and pregnant woman). They never asked for too much- just access to very basic human rights which they have been denied for far too long.

Kasekulo, a village of approximately 3,000

                At night after our field visits, Dr. Mike, Hilary and I had long drawn conversations and reflected on the happenings of the day. We would recount the interactions of the day and were constantly generating new questions. One of the questions we asked to a nurse in a health centre II was, “Why do you think the prevalence on HIV is so much higher here on the island (30%) than it is on the mainland (6%)”. Her response, “People here like sex too much”. Hmmmm…. We probed a little farther and were struck with another reality. On the island several of the inhabitants are transient. During fishing season high time many men come and go and bring with them the attitude “My job’s risky, I may die tomorrow, mine as well live it up today.” This promotes the intake of homemade alcohols, an influx of sex workers and fishermen with cash on hand daily. With no government structure to promote savings or any reason to believe the money can be better spent, there is a very laissez faire attitude toward personal responsibility. So who to blame? The fishermen? The government who demand high levels of exports? The importers who demand low prices for Nile perch?

Fishing village of Mazinga

                Aside from transient fishermen, there is a new industry on the island bringing transient palm plantation workers, thus exacerbating the above scenario. At first glance, it appears as though these plantations are a great initiative and an opportunity for income generation for locals, but one has to consider, at what cost? Hundreds of acres of rain forest have been flattened to make way for palm, a slow growing tree with a small yield per hector. Since the establishment of the plantations, the temperatures on the land have increased and draught has paralleled. When rain does come, there are less tree root systems to manage floods, causing pools of stagnant water- just perfect for breeding mosquitoes that often carry the malaria parasite. There is a loss of diversity in both flora and fauna on land in the surrounding water leading to less minnows, less fish, and less work for fisherman, leading to longer hours on the water, riskier nights works, reinforcing the attitudes mentioned above. Palm plantations. Good idea or bad idea for the people of the islands? To me, this is an excellent example of how short term solutions (palm plantations to increase income generation for locals within a short time frame) can have negative long term implications. Improving quality for the people on this island cannot come vertically from the outside; solutions have to be generated by the people, for the people and with the support of nations who can afford to share their wealth. We need holistic approaches.

Charles holding raw palm fruit ready to be boiled, juiced, reduced
and sold as cooking oil or further produced into body lotion

Acres upon acres of palm

                I’ll end this post here for today. I think this is enough food for thought for one afternoon- I could go on, but I’d never sleep! Share your thoughts, I’m interested to hear.

               

My Feet in Kampala and First Impressions

Week 1

                My first steps on the ground in Uganda occurred October 6^th, approximately 30 hours after Colin (Colin’s blog) and I departed from Toronto the evening of October 4th. Shortly after our arrival at the Entebbe airport, we were greeted by Charles, an employee from AMREF who shared invaluable “need to know” information about the country with us on our way to the busy, face-paced city of Kampala. After a brief DaVinci style nap at our hotel, Colin and I ventured on to the AMREF Uganda district office where we received several warm welcomes.

                This is the beginning of my second experience living in East Africa, the first being in 2008 when I lived in Mwanza, Tanzania, a coastal city that shares the plenty of Lake Victoria with Uganda and Kenya. Kampala, being situated only a few hundred kilometers away, I suspected, would share a wide array of similarities with Mwanza-  was I wrong! For starters, I thought I would be able to hit the ground running with my fair sized vocabulary in Kiswahilli- one of the languages I was advised would also be quite prominent here in Uganda. It’s safe to say that the Lonely Planet and a few others broke that promise- however, I am excited to say that I have now been afforded a new opportunity to learn Luganda, also a Bantu language spoke by several Ugandans. Secondly, Kampala is very well developed. From the four-story shopping malls and supermarkets, to the upscale hotels, restaurants, bars and cafés, to the golf courses, gyms and spas, Kampala is more than just home to a several prominent NGO’s!

                On day two we met with the Joshua Kyallo, Country Director and Susan Wandera, Deputy Country Director of AMREF Uganda and were introduced to our responsibilities for our time in Uganda. My first project will be to assist with a proposal for a project titled “The Lake Victoria Basin Integrated Health Initiative” (LVBIHI), quite the mouthful! The second project will be to design, test and implement a feasible E-learning solution to upgrade the skills of various medical workers in Uganda. Stay tuned for project updates.

                The remainder of week one was spent searching for permanent accommodations in Kampala, a task that is certainly not easy to do without city bearings. As mentioned earlier, Kampala is a very developed city and in many ways strikes a resemblance to Toronto. As such, rent is nearly the same- anywhere from $400/month for a somewhat dodgy apartment, to $2000/month ++ for a two bedroom unfurnished apartment on the outskirts of the city. A shock to say the least! Time was also spent procuring the essentials for our role with AMREF, a wireless usb internet stick and a cell phone and trying my best not to get lost in the deep holes situated in the middle of many sidewalks.

                After a somewhat unsuccessful apartment search, I needed to get out of the Land Rover, move my body and see the city by foot. The further out of the city centre I wandered, the more familiar the territory became. Still, very concentrated with people, shops, boda boda’s (motorcycle taxis) and taxi’s (minivan style public transit bus, aka "dala dala"), but also fresh produce markets, tropical farmland, charcoal fire cookeries and other signs that remind me that I am far from home!

 

Fresh produce and second hand market

Mangos- oh my!

When opportunity knocks...

                First, I must take the opportunity to introduce the Non-Governmental Organization (NGO) that has been gracious enough to host me here in Uganda for six months, the African Medical and Research Foundation, here on in, referred to as AMREF. AMREF is one of the most proactive, forward-thinking African NGO’s and is unique in its organizational structure in that a great majority of staff members are located in the countries in which they serve. AMREF is present in seven countries in Eastern and Southern Africa: Ethiopia, Southern Sudan, Kenya, Tanzania, South Africa and of course, right here in Uganda. Twelve international headquarters also exists throughout North America and Europe, all with the shared vision, “Better health for the people of Africa”.

                 I find myself drawn to AMREF for their holistic idealisms and grassroots initiatives that focus on improving health systems as a whole. The goal of each program revolves around capacity building, advocacy and empowerment at all levels from district to village. The communities in which AMREF functions are essentially responsible for identifying their own strengths, weaknesses and needs, promoting local ownership of initiatives leading to effective programming. Priorities and resources are allocated in areas of greatest need and those most vulnerable are targeted, namely women and children five years old and under.

African Medical and Research Foundation
African Medical and Reseach Foundation- Canada

                I certainly encourage you to learn more by visiting the links that I have posted to the left. I will be using this blog as a means to communicate with you, offering weekly reflections and questions that have resulted. At anytime, feel free to post comments and leave your email address if you would like my response. I hope you enjoy the posts and share your insight and wisdom with other readers.