Saturday, February 28, 2009

Kasensero

Last Thursday through Sunday I traveled to a small fishing village on Lake Victoria called Kasensero. It’s taken me a while to finish writing this blog post, maybe because I’m still mentally and emotionally processing. This is by no means a complete account, but I’ll try to share some of my thoughts and observations.

Kasensero is a rural village whose local economy depends upon commercial fishing in Lake Victoria. However, the boats used are small and hand woven nets are utilized to bring in the catch, probably much like what you can read about in the Bible. The waters have been over-fished, so it is increasingly harder for fishermen to make a living. To get to Kansensero from Kampala it is a 3-4 hour trip on paved roads, then another two hours on a dirt road with ruts that can be up to 4 feet deep and literally the size of a pickup truck. When it rains the road is almost impassable. Naked telephone poles line the road all the way through town, but without electrical wires. There is almost no electricity and no running water in the town. When you arrive in Kansensero it literally feels like you’ve reached the end of the world with the lake on one side and the road on the other, and little more than swampy marshland on either side.

Kasensero’s unfortunate notoriety comes from the fact that the first case of AIDS in Uganda was documented there. This is a village that has been devastated by the disease. It would not be far-fetched to say that every single household has lost someone because of it. There is one small clinic on the outskirts of town, but only three nurses work there. There are no permanently employed doctors. Every two weeks someone comes from the district health center to deliver antiretroviral drugs for adults and children, and to do HIV testing.

One of the many terrible consequences of this epidemic is the number of children who have been orphaned because one or both of their parents died from AIDS. The word ‘orphan’ in Uganda is also used to describe a child who has lost their father. Typically, in most places in Africa, when a child is orphaned she or he is absorbed into the larger extended family and cared for by an aunt, uncle, cousin or grandparent. However, when those extended family members are also dying from AIDS the social support network begins to collapse, overwhelming the family members who do remain and often leaving orphaned children as heads of households. I met one resilient grandmother who was single-handedly taking care of 24 grandchildren because all her sons and daughters had died. The level of destitution seems magnified in rural areas where there are few opportunities for economic advancement and markedly less formal social service systems.

In response to this crisis, several years ago an orphanage was built in Kasensero. Currently, about 40-50 children reside there, though not all of them have lost both parents. Then 70-100 more attend school there during the day. Their ages range from 3 – 14 years old. When we arrived, all of the children rushed up to greet us, each one wanting to ask how we are and to hold our hands, eager for attention. Two small girls named Lita and Florence latched on to me and would not let go for hours. We sat in a classroom where we were formally greeted by everyone and filled in by the headmistress and other teachers about the state of the orphanage. We learned that the finances of the orphange are in dire straits, exemplified by the fact that the children only receive one meal a day (usually a corn meal porridge) and other basic necessities. Last year three of the teachers left because they were not being paid. One of these teachers with whom I spoke (she was visiting in town, though she had left) told me she had worked there for three years without pay!

I had come to the orphange because the doctor with whom I traveled – Dr. Charles Holt (from Iowa) – wanted me to help him conduct physical exams for all the children residing at the orphange and make up a medical chart so they would have a bit more continuity of care in the future and any very serious medical issues could be addressed. For two solid days I examined every inch of their little bodies, carefully recording any abnormalities, noting signs of malnourishment like protuberant bellies and fine, lightened hair. My parents had graciously given money for me to buy toothbrushes and toothpaste for all the children, so I gave one to each of them and taught them how to brush their teeth. That many of them had never brushed their teeth before was quite evident when I looked into their mouths – almost all of them had widespread dental caries and about half of them had teeth that would need to be extracted. I hope perhaps from now on their teeth will be in better shape. About 20% of the kids had symptoms serious enough that I felt needed to be treated, so on the last day (under Dr. Holt’s approval) I went to a local pharmacy and bought medications for them, writing out instructions for administration in their new medical charts. In addition, there were a handful of adolescent girls who had begun menstruating, but many of them did not have underwear, much less pads (they often use old rags instead). So I bought them all underwear and a large box of pads. It broke my heart when I gave one girl a pair of underwear, a package of pads and a small bar of soap. Her face broke into the biggest smile I have ever seen, she knelt in the traditional way at my feet to say thank you, then impulsively gave me an enormous hug, smiling all the time. It is hard enough to be 13 year old girl going through adolescence, much less to go through it without a mother and without underwear while you are menstruating. This same girl took me through the village to show me her house, left by her parents who had died. It was a small shack, made of pieces of driftwood with a rusty corrugated iron roof. She was the head of the household, in charge of her younger siblings. It made me wish I could stay longer, to talk with these girls more, encourage them to study hard and keep going. Another 13 year old boy, Fred, interpreted for me while I was examining the rest of the children. His English was nearly impeccable and he was very quick at understanding exactly what I needed asked – I almost never had to repeat myself. He introduced me to his mother, who is very sick with AIDS, and shared that he wanted to continue onto secondary school but did not have school fees. It is hard to see such bright children like Fred limited by socioeconomic circumstances and choices they did not make. Dr. Holt is doing what he can, sponsoring the school fees of the older kids to continue on to a boarding school in another town – there is no secondary school in Kasensero. He says it is an investment in the future of Uganda.

I wanted to paint a stark picture with the above description because it is just that. Kasensero is a terribly impoverished villaged that has been ravished by HIV/AIDS. But that said, I’d like to end on a positive note. I traveled to Kasensero with a group of Ugandan evangelical Christians who went in order to carry out a 3-day revival with a local church. They were a lively bunch, singing hymns on the way and shouting, “Hallelujah, Amen!” every time we would manage to get through a massive pothole without getting stuck. Kind and generous, they called me ‘sister’ and brought lunch to me at the orphanage when I didn’t have a break until 5pm. The church members and pastor of the church in Kasensero took care of us like we were family, feeding us delicious, fresh fried tilapia every day and walking us home to the guest house each night (the village is pitch black after dark, but the stars are incredible). They thanked us profusely for coming to help ‘their’ children. The local pastor worked tirelessly while we were there to arrange for a volunteer board of community members to be established to oversee the orphanage and school in order to provide more accountability and transparency. In some ways the church there reminds me of the early church as described in the book of Acts in the Bible: meager resources are pooled together to support those in need, particularly widows and orphans.

I’d like to believe that there is hope for Kasensero.

Wednesday, February 18, 2009

“You are welcome”

This past weekend Sara, Coeurlida and I took a four-hour taxi ride (minibuses with 14 people plus the driver stuffed into them) to Mbale in eastern Uganda near the Kenyan border. From there we got a private taxi, aka “special hire”, for the 45 minute drive north to Sipi falls, which are reportedly the most beautiful waterfalls in Uganda. The road wound through gently rolling countryside with rural villages, then sharply began to gain elevation into formerly volcanic mountains. As we rounded a bend, we were met suddenly by a large crowd of ululating people who were waving leaves and cloth in the air, running down the mountain. Puzzled, I asked the taxi driver what was going on. He said they were celebrating a circumcision ceremony, which is a tradition the Bagisu people perform for males between the ages of 15-26, but typically at age 15-16. It is a coming-of-age ceremony marking the transition to manhood and is performed publicly, in front of men and women. The boy being circumcised cannot cry out in pain or he will be branded a coward.

We arrived at the place we were going to stay – Crow’s Nest – and were greeted warmly by the staff. It is a simple establishment with tiny cabins nestled into the side of the mountain that cost $15/night. They are equipped with a bed, mosquito net and pit toilet. There is normally electricity via a generator, but we were informed that it was broken (fortunately I had my headlamp!). Yet whatever was lacking in amenities was made up for by the breathtaking view from our porch of the largest waterfall, the surrounding basin and savannah that stretches out for miles. It was truly stunning. After relaxing for a while, enjoying the vista, we decided to take a walk before dinner to see the sunset.

Meandering down a dirt road we met a teenage boy named Isaac with whom we struck up a conversation. He offered to show us his nearby village. As we walked through we were greeted by small children throwing toy parachutes into the air and an old woman came out of her house to greet us. As we were speaking to her another woman named Nancy came by and with impeccable English asked if we would come see her house a short distance away. We arrived to the rectangular abode with a wooden frame plastered in mud to form the walls. She opened her doors and invited us to sit on the couch in her living room - probably the most prized possession of the household. "You are welcome," she declared, with a huge grin on her round cheery face. As she left the room to find a candle (there was no electricity) we found out that the group of children peering through the door were hers and 'adopted children' she cared for. In fact, our guide Isaac was an orphan whom she had taken under her wing. "I call her mother," he said. When Nancy returned with an oil lamp we chatted for a while about the small business she and her husband owned in town, as well as the livestock she was raising, before she said, "Okay, let's make dinner!", with the full intention of including all of us in her evening meal. Though overwhelmed by her hospitality, we politely declined both because we had already made dinner reservations at our hotel and because we did not want to consume her meager resources with so many other hungry bellies to feed.

Almost every time I meet someone new in Uganda, greetings and introductions are followed with ‘You are welcome.’ It is not the ‘you are welcome’ that Americans say after a ‘thank you’ but means ‘ you are welcome to this place’ and on a larger level, ‘you are welcome to Uganda.’

If only we could all be so welcoming and gracious to newcomers. Most of the time the generosity of Ugandans puts me to shame.



(Coeurlida is the chief resident of the primary care internal medicine program at Yale and arrived a week and a half ago).

Monday, February 16, 2009

“When is independence ending?”

Each Tuesday afternoon we have classes on the history, culture and politics of Uganda with Professor Simba, who is the acting Dean of the Political Science Department at Makerere University. Makerere historically was, and still is, a very prestigious university in East Africa. Many heads of state (former and current), including Jomo Kenyatta and Mwai Kibaki of Kenya, as well as Julius Nyerere of Tanzania earned degrees here. Last week Professor Simba lectured on highlights of Uganda’s political history since its independence from Great Britain in 1962. Following is a summary of the lecture, which I found very interesting, with not many of my own original thoughts included.

Like many post-colonial African countries, Uganda has had a tumultuous, and at times violent, history since independence. Milton Obote was the first Prime Minister of Uganda. He initially left all of the army commanders in their posts(who had been trained by the British), giving into their demands and appointing Idi Amin as the Deputy Army Commander. This is contrasted with Kenyatta in Kenya and Nyerere of Tanzania who sacked all of the army commanders under colonialism and redistributed positions and power. Neither of those leaders were sacked by violent coups d’etat. In contrast, Obote was overthrown by Idi Amin in 1971 when he was out of the country. Obote’s regime had been characterized by increasing violence toward dissenters who might challenge his power, as well as paranoia after an assassination attempt.

Idi Amin was semi-literate and spent his entire career in the Ugandan army until he became the self-appointed president (read: dictator). Under the Obote regime, Amin built up an army that was based upon personal allegiance and aggrandizement. He recruited soldiers from the Sudan that had little concern for the well-being of Uganda and were loyal only to Amin himself. Before he took over in the coup he was being investigated by Obote for being unable to account for US$5 million (that was a LOT of money in the 1970s in Uganda). Amin single-handedly drove the economy into ruin. When he became president he promoted many people who had no qualification for positions - he also had no conception of a budget and spent large amounts of money on pet projects. In order to quelch unrest in the military he issued a decree to force all people of Indian descent to leave the country on very short notice. This substantive population formed the prosperous backbone of the middle class in Uganda. Their businesses and personal assets were seized and given to the army, most of which was squandered. Amin’s foreign policy was erratic and driven mostly by the goal of obtaining as much aid as possible. For years Uganda was supported financially and militarily by Israel; within a period of days he decided to switch alliances to receive support from the PLO and Libya, kicking Israelis out of the country in the meantime. Perhaps what Amin was most notorious for was the abduction and killing of over 300,000 of his own citizens. Most of them were the rich elite, many very well educated, and those who spoke out against him. Many would just disappear, never to be seen by their families again. Often their bodies were dumped in the Nile to be eaten by crocodiles, though he was also famous for brutal forms of torture frequently involving mutilation of corpses. Amin was overthrown by the combined Tanzanian People’s Defense Force and Ugandan exiles who invaded Uganda in 1979. There is a theory that Amin actually tried to start a war with Tanzania because he wanted to capture a corridor of (Tanzanian) land in order to gain access to the ocean, but the Ugandan army was ill-prepared because of Amin’s rapid promotion of unqualified soldiers through its ranks.

After Amin there was a brief succession of two leaders (both overthrown by coups) then elections that were marred by allegations of rigging in which Milton Obote won (making him President for a second time). He was overthrown in 1985 and the following regime was then overthrown by the current president, Museveni in 1986.


Professor Simba said if you speak to many elderly people in the country they will ask, “When is independence ending?” For them, the stability and quality of their lives under colonialism was better than what they have lost since 1962.

However, one thing that current president Yoweri Museveni has brought to the country is stability. The 1980s in Uganda was marred by high levels of insecurity and violence. Museveni has successfully improved security (in most parts of the country) and has complete control over the military. He is credited with “turning the economy around” through some positive economic development. At the beginning of the HIV epidemic Uganda sent a group of soldiers to Cuba to receive training. Health screening was mandated for all the soldiers and it was found that 20-30% of them were infected with HIV. Supposedly Castro called Museveni and asked him how he expected to have a stable army if a third of them were going to die of AIDS. This evidently was enough of an impetus to spur him to act – Uganda has subsequently become an international model for its early and widespread efforts to tackle the impact and spread of the disease. Museveni is also credited with improving gender equality in Uganda and enjoys strong support from women’s rights groups. For example, he supported banning the practice of female genital mutilization in eastern Uganda (which is now illegal) and also is credited with increasing the percentage of women attending Makerere from 17% to 48%. Finally, Museveni is responsible for decentralizing government so that there is more regional and local control.

Museveni’s weaknesses are many, not the least of which is that he has been in power for 23 years. When he first came to power he was expected to be a model African leader by stepping down from power after a reasonable amount of time. In fact, initially he strongly criticized other African leaders for staying in power for too long. Additionally, he has failed to end the war in northern Uganda with the Lord’s Resistance Army that has been going on for over 20 years. There is some speculation that he has deliberately not ended the conflict because it gives him a reason to maintain military power and resources. Many other ‘uprisings’ have occurred since Museveni came to power and they have all been squelched within a very short period of time. The Ugandan army under Museveni has been accused of gross human rights violations, most of which Museveni denies. Finally, Museveni is criticized for his failure to build lasting, self-sustaining institutions in Ugandan government and civil society. His has largely been a “one person rule” and is supported by a base of people who have benefited from his rule through corruption. He does not endorse multiparty democracy.

Uganda will have elections in 2011 and Professor Simba thinks that Museveni will ‘win’ again, as he has in the last 3 elections because he has a base of support from several constituents, including those benefiting from corruption, leaders in the military, many women’s groups, and conservative people in rural areas who tend to vote against change. Additionally, there is not a clear strong opponent for Museveni. However, he thinks Museveni will not run again in 2016.

To end I’ll just touch on Uganda’s relations with the United States. In the 1990s there was a spread of Islamic fundamentalism in the Sudan, around the time that Osama bin Laden was based there. After the 1996 bombings attributed to bin Laden the US looked at Museveni as the strongest ally against that influence, massively increasing its funding to Uganda, Ethiopia, Eritrea and Rwanda. The bottom line (which is not new for US history) is that the US turns a blind eye to undemocratic leaders when they help us defend our own interests. Thus, there has been no pressure on Museveni to step down.

I think the part of Museveni’s 23-year rule I find the most dangerous is the complacency it breeds to the democratic process. The people who would want change don’t believe they have any power to achieve it and the people who don’t want change have deeply entrenched interests, digging in their feet to prevent losing that power. Voter turnout in Uganda is about 70% in national elections, but many people, especially those in rural areas, often rush to the polls because a rumor spread that they will be arrested if they don’t vote.

Professor Simba said that the mark of a true democracy is when leadership is transferred peacefully back and forth between different parties. Uganda has a long way to go. We shouldn't take this for granted in the U.S.

Sunday, February 8, 2009

Rafting on the Nile River

Yesterday Esi, Sara and I all went on an all-day white water rafting trip on the Nile River, near Jinja, Uganda. Though I have been rafting many many times on rivers in Colorado, this experience was hands down the most intense and fun trip I've ever done. The sheer amount of water flowing through the Nile is daunting and there are actually class VI rapids (though we only went through class V). We met up with some medical students from other medical schools in the U.S. and shared a raft with them, which was fun. For the first three rapids all or most of us fell out of the boat just because the rapids were so huge and crazy. On the first dump one guy got a pretty deep gash in his shin on a rock, but I guess if that's going to happen it's better to happen in a boat full of fourth year medical students. So we all patched him up as best we could.

For the fourth rapid the guide neglected to tell us there was a 10 foot drop down a waterfall and we went down it backwards! Miraculously, none of us fell out. Another thing I really loved is that there are long, wide swaths of river in between the rapids, so we had time to jump in and swim. We didn't see any crocodiles or hippos and hoped and prayed that we don't get schistosomiasis.

The guides were amazing and most of them are Ugandan - it's great that the company we went with employs locals. There were five safety kayakers and they were sooooo good. If someone fell out they were there in like 5 seconds. After we finished they transported us to their camp with bandas that is set up on a cliff overlooking the Nile, which was gorgeous.

I've posted some pictures on Facebook of my trip thus far and even if you don't have a Facebook profile you should still be able to view them. Just go to www.facebook.com and type my name into the search box. Let me know if you have troubles and I'll see what I can do about posting them elsewhere.

Monday, February 2, 2009

Rwanda

Last week, on Thursday night (1/22/09), we were informed that the following Monday was a public holiday (Heroes’ Day) to honor the date that Uganda’s President Yoweri Museveni took over the government. Meaning we didn’t have to go the hospital. So we decided to go on the weekend trip we wanted to take that had the longest traveling time, which was to Rwanda.

It was a whirlwind trip with really only a day and a half spent in Kigali because it is a ten-hour bus ride from Kampala. I think anyone who travels in Africa should experience African public transport. I had a window seat and about half an hour into the trip it began thunderstorming outside: big, black clouds with a torrential downpour so heavy everything outside just looked like green and brown blobs. So I started reading a book and a few pages in suddenly realized that my entire sleeve was wet – the rain was leaking all over me through the window. Other joys of the bus ride included: peeing in an uncovered, tiled, walled-off hole in the ground at a service station with my bare butt exposed to the rain; watching melodramatic Nigerian soap operas (the African equivalent of Latin American telenovelas) that inevitably involve crazy love triangles and witch doctors; the bus veering off the road at a 45 degree angle to avoid potholes; bouncing 6 inches into the air when the bus hits a pothole; and seeing two old overturned passenger buses and an overturned petrol truck on the side of the road. That said, the bus was relatively comfortable, I had my own seat (pre-assigned!) and I had no livestock or small children (who might wet their pants) sitting in my lap. Plus, the round-trip ticket cost $24.

We got to Kigali around 7pm and took a taxi to a hotel we thought we might stay at. However, the guide book we were using was two years old and it turned out the price was twice as high, out of our price range. Then we went to another place, but they only had one double room available. At this point we were tired from the trip and didn’t feel like running all over Kigali in the dark to try to find another place to stay. So the three of us all shared a queen-sized bed and were able to get another room for the next night. That evening we met up for dinner with a classmate of ours, Oliver, who is working in Rwanda. He speaks both Kinyarwanda and French, and knows his way around Kigali, so he was a great guide for our first evening (despite accidentally ordering three heaping platters of food that would have fed 8 people).

The next morning we wandered around downtown Kigali, stopping by Hotel des Milles Collines (the famous setting for the Hollywoood film Hotel Rwanda) before making our way over to the Kigali Memorial Center, which commemorates the 1994 genocide in Rwanda. It was an intensely emotional experience – the only thing I have to compare it to is the Holocaust Museum in D.C. One major difference is that there are actually mass graves on the grounds of the Center. The grounds are beautifully landscaped with peaceful meditation gardens and fountains, but these are ominously interrupted with 8’x20’ slabs of concrete that cover the remains of victims of the genocide. There is a wall that surrounds them with the names of those who were slaughtered. However, our guide, Clauden, told us that there are many many names that are not known because entire families were killed. Even after almost 15 years they are still finding the remains of victims and some of the mass graves have not yet been sealed to allow for more burials.

The Center is split into two floors. The bottom floor has a time line, in Kinyarwanda first, followed by French and English, encircling the entire room that takes you from colonial times in Rwanda through the genocide and recovery period, complete with videos of survivors telling their stories and walls of victims’ pictures that were donated by their families. The top floor has an exhibit detailing a global history of contemporary genocide and a memorial to children who were killed in the Rwandan genocide. All of the staff are survivors of the genocide and were very gracious to share their stories with us. At times it seemed curious to us that this would help them cope and move on, to revisit it all, day in and day out. But somehow, for them, it did.

One employee of the Center asked ‘How is what you saw in the Kigali Memorial Center different from what you see in Hollywood movies like Hotel Rwanda?’ During college and grad school, I read lots of books on Rwanda and felt like I had a decent historical grasp of the genocide. But none of that prepared me for how personal and real it became to hear the stories of survivors and stare into the photographed eyes of the dead. There were many courageous stories – old women in their 80s who hid and saved so many, a man who dug an elaborate hole in the ground It was terrifying and beyond my emotional comprehension to walk into a room with skulls, femurs, and clothing and hear the names of those killed read off, one by one, like a roll call. I felt some strange internal compulsion to sit in front of each photograph clipped like clothes on a clothesline to the wall, as a way of paying respects to lives wrongly taken. When I was in the children’s room, something snapped inside me and my eyes flooded with tears. Seeing the enlarged faces of children with a plaque beneath with their name, their favorite food, pastime, the last thing they said, and how they died was just too much. It’s hard enough to read that a child who was nine months old was hacked to death by machete, much less imagine it actually happening. And walking through the streets of Kigali you see mostly young people, around my age or a little older. It struck me that all of those people were children when the genocide occurred. This is an entire nation of children who were traumatized.

But I don’t want to stop my description of Rwanda with this. A friend of a friend, who showed us around Kigali our last night there, asked us a very profound question. He queried: What have you seen about Rwanda that is not related to the genocide? Sara also complained that we don’t speak as much as we ought to about what is good about Africa, because there is much to be told, though mine is just a small glimpse since I was there for such a short time.

Rwanda is stunningly beautiful. As the bus crossed over the border the road snakes its way through rising smoky blue mountains, terraced with stairs of emerald green crops. Peasants are hard at work with hoes and shovels, trying to eke a living out of the land. Kigali is the cleanest African city I have ever seen. Paul Kagame, Rwanda’s president, outlawed the use of plastic bags and on the third Saturday of every month it is a public ‘clean up’ day where everyone has to go out and pick up litter. Rwandan people are warm, generous and go out of their way to be hospitable. The clerk at the hotel where we stayed gave us a 25% discount for our second night, just because they didn’t have enough rooms the first night. The staff at the Memorial Center took hours of their time to talk with us and patiently answer our questions.

Rwanda is a country of survivors, living still.