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The last days in Uganda

The rest of the trip!
I apologize for not posting this sooner but my last week in Uganda was really full and since I got back I have been really jetlagged, probably due to the eleven-hour time difference.
On Sunday the 20th Joan and I went back to Mukono to see the progress on Margaret's house and to deliver the rest of the food I had purchased. Everyone was really glad to receive the food; we split it among the older members of the community. Margaret's house is really coming along but we need more donations to finish it. I want to let everyone know that, one all of the donations have not been dispersed yet because we wanted to be sure that those receiving the animals would be able to care for them. Joan is still working out who to give them to. She and I opened an account together so I can send her money in an easy way from here. I also feel totally satisfied that her accounting methods are impeccable. If anyone that donated would like to change his or her donation to go towards a subsistence garden rather than an animal that is also something that is greatly needed, so just let me know. Secondly, I wanted to be clear that 100% of any donation given goes to individuals in Uganda who are in need. The way we accomplish this is that we are still small and don't need to charge for administration yet. All our time is donated; including Joan's, so there isn't any overhead. Since I am home now I won't be able to continue to take pictures of the recipients but I will communicate their names to those who donated. I can tell you that everyone there was so appreciative of what we were doing and asked that I communicate to all the donors how grateful they are. In the next few weeks there will be a link on our website for projects called “how you can help”. This will allow you to look and see what the immediate needs are and then you can decide how you would like to contribute. Additionally, anyone who got a donation of an animal that can reproduce or for a garden that will generate a cash crop has agreed to repay the donation either in kind or with money once the donation begins to reproduce or the cash crop is viable. In this way we can keep the money going and help more people.
Monday through Thursday, November 21 to 24, I attended a conference put on by the “African Midwives Research Network” or AMRN. It was really informative and I met a lot of midwives from the eastern part of Africa. There was general consensus that traditional birth attendants or TBA's had not been effective in lowering the maternal mortality ratio over the last 20 years although no one presented a study that measured their effectiveness directly and on their own. This was a view also held by the World Health Organization (WHO). There was also a lot of information presented on HIV/AIDS including a lively debate about whether or not to recommend infant formula feeding for babies whose mothers are HIV positive, particularly if it was questionable whether or not the mother could afford the formula and effectively prepare it for at least six months. The data presented by the WHO representative was that if it was questionable whether or not the mother had the resources to safely formula feed her infant then she should be advised to breastfeed exclusively. The debate centered around the ethics of that recommendation when the risk of the infant contracting HIV from breastmilk was real. However, the proponents of this approach contended that the statistics show the infant is more likely to die from diarrheal disease (than HIV) if the mother cannot properly prepare the formula. This is a very difficult decision for midwives. Many felt that they would rather just give the woman the information and let her decide. A decision especially difficult when dealing with an effectively illiterate population without a clean water supply and with an average annual income of about $350 US dollars per capita.
On Friday I visited Mukono one last time and told Loy goodbye. It was a good visit but I already miss my new friends there.
Saturday and Sunday I visited Enid's country residence. Enid is the midwife that I have been e-mailing for the last year and is the main reason I went to Uganda in November. She and I will continue working together on the clinic project. I had a great time at her home. She lives in southwest Uganda, in Mbarara district, which is set in rolling hills. There is less brush type growth there and much cattle grazing on open pastures. The elevation is higher, about 3,000 feet, so it was cooler and less humid than Kampala. We were able to go to the animal park for a short time on Sunday and I got to see many antelope, gazelle and zebra as well as some baboons and a few wart hogs. It was pretty fun and we all had a good time.
On the trip home to Kampala we stopped at a roadside restaurant for some lunch and Enid's husband purchased some fried grasshoppers from a group selling them on the curb. They are a delicacy in Uganda and I decided to try some. They taste a lot like really greasy potato chips and really tasted quite good but I couldn't get over the fact that they were grasshoppers! Later on in the day we stopped at a market along the road and everyone bought roasted ears of corn. I really didn't like them cooked so I bought one that was raw and began to eat it. Everyone thought this was really odd and began to laugh at me. And this from people who eat grasshoppers! We all had a really good laugh over the differences in culture.
I left Uganda with many plans. We identified three sites for clinics, one in Mukono and two in southwest Uganda. Joan has agreed to work with us and we will be working together over the coming months to create the details of what that means. Enid and I will also continue to map out this project and the details of who will do what. My job now is to fundraise so that we can build and staff these clinics. I will get information up on the website as soon as I have details so keep checking.
Thanks to all of you for your support.
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(no subject)

November 19, 2005

Clinic Plans
As most of you know I came to Uganda to create a midwifery education program. As I have been here and talked to people, both in health care and in the communities, what seems to really be needed is community based health care that includes midwifery care. Midwives are not in short supply here but they are under utilized in the rural areas, mainly due to their inability to make money there. In working with Joan Kakwenzire I have learned that many of the communities she is working with for food security lack a health care component. She and I have recognized the positive results that could be achieved if we work together. She is identifying 5 villages, similar to (and including Mukono) for us to begin working in. We will purchase land and build clinics in these villages as pilot projects. Ideally, the clinics will be built by the villagers and will include living quarters for the health care workers on site, the land plot will be big enough for a subsistence garden for the workers and a small cash crop to generate funds to run the clinic on. I want to involve the village so that they are invested in their clinic and will really use it.
Thank you to all of you who are contributing money to help the poor of Uganda, as you now know the need is great. I would like to suggest that rather than donating for livestock we turn the donations to subsistence or food security farming. Joan Kakwenzire is a great partner for this and is quite good at making sure the money goes where it should. As people are well fed their health will improve and they will see that things are not so desperate. I have agreed to help Margaret build a house and those of you who want to contribute to that will be welcome. I will put the entire cost of materials etc on the journal early next week and there are many items for small amounts of money that people can sign up to give. Part of the plan for Margaret is to plant cash crops so that she can repay the money. Margaret will be expected to re-pay the money after her cash crops are in and generating income. The money will then be turned around to help someone else in the community. This way people help each other and themselves, rather than just getting a handout and the community is built.
I will be writing an entire plan for the first clinic, in Mukono, and will post it early next week.
Thank you all so much for your support.
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(no subject)

November 17, 2005
I saw Margaret again today. Yesterday I purchased many things for her, a mattress ($10), beans and rice and peanuts, a new dress, and many other things for basic subsistence. I gave her granddaughter, Loy, underwear (she didn't have any), soap, a basin, a tooth brush and paste and then had someone help me instruct her on their uses. Loy and Margaret have never been to the town of Mukono, which is only 5K from their village. For the huge price of 50,000 UG shillings I have sponsored Loy for school for an entire year. This pays her fees, two uniforms, shoes and books and supplies. 50,000 shillings is about $25. There are many children at the school in Mukono who need to be sponsored and I didn't see a one with shoes and many didn't have uniforms. (see the web page for pictures).
I went back to the school to show the children how I got the pictures out of the camera. I had gotten some printed for them to see and then showed them on the computer how all the pictures were there. They had to look at the computer in groups and could hardly wait for their turn, crowding around to get a look. After showing the pictures I showed them how the computer could play music and how you could also write on it. These children barely had the concept of electricity and have never seen a TV so seeing the computer was a bit like magic for them. I also took some supplies to the school, paper, crayons and pens for them to use.
So much can be done for so little here that the results are really gratifying.
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Midwives meeting

November 14, 2005
Today I finally met with Enid Mwebaza and her colleagues, Sarah Kabenae and Margaret Byabakama-Muyinda who are also midwives at Mulago hospital. We began discussing the midwifery project. I learned that there are many trained midwives who are not working because there are no jobs. They felt that those skills could be utilized in a more immediate way than would be possible if we began by training midwives.
We also discussed the problems that lead to maternal death. One third of the maternal deaths are from septic, induced abortion. As I mentioned earlier, abortion is not legal in Uganda and so desperate women self induce. This of course leads to complications including death. Another large cause of maternal death is post-partum hemorrhage, or PPH. Delay in access to care is a major contributing factor in PPH. Delay in recognizing problems and then delay in getting to a facility for care. We discussed the problem of transportation from rural settings to a clinic with the ability to handle the emergency. We also discussed the problem of no trained personnel in the vicinity of the mother to help her with the delivery and treat PPH should it occur and prior to it becoming life threatening. Traditional birth attendants were trained about twenty years ago and then essentially turned loose in rural areas without the supervision of a trained midwife. The midwives I met with felt that these TBAs habitually over stepped there training and rather than referring women to a center for care were trying to treat them at home. There is the additional problem of the husband not being willing or able to pay for transport to another facility. The maternal death ratio has not changed since TBAs began to be utilized, which seems to indicate that they are inefficient at reducing maternal mortality.
One approach that was discussed was improving the access to care by putting the unemployed midwives to work in the rural areas and giving them the supplies necessary to do the job. This would become the primary objective, with improving transport being a secondary goal. One of the obstacles to determining whether or not any project is successful is knowing what the birth and death rate is currently and what the maternal mortality ratio is in a given area. The general consensus was that the records were not being kept, currently, in any reliable way.

Later in the day the city experienced riots with looting and tear gas, etc. The man running for president in opposition to the current president was arrested on charges of rape and treason and this sparked a great amount of civil disobedience and unrest. I was at the café I like to go to and saw a number of police vehicles (which was unusual) but it wasn’t until my driver came that I found out what was happening. I was quite safe as I was out of the city center but it was unsettling just the same.
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website pictures

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November 15, 2005
I cried today. Joan took me to the village she is working with to create food security and cash crops. We stopped to talk to a woman growing sweet potatoes and then to an old man whose clothes where so old they were literally falling apart. From there we went to Mwanyangiri Primary School. This school houses 600 to 700 children. I had brought a soccer ball to give them and they were so excited and got me to even play with them. The children have been planting pineapples around the school as a way to earn money for the school. Joan has promised the school a pig and a cow once they have sheds for them. The idea is to teach the children how to manage crops and animals so that when they are adults they will carry on with the knowledge. Andrea, your generous gift goes to the school to create this learning experience. The soil is clay and everyone builds structures from clay bricks made right on the premises. The children will be involved in the process of building the structures for the animals. The teachers were most excited to have the gift. I will get pictures of the school and the children up as soon as possible.
After the school Joan took me to her own home where she is creating a demonstration farm. She has a poultry house with about 80 chickens that are laying eggs to sell. There are about 6 head of cattle that she breeds and about 15 offspring. There are also two donkeys, which are currently useless but will be trained to carry things. There is about 20 acres under cultivation in bananas, mangos, pineapples, aloe, beans, vanilla, peanuts and other edible and cash crops. Joan puts all the proceeds back into the farm. There was also a pig house with a boar, about 5 sows and a number of piglets. Joan employs 5 workers on the property and they were all working hard at cleaning up and working with the animals. The house is still being finished but the septic tank is in as well as a huge cistern for collecting rainwater for the house and for irrigation. Currently, the toilets are pit toilets to the rear of the house. Here they dig them very deep, 80 feet, and then place a foundation of concrete over them with a hole in the center to use fro elimination. The toilet invention I had described earlier has not been installed but we did put it over the pit so we could sit down to pee. I have taken pictures so they will be up on the web soon.
After an extensive tour of Joan’s property she wanted to show me the woman’s property next door. The house consisted of one room that was wattle and daub without brick. There was also a cooking structure outside and the woman was cooking dinner. Joan had told the woman that she would supply the metal sheets for a roof if the woman made the bricks from her land. Joan had noticed that this was becoming an overwhelming task for this woman and we decided that one of the donations I had received would go for labor to make the bricks and build the house.
The woman, Margaret, is 43 years old and cares for her three grandchildren. Her son has taken off and provides her with no assistance. I took some pictures and we began to look about the place with the idea in mind of helping her plant some cash crops. She has about 2 acres and Debra, one of the women working on Joan’s place thought it very promising and said she would get back to me with an estimate of how much it would cost to put in a food security garden as well as some cash crops of bananas and pineapples.
As we were preparing to go I took some more pictures of the cooking area and asked Debra what was cooking. It was food for the pigs (Margaret has 2). I then asked what the children were going to eat and was told the same as the pigs. This was a pot full of what looked like sticks and such. This of course upset me and I asked if I gave money would they be able to get some food. Yes that would happen. I gave the woman 35,000 Uganda shillings, about $20 and then lost it. I have seen a lot of poverty since I arrived, but the idea of the children going to be with nothing substantial to eat was too much, and I broke down and cried. The pictures will be on the web soon.
An anonymous donation of $150 will be given to build the bricks and the house for Margaret and as soon as the bid is in from Debra the garden and cash crops will be funded.
Thank you to all the donors that gave money so that I have a little cash to work with here. Can you believe that for less than $250 Margaret can have a new house of brick with leak free metal sheet roofing?
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Saturday November 12, 2005
I went to a traditional Ugandan Wedding, or Kwanjula, today. My hostess, Joan asked me to attend with her. She had been asked to appear for the groom. This was a very elaborate “engagement celebration”. The groom and his family and entourage show up at the bride's house to ask for her hand. Of course the bride and her family are expecting them but a great show is made to pretend that they are not known by the bride's family. We drove about an hour and a half outside Kampala with many stops and starts as we waited for everyone to catch up. Everyone was dressed in his or her finest traditional dress. We walked in to the celebration as couples, man and woman, being paired up by the organizer outside the compound. There then proceeded to be a back and forth that went on for several hours, between the speakers for the two families. All this was aimed at getting the bride's family to agree to the marriage. The speaker for the bride's family made many jokes about the groom's family, all in good fun, even when they were directed at me. I could not understand the goings on since they were not speaking English but it was clear when they were directing their laughter at me. After a time the groom was accepted and the ceremony turned to the bringing of gifts by the groom's entourage, a modern day bride's price, if you will. My hostess explained to me that their culture does not see it as “buying the bride” rather as showing good will between the families and showing the groom is serious about taking care of the bride. The gifts consisted of practical things, mostly foodstuffs and some clothes, however three live animals were included, a cow, a goat and a chicken. After the bringing of gifts and the taking away of them we moved on to more talking between the families and introductions. I was given a new African name by my hostess, Joan. I am now Kirabo, which means gift. Joan introduced me as a gift to the people since I had come to Uganda to work with them to help mothers. I felt quite honored.
We started the event in Kampala at 10:30 in the morning and by now it was past seven in the evening, the darkness having settled. They were ready to serve dinner now and as everyone got up to go through the dinner line the lights went out. Joan and I desperately needed a toilet, having sat for many hours without any opportunity to relieve ourselves. We were guided by a family member through the darkened house to the toilet by the light of cell phones. When we got there and looked at the facilities we both broke out laughing. There was a hole in the floor only. Well there was nothing to do but use it and we both had quite a good laugh about peeing by cell phone light. The irony of the situation was just too much. Such plenty displayed outside for the wedding and yet not even a flush toilet inside.
I thoroughly enjoyed the day but was exhausted by the time we returned home at about 10:30 PM. We arrived to darkness as the electricity was out, but this time I remembered that I had a flashlight in my purse (my purse had been in the car earlier at the wedding). Joan and I sat and talked for a while and I am hopeful that we will be able to work together in a complimentary way, she teaching the people how to become self-sufficient and me working to make a difference in health care.
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Malago Hospital

November 11, 2005

Today Dr. Joseph took me for a tour of Malago Hospital. This is the largest public hospital in Kampala. They have one public floor but the majority of the patients they see are without funds. We started the tour in the delivery ward. There were many women waiting for a first exam by the doctor. There were two examining beds off the waiting area and the twenty or so women waiting were waiting for those beds. Most of these women seemed to be either in early labor or not in labor at all. After the first exam the women are then either taking to the first stage labor room or directly to the delivery room. They walk under their own power to get to their assigned area. The first stage labor area was quite crowded and some of the women in there had given birth there, not it making it to the delivery room. The delivery room was a raised bed, without stirrups or linens. The woman that I saw while I was there delivered onto a plastic mattress with no pad or linen under her. The gown she had been wearing was used to wrap the infant, as she had nothing else to use. The hospital has no linens or blankets to give the women. The cord was tied with a piece of latex glove and cut with a razor blade. I learned that all the delivery pacs were being autoclaved. There was also a small area for resuscitation of the infant when necessary. Despite the conditions, I observed the staff being quite kind to the women given the overwhelming task at hand for them. After a few hours the women are moved to the post partum ward and as soon as they are stable they are discharged, usually only a few hours. The post-natal ward had over 100 patients when we were there and is designed for 45. Many of the women were lying on mattresses under the beds of other patients. This maternity unit sees somewhere between 75 and 100 deliveries in twenty-four hours. The workload is enormous. The number of midwives on duty in the same period is roughly 10. There were many student midwives as well working on the unit.
All of the halls on this floor were filled with patients and “attendants”. Outside on a grassy area many were washing and drying clothes and linens. (Despite the sign that said not to).
After visiting the unit there we went over to the antenatal area. It was packed with women waiting to be evaluated and seen. Everyone is offered confidential HIV testing and counseling. If they decide to test they get the results at the end of their visit that day. After they go through the counseling and testing they then wait to see the midwife. This is the point at which it is decided whether or not they will go to the higher risk unit (just described) or to the lower risk one. They then show up in labor at the designated area.
The lower risk maternity area was not nearly so crowded. The age of the equipment was the same, antique, and the women there also supplied there own linens and baby clothes. Family members attend the women for the most part with midwives there for the medical part of the care. Lack of sufficient instruments was again a problem.
From here we toured the gynecology area. They have a special clinic for vasectomy and tubal ligation as well as for vesico-vaginal fistula repair, or VVF as it is called. I quizzed Dr. Joseph about VVF and it's causes. He said that due to malnutrition in childhood many women do not have the bony structure of the pelvis to accommodate childbirth. If they have an arrested labor and the baby sits in the upper vagina putting pressure on the bladder and surrounding tissues, loss of blood flow results. This in turn causes the tissue to die and slough off leaving the woman with an open area between the bladder/urethra and the vagina or VVF. Apparently it is a relatively common event and one for which there are not enough resources to fully treat. Consequences for the woman of VVF are the obvious leaking of urine without control, which causes her family and husband to reject her. She is then left even more destitute than she was prior to the birth.
The highlight of my visit was seeing the special care nursery. Mothers of these low birth weight and premature infants are totally involved in their care. They are taught to gavage feed (with a tube ) their infants themselves and kangaroo care is the norm for the babies. The Pediatrician who showed us around said that they have just concluded a study showing the effectiveness of the care they are giving to these special infants. The doctor said that they release many of the infants after only two days, even some that weigh less than 1000 grams (about 2 pounds, give or take). The mothers then give them expressed breast milk through the gavage tube until they are old enough and strong enough to latch to the breast. The mothers return weekly with the infants, to the unit, for follow-up. This was the most impressive unit I have seen so far. Although very low tech and antique it was well run with all the infants getting what they needed to survive. The mothers were very involved in contrast to the neonatal units in the US where the nurses do all the care taking and the mothers just visit. Mothers are given beds so that they may stay with their infant until it is discharged. They had two infants of a set of triplets that had been born there, vaginally. The third baby had just died that morning unfortunately.
So that is my experience so far. Rather overwhelming and yet the staff seem to keep on. So far I have learned that there is a great need for instruments so any one out there willing to donate please do and I will bring them on my next visit.
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maternity centers in Kampala

November 10, 2005

Today I visited several different maternity units. The first was a private office of a midwife, Musoke Clinic. Imelda Musoke, the owner and midwife was quite gracious and showed Dr. Joseph Okia and myself around her facility. She does antenatal, deliveries, and post-partum care. She also provides family planning, STD counseling and confidential HIV testing, as well as immunizations and post-abortal care. Abortions are not legal in Uganda, but as anywhere there are women desperate enough to attempt it on their own and then they need care afterwards. Often this includes aspiration of the uterus by the midwife. Imelda made it clear that she saw her job as having many aspects. All patients coming to her office get counseling on birth control methods as well as general health information, such as malaria and cholera education, STD and HIV information. She also provides a place for children to come for primary education and a place for adults to come for literacy training. Imelda's clinic had many necessary items but she would like to have more beds for her patients. I noticed that her lab had a microscope that was functional but the light was not operational. She had improvised by having a light bulb sitting next to the microscope as a light source.
The second place we visited was the private hospital, Kololo. I felt I had time traveled to the forty's or fifty's in the US. The scene looked like something out of the older medical textbooks we are so familiar with. It was clean and not over crowded but the beds and facility were quite antique. There was an incubator for infants but it too seemed outdated. Women are moved from the labor room to a delivery room, which also looked like something you would see in a very old medical text. Women's families are responsible for bringing them food and a female relative stays with them to act as an “attendant”. They are too short on nurses to have them perform that function. The staff was quite friendly and the hospital not very busy when we were there.
The third hospital we visited toady was the International Hospital of Kampala. It was founded by an Irish physician Dr. Ian Clarke and is a private center. He is building a public wing but it is not open yet. This hospital is much newer and Ian gave us a full tour. The maternity unit was not full but this hospital was much newer with many newer pieces of equipment. Ian also told us that he is beginning a school that will supplement the regular training provided to health care workers, and showed us the lovely new class room that is large enough for about fifty students. Ian hopes to create an exchange program for students and faculty from the west to experience health care in Uganda and a chance for Ugandan's to travel to the west and experience health care there.
The differences of the three facilities we saw today were vast but even the best equipped International hospital does not compare to the facilities we are used to in the US.
Dr. Okia has been a Godsend. He works in the office of the first lady of Uganda and I think this has gained him entrance where I might not have otherwise been allowed in.
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(no subject)

Hi Everyone,
I am here in Uganda now. I arrived yesterday. What a beautiful country. It is very green and lush, but not too hot. I have had fresh fruit for breakfast twice and what a treat. The papayas are huge and the bananas are really sweet. There is much poverty evident every where you go. The rich and poor are not separated, with very plush residences right next to ramshakle huts. (All the plush residences are fenced, however). I am going to a private hospital today and then tomorrow to a private one. In the afternoon tomorrow my hostess will take me to a village she is working with and I will meet the midwife there. Joan Kakwenzire (my hostess)is a senior advisor to the president on poverty alleviation, and is well placed to help with our project.
I will update as I can, internet access requires going to an internet cafe. I am not sure I will be able to upload pictures, as I have not found a place where I can use my own computer. I will post them when I get home if nothing else.