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
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.
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).
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.
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.
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