Liz's boyfriend Nathan here. I am at the tail end of my visit to Uganda, and having seen Kampala, Mulago and toured a fair bit of the countryside, Liz has invited me to write a post to her blog. I will do my best to do justice to it.
We have just returned from Lake Bunyonyi, a lake in the southwest corner of Uganda formed by volcanic eruption only 10,000 years ago. Free from crocodiles, hippos, and schistosomiasis, it’s safe for swimming, both for us and for the otters that hunt crayfish. Along the shores live a variety of birds, including weavers and the crested crane, Uganda’s national bird. Over twenty islands dot the lake, and in the early morning they are interspersed with clouds of mist rising from the water. Because of its high altitude, the area is cooler than Kampala.
Liz and I spent three nights and two days at two different locations around the lake. The first, the Bunyonyi Overland Resort, is a popular stopover for enormous overland buses, on their way to or from gorilla trekking. Each evening, tourists spill out and fill the restaurant and bar, cheering football and rugby matches beamed in by satellite. The incompetent, mustachioed restaurant manager hovers near tables, berating the waiters when service seemed to slack. Not exactly a peaceful scene.
On our first morning on Bunyonyi we decided to escape the other tourists and take one of the dugout canoes out onto the lake, with the goal of paddling to Punishment Island. A desolate piece of local history, Punishment Island is a small flotilla of reeds with a single tree where women impregnated outside of wedlock were brought to either starve, or be picked up by any opportunistic man who could not afford to pay a bride price. (Many Ugandans, even those who live on the lake, have never learned to swim and the pregnant women would flounder in the few hundred meters from Punishment Island to the shore.)
As it turned out, paddling the dugout canoe was much more difficult than it appeared from the shore, where we had watched locals crisscrossing the lake with ease. Heavy, long and wider at the front than at the back, they were very different from the aluminum canoes we were used to. Paddle on the left, and the canoe would, as expected, turn to the right. However, gain too much rightward momentum and paddling on the right to straighten the canoe would only accelerate its rightward turn. Savage backpaddling could, eventually, straighten the boat out – and bring it to a halt. So we meandered our way happily enough, tracing a curlicue course out into the lake
But then the rain came up. It appeared over the hills behind us, wrapping the lake in grey curtains with the sound of a waterfall. Liz and I looked at each other, each without a raincoat, and suddenly, our inability to chart a straight path wasn’t so funny. We made for the nearest shore to beach the boat and get under a tree out of the rain. Liz, piloting, did her best to keep us on course, but we couldn’t avoid a thorough soaking.
While we waited out the rain under a eucalyptus tree, I decided I would try my hand at piloting on the return trip, confident I had learned from watching (criticizing) Liz’s technique. Not so. We didn’t make it to Punishment Island that day but we did, eventually, make it back to the restaurant. Eating lunch, we laughed as two canoes left the dock, filled with American tourists, to make wide, unintentional circles in the bay. Our waiter told us that these were “Mzungu circles” – the expected outcome when white tourists paddle the dugout canoes.
One of the surprises I’ve had here in Uganda is how infinitely forgiving Ugandans are of foreign tourists. While so much of getting around Uganda is completely unintuitive to me, Ugandans are always happy to help point in the right direction, or explain the way things work. (Luckily, I have Liz as a guide, so I don’t have to ask very often.) Mzungu tourists can be loud, arrogant, demanding, and oblivious. But as we make Mzungu circles around the country, Ugandans seem ever willing to straighten us out with a helping hand and a smile.
That afternoon, we walked to the Heart of Eridrisa, a commune where foreign volunteers and local employees run a nursery, a primary school, and a rudimentary, three-room clinic. The manager, who repeatedly invited Liz, the soon-to-be-doctor, to come back and volunteer, gave us a tour of the facilities. The seven-classroom primary school hosted nearly 600 pupils, and the nursery another few hundred. Like most Ugandans, the manager was mostly nonplussed with the beauty of the lake; unlike tourists who can see the countryside while sheltered from want, for the locals, the beauty of the region is of a piece with its remoteness, its poverty, its lacks. Tourists value remoteness while the locals curse it, and our compliments must seem deeply ironic.
The next morning, we planned to transfer to a camp on Bushara Island, more secluded and quiet than Overland Camp. But before leaving, we wanted to hike one of the hills along the shore to get a better view of the lake. While ascending on a local footpath, we ran into 14-year old Lucky and his younger brother, Christophe. Lucky immediately demonstrated his very skilled English, and asked if we wanted a guide up the hill. When we told him we were only on a short walk, he offered to paddle us out to Bushara in a dugout canoe. We negotiated a price, and he ran the few hundred yards to his house to collect his paddles.
Liz and I, meanwhile, returned to Overland to checkout. Lucky and his friend Moses paddled up a half-hour later, helped us into the canoe, and provided me a paddle. As we made our way to Bushara, a trip that took about 45-minutes with Moses piloting an arrow-straight course, Lucky told us about himself. He is a Manchester United supporter, and a fan of Christiano Ronaldo. He attends the primary school at Eridrisa, which we had visited the day before. His father died before he was old enough to remember him, and his mother farms to support him, his younger brother, and three older sisters. Two of his sisters were in secondary school, their school fees paid by sponsors, and he was currently working to save the 100,000 shillings ($50) he would need to take his tests for the term. So far, he had saved 65,000, and would need the balance by early April. Upon reaching Bushara, we paid Lucky and made arrangements to have him pick us up the next morning before school to paddle us to Rutinda village for transport back to Kabale to catch a bus to Kampala. Lucky asked us to give him our email addresses, and we said we would have them for him the next day.
Our stay on Bushara was very restful. We read, watched the rain, and made the trip to nearby Punishment Island late that afternoon, catching a glimpse of two pairs of otters. Liz demonstrated what she had learned from watching Moses; I still couldn’t paddle straight.
The next morning, it was 45-minutes back to Rutinda. Liz and I decided to pay Lucky double what we had given him the day before, and throw in the rest of what he would need to pay his school fees that term. When we reached Rutinda, Liz handed him the money and our email addresses, and we waved goodbye.
Our ten-hour bus ride back to Kampala featured mid-journey repairs and a live chicken in the overhead luggage rack. Along the way, we passed stores in every village selling mobile phone credits, painted pink (Zain), turquoise (Uganda Mobile), yellow (MTN), or white (Warid). As a student of economics and business, I found myself thinking about development – why it had moved so quickly in some directions (mobile phones), and so slowly in others (absence of free secondary education).
And so it seemed to me that the story of African economic development is a massive Mzungu circle. Western governments gave large loans to newly independent countries for development in the ‘60s and ‘70s, and then forgive the debt, sometimes, thirty years later. American policy propped up brutal dictators during the Cold War, and today the World Bank punishes countries for corruption and bad governance. The World Bank spends billions digging tube wells and building dams with dreams of development at a grand scale decades ago, and then the Nobel committee awards the Peace Prize for the development of microfinance. Western policy-makers still don’t really know how to guide development, and we have just taken another turn in our great Mzungu circle to try and fix our own broken economies. Hopefully we’ll find someone who can paddle this thing straight ahead.
Wednesday, March 25, 2009
Thursday, March 19, 2009
Lacor Hospital
For the past two weeks I worked in the medicine department of Lacor Hospital in Gulu, northern Uganda (pronounced Lah-chore). I also spent a day in the outpatient HIV clinic and was able to travel to an internally-displaced persons camp with a physician who provides HIV care there.
In 2000 Lacor hospital was made famous by an Ebola outbreak that killed many patients, Dr. Matthew Lukwiya the head physician of the medicine department at the time, and several other hospital staff. Evidently the patient who was the sentinel case sat on the ward for days before medical professionals were able to recognize exactly what was going on. Ebola is caused by a hemorrhagic fever virus that infects endothelial cells lining blood vessels, damaging them and causing the infected patient to bleed to death internally and from every bodily orifice. It’s highly contagious (transmitted through bodily fluids) and difficult to recognize in the prodromal phase because the symptoms are like the flu: fever, fatigue, body aches. It isn’t until the advanced stage, after the patient has had many contacts with other people, that it is usually recognized and attempts are made to contain it. But at that point there are usually many other infected people, which is why you typically hear about Ebola “outbreaks” instead of isolated Ebola cases. Though there is an isolation ward at Lacor and many staff members who were present in 2000 are still working there, it is difficult even now to imagine identifying Ebola in the early stages of the disease to be able to act quickly – particularly when most physicians have never seen and will never see Ebola in their careers. There is no emergency department (called a ‘casualty’ department in Uganda), so patients are sent from the outpatient medical clinic directly to the hospital ward if they need admission. However, once there they sit on benches in a waiting area until the medical officers on the ward have a chance to see them and give them a bed, assuming they are deemed sick enough to need admission. Yet this doesn’t typically happen until the afternoon, when rounds finish on the 40-50 in-patients that have to be seen. So an Ebola-infected patient could presumably sit in line all morning at the outpatient clinic, then sit for a few more hours in the waiting area, then could be given a bed and their condition not identified for however long it takes the patient to present with fulminant manifestations of the disease. This is further complicated by the fact that there are so many deathly ill AIDS patients and one tends to put very sick patients into that category until proven otherwise. I must admit, it’s frightening to think about.
But not to worry – that was nearly ten years ago and there’s been no Ebola since then. My time at Lacor was actually very quiet and rewarding. It was good to see a relatively well-functioning hospital in a resource poor setting like northern Uganda, particularly taking into account that this region was heavily affected by the now-quiet civil conflict with the Lord’s Resistance Army.
Lacor is a much smaller hospital than Mulago, and privately funded, mostly by the Italians and the Catholic church. It has pediatric, medicine, surgery, and osbstetrics/gynecology wards, in addition to a tuberculosis ward, burn unit and an intensive care unit. There are also outpatient clinics, including an HIV/AIDS clinic where patients are provided with antiretroviral drugs courtesy of PEPFAR (former President Bush’s funding). The medicine ward has 80 beds officially, but at any given time you can find 20-40 patients on the floor in between the other beds. I worked with Dr. Anthony Muyingo, an internist who did half a year of training at Yale whom I met briefly while he was there, a medical officer named Patricia and an intern named Ruth. We split up the patients evenly with another medical team headed by an Italian doctor. The number of patients to be seen is daunting, but somehow we managed. As compared to Mulago, Lacor functions much better in many ways. Although it does not have some things like a CT scanner or amphotericin B to treat serious fungal infections common with advanced HIV, things seem to work a bit more efficiently for several reasons. First, patients pay a base fee of 25,000 shillings (equivalent to about $12) and then receive all the care that they need. Second, patients are not required to pay before they receive treatment so care is not withheld if a patient can’t afford it. Third, the nursing care is MUCH better at Lacor. It makes such an enormous difference when nurses are rounding with the medical team, reading patients charts and starting to fulfill orders soon after they are written. If a nurse is asked to do something at Lacor, within limits, it can be expected to get done. This is not the case at Mulago. Fourth, medical patients can actually be admitted to the intensive care unit, which is run by a British anesthesiologist. We had a young woman with severe persistent asthma admitted with what could have been a life-threatening asthma attack who was admitted to the ICU with no problem and we were able to discharge her home a week later. It was enormously satisfying to work cooperatively with the intensive care team for the benefit of the patient. Finally, at a smaller hospital most of the doctors know each other, which facilitates communication about patients, making it easier to carry out relatively comprehensive patient care.
I have a lot more to write about my time at Lacor, but it will have to wait as Nathan, my boyfriend, arrived in Kampala this past Sunday and we’re preparing to travel to Lake Bunyoni in the southwest part of Uganda near the Rwanda border early tomorrow morning.
In 2000 Lacor hospital was made famous by an Ebola outbreak that killed many patients, Dr. Matthew Lukwiya the head physician of the medicine department at the time, and several other hospital staff. Evidently the patient who was the sentinel case sat on the ward for days before medical professionals were able to recognize exactly what was going on. Ebola is caused by a hemorrhagic fever virus that infects endothelial cells lining blood vessels, damaging them and causing the infected patient to bleed to death internally and from every bodily orifice. It’s highly contagious (transmitted through bodily fluids) and difficult to recognize in the prodromal phase because the symptoms are like the flu: fever, fatigue, body aches. It isn’t until the advanced stage, after the patient has had many contacts with other people, that it is usually recognized and attempts are made to contain it. But at that point there are usually many other infected people, which is why you typically hear about Ebola “outbreaks” instead of isolated Ebola cases. Though there is an isolation ward at Lacor and many staff members who were present in 2000 are still working there, it is difficult even now to imagine identifying Ebola in the early stages of the disease to be able to act quickly – particularly when most physicians have never seen and will never see Ebola in their careers. There is no emergency department (called a ‘casualty’ department in Uganda), so patients are sent from the outpatient medical clinic directly to the hospital ward if they need admission. However, once there they sit on benches in a waiting area until the medical officers on the ward have a chance to see them and give them a bed, assuming they are deemed sick enough to need admission. Yet this doesn’t typically happen until the afternoon, when rounds finish on the 40-50 in-patients that have to be seen. So an Ebola-infected patient could presumably sit in line all morning at the outpatient clinic, then sit for a few more hours in the waiting area, then could be given a bed and their condition not identified for however long it takes the patient to present with fulminant manifestations of the disease. This is further complicated by the fact that there are so many deathly ill AIDS patients and one tends to put very sick patients into that category until proven otherwise. I must admit, it’s frightening to think about.
But not to worry – that was nearly ten years ago and there’s been no Ebola since then. My time at Lacor was actually very quiet and rewarding. It was good to see a relatively well-functioning hospital in a resource poor setting like northern Uganda, particularly taking into account that this region was heavily affected by the now-quiet civil conflict with the Lord’s Resistance Army.
Lacor is a much smaller hospital than Mulago, and privately funded, mostly by the Italians and the Catholic church. It has pediatric, medicine, surgery, and osbstetrics/gynecology wards, in addition to a tuberculosis ward, burn unit and an intensive care unit. There are also outpatient clinics, including an HIV/AIDS clinic where patients are provided with antiretroviral drugs courtesy of PEPFAR (former President Bush’s funding). The medicine ward has 80 beds officially, but at any given time you can find 20-40 patients on the floor in between the other beds. I worked with Dr. Anthony Muyingo, an internist who did half a year of training at Yale whom I met briefly while he was there, a medical officer named Patricia and an intern named Ruth. We split up the patients evenly with another medical team headed by an Italian doctor. The number of patients to be seen is daunting, but somehow we managed. As compared to Mulago, Lacor functions much better in many ways. Although it does not have some things like a CT scanner or amphotericin B to treat serious fungal infections common with advanced HIV, things seem to work a bit more efficiently for several reasons. First, patients pay a base fee of 25,000 shillings (equivalent to about $12) and then receive all the care that they need. Second, patients are not required to pay before they receive treatment so care is not withheld if a patient can’t afford it. Third, the nursing care is MUCH better at Lacor. It makes such an enormous difference when nurses are rounding with the medical team, reading patients charts and starting to fulfill orders soon after they are written. If a nurse is asked to do something at Lacor, within limits, it can be expected to get done. This is not the case at Mulago. Fourth, medical patients can actually be admitted to the intensive care unit, which is run by a British anesthesiologist. We had a young woman with severe persistent asthma admitted with what could have been a life-threatening asthma attack who was admitted to the ICU with no problem and we were able to discharge her home a week later. It was enormously satisfying to work cooperatively with the intensive care team for the benefit of the patient. Finally, at a smaller hospital most of the doctors know each other, which facilitates communication about patients, making it easier to carry out relatively comprehensive patient care.
I have a lot more to write about my time at Lacor, but it will have to wait as Nathan, my boyfriend, arrived in Kampala this past Sunday and we’re preparing to travel to Lake Bunyoni in the southwest part of Uganda near the Rwanda border early tomorrow morning.
Thursday, March 12, 2009
Small Prayers
Prayers I have prayed while in Uganda:
Lord, please don’t let this bus tip over.
Please don’t let that lady with the live chicken in her hands sit next to me for the four hour taxi ride.
Please don’t let the car get stuck in this 3-foot deep mud hole.
Please don’t let me get schistosomiasis while swimming in the Nile.
Please don’t let me get aspiration pneumonia from Nile River water.
Thank You for hot water.
Thank You for food.
Thank You for bringing me here.
I pray that I might be of use to You and serve You today.
Please help me to be kind, compassionate, humble and patient today.
Please have mercy and don’t let this patient die.
I pray for those who have lost loved ones, that they might be surrounded by Your comfort and love, and filled with Your peace.
Thank You for the kindness and overwhelming generosity of Ugandans who have so little.
Lord, please don’t let this bus tip over.
Please don’t let that lady with the live chicken in her hands sit next to me for the four hour taxi ride.
Please don’t let the car get stuck in this 3-foot deep mud hole.
Please don’t let me get schistosomiasis while swimming in the Nile.
Please don’t let me get aspiration pneumonia from Nile River water.
Thank You for hot water.
Thank You for food.
Thank You for bringing me here.
I pray that I might be of use to You and serve You today.
Please help me to be kind, compassionate, humble and patient today.
Please have mercy and don’t let this patient die.
I pray for those who have lost loved ones, that they might be surrounded by Your comfort and love, and filled with Your peace.
Thank You for the kindness and overwhelming generosity of Ugandans who have so little.
Monday, March 9, 2009
Kasensero, Part II
A few weeks have passed since I traveled to Kasensero and I have a few more thoughts I’d like to share. There is a level of indignation I failed to express in the previous blog post which has been smoldering, waiting to catch fire. Also, I've posted some pictures of Kasensero on Facebook - just click on the link to view them.
Yesterday I finished reading a book entitled Mountains Beyond Mountains, by Tracy Kidder. It’s a biography of Dr. Paul Farmer, a Harvard physician famous for his tireless work in the central plateau of Haiti – the poorest country in the Western hemisphere – to improve health care there. Farmer advocates a “preferential option for the poor” that is backed by his belief in liberation theology. Liberation theology was developed by priests in Latin America who preached that “the oppression of the poor was ‘institutionalized sin’” and as Christians we are fundamentally called to do something about it. For Farmer, this translates into a duty to serve the poor of the world, to work toward rectifying the stark inequality humanity has created between the rich and the poor. Kidder writes:
How could a just God permit great misery? The Haitian peasants answered with a proverb: “Bondye konn bay, men li pa konn separe,” in literal translation, “God gives but doesn’t share.” This meant, as Farmer would later explain it, “God gives us humans everything we need to flourish, but he’s not the one who’s supposed to divvy up the loot. That charge was laid upon us.” Liberation theologians had a similar answer: “You want to see where Christ crucified abides today? Go to where the poor are suffering and fighting back, and that’s where He is.” Liberation theology, with its emphasis on the horrors of poverty and redressing them in the here and how, its emphasis on service and remediation, seemed to fit the circumstances in Haiti. (p79)
Fundamental to this argument is the global (mal)distribution of resources, particularly those allocated for health care. Farmer is frequently criticized in his work for not adhering to standards of ‘cost-effectiveness,’ ‘sustainability,’ and ‘appropriate technologies’ for health development work in resource-limited settings in developing countries. Again, Kidder writes:
“Resources are always limited.” In international health, this saying had great force. It lay behind most cost-effectiveness analyses. It often meant, “Be realistic.” But it was usually uttered…without any recognition of how, in a given place, resources had come to be limited, as if God had imposed poverty on places like Haiti. Strictly speaking, all resources everywhere were limited, Farmer would say in his speeches. Then he’d add, “But they’re less limited now than ever before in human history.” That is, medicine now had the tools for stopping many plagues, and no one could say there wasn’t enough money in the world to pay for them.
What it ultimately comes down to is how much human life is valued. Farmer would argue that “cost-effectiveness” frequently translates into the lives of the poor being less valuable than the lives of the rich – those who can afford quality health care, or who live in a country where it is provided for them. In essence, he medically treats his Haitian patients in the way he himself would want to be treated as a patient.
Now, coming back to Uganda. Kasensero, in many ways, might as well be central Haiti. Its people are impoverished, socially and economically isolated by a nearly impassable road, in addition to a dying fishing industry. This road is such a huge source of frustration that the head of the Kasensero fisherman’s association was recently caught on the local news with his hands around the neck of the head of the district, who has been offering empty promises to pave the road for years. The HIV/AIDS epidemic there is like a magnifying glass held up in the sun: it distorts and enlarges the underlying inequity and, if left long enough, will cause it to burst into flames. Scores of children are being orphaned, not to mention contracting HIV, and social support networks are stretched to the point of collapse.
What makes me most angry is that the world outside of Kasensero knows about it, yet little has been done. Epidemiologic studies have shown that HIV probably originated in what is now the Democratic Republic of Congo and migrated east. Uganda was one of the first places that was hit, and it was hit hard. Over 20 years ago, the first case of HIV/AIDS was reported out of Kasensero. The Rakai District, in which Kasensero lies, has been a source of a prolific number of research projects and landmark published papers on the HIV epidemic. Yet there seems to be little to concretely show for it in Kasensero. After 20 years of knowing about a burgeoning epidemic, there is only a tiny clinic staffed by nurses, with no permanently stationed physicians. Supposedly someone comes every two weeks to distribute antiretroviral drugs. But these drugs, if not carefully managed and monitored, can have deadly side effects. I have no idea what HIV+ patients do if they have problems with their treatments regimens, or develop an opportunistic infection. It would take them 3 hours at least to travel to the nearest hospital, assuming they can find and afford transport, and that it doesn’t get stuck on the road on the way. They also have to be able to afford the cost of hospitalization.
HIV is only one of Kasensero’s health problems. The day I left, a concerned set of parents approached me to look at their 1 ½ year old child. She looked like she was about 9 months old and couldn’t hold her head up well. They told me she couldn’t walk and was not yet saying any words. In sum, she was grossly underdeveloped for her age and had some signs of mild flaccid paralysis that had been present for some time, according ot the parents. Upon further questioning, the mother had delivered at home and the child had not received any vaccinations at all. In fact, I was the first medical professional who had ever seen the child. There were many things that it could have been, some preventable, some not. The child could have had a polio infection or cerebral palsy, possibly due to injury during pregnancy or birth. She also could have had a genetic muscular dystrophy. My first internal reaction was to be irritated with the parents, that they hadn’t taken the child to see a medical professional before then. It seemed to me there was little excuse for not vaccinating children when vaccines are free. Yet after some reflection I began to feel that it is the health care system that has failed these parents, and this child. If there were trained birth attendants at every birth and community health workers to conduct child vaccination campaigns, or do home visits to check on neonates and mothers perhaps things would have turned out differently.
A ‘preferential option for the poor’ does not mean that it is the sole burden of the poor to rectify their own oppression and unequal treatment. Moreover, the poor cannot ‘fight back’ when they are dying of AIDS, malaria and tuberculosis. In answering my call to become a physician, it is my duty to go to the poor, meet them where they’re at, especially in miserable places like Kasensero. Especially there. Farmer says, “It’s through journeys to the sick that we identify needs and problems.”
God never promised it would be easy to fight against oppression or serve the poor. But, for Christians, He very clearly called us to do it. My pastor, Bill, once preached a sermon about a man who decided to physically cut out every reference to serving the poor in the Bible. Once he was done the book barely held together – the tattered pages had gaping holes through the Old and New Testament. This image struck me as incredibly profound. The physical representation of my faith, the word of God, literally does not hold together if you take out the call to serve the poor.
To whom much has been given, much will be required. Luke 12:48
Yesterday I finished reading a book entitled Mountains Beyond Mountains, by Tracy Kidder. It’s a biography of Dr. Paul Farmer, a Harvard physician famous for his tireless work in the central plateau of Haiti – the poorest country in the Western hemisphere – to improve health care there. Farmer advocates a “preferential option for the poor” that is backed by his belief in liberation theology. Liberation theology was developed by priests in Latin America who preached that “the oppression of the poor was ‘institutionalized sin’” and as Christians we are fundamentally called to do something about it. For Farmer, this translates into a duty to serve the poor of the world, to work toward rectifying the stark inequality humanity has created between the rich and the poor. Kidder writes:
How could a just God permit great misery? The Haitian peasants answered with a proverb: “Bondye konn bay, men li pa konn separe,” in literal translation, “God gives but doesn’t share.” This meant, as Farmer would later explain it, “God gives us humans everything we need to flourish, but he’s not the one who’s supposed to divvy up the loot. That charge was laid upon us.” Liberation theologians had a similar answer: “You want to see where Christ crucified abides today? Go to where the poor are suffering and fighting back, and that’s where He is.” Liberation theology, with its emphasis on the horrors of poverty and redressing them in the here and how, its emphasis on service and remediation, seemed to fit the circumstances in Haiti. (p79)
Fundamental to this argument is the global (mal)distribution of resources, particularly those allocated for health care. Farmer is frequently criticized in his work for not adhering to standards of ‘cost-effectiveness,’ ‘sustainability,’ and ‘appropriate technologies’ for health development work in resource-limited settings in developing countries. Again, Kidder writes:
“Resources are always limited.” In international health, this saying had great force. It lay behind most cost-effectiveness analyses. It often meant, “Be realistic.” But it was usually uttered…without any recognition of how, in a given place, resources had come to be limited, as if God had imposed poverty on places like Haiti. Strictly speaking, all resources everywhere were limited, Farmer would say in his speeches. Then he’d add, “But they’re less limited now than ever before in human history.” That is, medicine now had the tools for stopping many plagues, and no one could say there wasn’t enough money in the world to pay for them.
What it ultimately comes down to is how much human life is valued. Farmer would argue that “cost-effectiveness” frequently translates into the lives of the poor being less valuable than the lives of the rich – those who can afford quality health care, or who live in a country where it is provided for them. In essence, he medically treats his Haitian patients in the way he himself would want to be treated as a patient.
Now, coming back to Uganda. Kasensero, in many ways, might as well be central Haiti. Its people are impoverished, socially and economically isolated by a nearly impassable road, in addition to a dying fishing industry. This road is such a huge source of frustration that the head of the Kasensero fisherman’s association was recently caught on the local news with his hands around the neck of the head of the district, who has been offering empty promises to pave the road for years. The HIV/AIDS epidemic there is like a magnifying glass held up in the sun: it distorts and enlarges the underlying inequity and, if left long enough, will cause it to burst into flames. Scores of children are being orphaned, not to mention contracting HIV, and social support networks are stretched to the point of collapse.
What makes me most angry is that the world outside of Kasensero knows about it, yet little has been done. Epidemiologic studies have shown that HIV probably originated in what is now the Democratic Republic of Congo and migrated east. Uganda was one of the first places that was hit, and it was hit hard. Over 20 years ago, the first case of HIV/AIDS was reported out of Kasensero. The Rakai District, in which Kasensero lies, has been a source of a prolific number of research projects and landmark published papers on the HIV epidemic. Yet there seems to be little to concretely show for it in Kasensero. After 20 years of knowing about a burgeoning epidemic, there is only a tiny clinic staffed by nurses, with no permanently stationed physicians. Supposedly someone comes every two weeks to distribute antiretroviral drugs. But these drugs, if not carefully managed and monitored, can have deadly side effects. I have no idea what HIV+ patients do if they have problems with their treatments regimens, or develop an opportunistic infection. It would take them 3 hours at least to travel to the nearest hospital, assuming they can find and afford transport, and that it doesn’t get stuck on the road on the way. They also have to be able to afford the cost of hospitalization.
HIV is only one of Kasensero’s health problems. The day I left, a concerned set of parents approached me to look at their 1 ½ year old child. She looked like she was about 9 months old and couldn’t hold her head up well. They told me she couldn’t walk and was not yet saying any words. In sum, she was grossly underdeveloped for her age and had some signs of mild flaccid paralysis that had been present for some time, according ot the parents. Upon further questioning, the mother had delivered at home and the child had not received any vaccinations at all. In fact, I was the first medical professional who had ever seen the child. There were many things that it could have been, some preventable, some not. The child could have had a polio infection or cerebral palsy, possibly due to injury during pregnancy or birth. She also could have had a genetic muscular dystrophy. My first internal reaction was to be irritated with the parents, that they hadn’t taken the child to see a medical professional before then. It seemed to me there was little excuse for not vaccinating children when vaccines are free. Yet after some reflection I began to feel that it is the health care system that has failed these parents, and this child. If there were trained birth attendants at every birth and community health workers to conduct child vaccination campaigns, or do home visits to check on neonates and mothers perhaps things would have turned out differently.
A ‘preferential option for the poor’ does not mean that it is the sole burden of the poor to rectify their own oppression and unequal treatment. Moreover, the poor cannot ‘fight back’ when they are dying of AIDS, malaria and tuberculosis. In answering my call to become a physician, it is my duty to go to the poor, meet them where they’re at, especially in miserable places like Kasensero. Especially there. Farmer says, “It’s through journeys to the sick that we identify needs and problems.”
God never promised it would be easy to fight against oppression or serve the poor. But, for Christians, He very clearly called us to do it. My pastor, Bill, once preached a sermon about a man who decided to physically cut out every reference to serving the poor in the Bible. Once he was done the book barely held together – the tattered pages had gaping holes through the Old and New Testament. This image struck me as incredibly profound. The physical representation of my faith, the word of God, literally does not hold together if you take out the call to serve the poor.
To whom much has been given, much will be required. Luke 12:48
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