Lessons Learned

                Over the past two weeks, I have had the opportunity to truly see Kabale. With two days days in each of the seven sub-districts, we visited 30 different level two health centers. It was nice to be re-acquainted with each of the 60 focal health workers I met at the training session in early November.  They invited me to see all around their health centers and introduced me to their village health team members who often sat in a group on the grounds outside. It is not very often that one has an opportunity to shake hands with nearly 900 people, meeting the VHT's was nothing short of extraordinary. Although the time spent at each facility was brief, the VHT's shared a lot about the world they experience, the people they serve, their triumphs and the obstacles they face as providers of care within their villages.   

Village Health Team

              Overall, the total distance between health units never exceeded ~120km, but often took 3-4 hours in travel time. The roads were an adventure, more than once crossed shallow rivers, climbed boulder paths and overtook fallen tree trunks- I have never appreciated a land rover or four-wheel drive so much. I'm posting these pictures to give an idea of the villages.

One of our many river crossings en route (the only path) to health center

Behind Charles you can see the homes
in the village and the cultivated fields below

Village

Trust in a neighbour-
when was the last time you saw unattended bikes unlocked?

                 The land in the villages was lush, green and very plentiful with rows upon rows of fresh huge, delicous, sun warmed produce. The people in the villages work hard, its physical labor and many dig from sunrise to sunset. Every woman I saw carried a days worth of food and a coal cooker on her head, had a baby strapped on her back and a hoe in her hand. Everything is very communal, never once did I see a person working alone, and kids are always around, dancing, helping out and generally just getting dirty.

                I was left without words on many occasions over the past two weeks. The scenery was breathtaking and the terrain was next to impossible to navigate. No signs, no rules, basically no roads. Many times I imagined what it would be like for say, the elderly man or the 9-month pregnant woman having to make the trek up up up the hills (the highest I recorded was nearly 3000 meters!) to these health centers, often at the very end of a path. Then once arriving, being in facilities so ill-equipped that bathrooms were made of bush, treatment beds were made of old church pews, medical waste was situated beside dressings. I am going to be sharing details in a report for the district health authories as they approach the time tfor setting priorities for the new year.

Toilet facilities outside Health Center

Treatment bed

Medical waste bins to the left and dressings corner to the right

               All of this time out of the office and in the field let me see, think and reflect on the things that I have learned since being in Uganda, working with AMREF. I am beginning to understand that immense amount of donor pressure on NGO's and CBOs (Community Based Organizations) to invest efforts in a few selected areas. For instance, so many dollars are to be spent procuring essential medicines for a disease under the spotlight throughout Africa, say HIV. The intervention is successful in that confirmed HIV cases are better able to access antiretrovirals, however this is not a solution to the health issue in its entirety. Handouts do not ensure access to diagnostic testing or the laboratory required for analysis; qualified personnel to perform testing and provide counseling; cold storage for medicines; effective communication channels for maintaining supply chains; prevention programs that target those most at risk...  Disease-based funding often unintentionally isolates communities from resource allocation and decision-making. It's a real bind and its difficult to find the balance between adequate accountability and realizing the long term value of community empowerment and grassroots solutions.  

                After two full weeks in the field, I found myself in the office yet again with 27,000 surveys. Hilary, Victoria and Dr. Mike travelled from Kampala for the survey closing and together we review preliminary findings and reflected on the validity of our data. We met over dinner at nights to discuss the trials and tribulations of the day. Most of our discussions circled around road blocks. The literal roads blocks- like the Mac-size trucks we would be stuck pushing as they spun deeper into the red mud (this is a story worth at least an hour! ahah) or the collapsed bridges en route that required long detours; then the contextual road blocks, those both that we acknowledged prior to the survey roll-out and also those that we did not anticipate. I feel so fortunate to be working on such an interesting great team. 

                We certainly noticed large gaps between the information we aimed to collect, verses that which we did in fact collect. Some of the barriers that we encountered include cross-cultural conceptualization, literary understanding and educational experience (and often lack there of), perceptions and descriptors used for health verses illness and disease.  While I was flipping through completed surveys at one facility, I came across a record of death for a 34 year old male, the cause was “natural”. Odd to me, as North Americans we really only accept “natural” as a cause of death when we're talking about a person in their nineties. I met with the VHT member who visited this particular household for clarification and found out that the natural cause was again fever and diarrhea. Goes to show cultural norms and how perceptions of "normal" are not universal.   

                This survey exercise is also teaching me a lot about social stigma and the delicate gleaning required for approaching and eliciting sensitive personal information. I experienced this while working with families of various backgrounds at SickKids throughout this past year, but to a different extent here in Uganda. I've come to realize in retrospect, that our survey tool inappropriately approached some health topics- a very valuable learning point in and of its own. We directly asked about HIV and TB status. There was an overwhelming amount of false negatives among what we expect would be true negatives. A more acceptable approach would be to ask about these types of conditions in a round-about manner. Not “are you HIV positive/negative”, rather, “are you/have you been sexually active” followed by probing questions, “did/do you use condoms? Have you experienced unusual weight loss or skin changes in the past few months? Have you been counseled for HIV? Tested? What was the outcome of the test?” From this I learned to always take the time.

                Another interesting question on our survey pertained to children five years of age and under and asked the surveyor to report the child’s specified role in the household. Some of the roles were entertaining such as “giving smiles” or “praying”, but here are some of the others:

                                Age 9 months      àBreastfeeding
                                Age 1 year           àPlaying            
                                Age 2 years         àFetching water
                                Age 3 years         àSelling fruits
                                Age 4 years         àTaking care of younger siblings
                                Age 5 years         àCutting and collecting firewood

Travelling through the villages I saw kids engaged in all of these roles. The amount of responsibility children have at such a young age makes me think all the time about how in Canada, children are not allowed out of eyesight until they reach double digits.
                

Selling avocados

Selling handicrafts

Caring for each other

Picking Fruit

                I am really excited to work with this data more. There are so many interesting findings that we have come across already, I hope we can use this information for the development of truly effective outcome based interventions in the near future. For now, I am off to Kampala to recruit some extra hands for survey coding and databasing over the next two weeks. I will share another post once I return to Kabale.