Two Months in the "Pearl of Africa" By Shirley Novak

As the first month as a DGH volunteer in Mbarara, Uganda, was coming to a close, I had already begun to view the trip as a true privilege, living in a different part of the world with the opportunity to experience the rich African culture I had known previously only from a distance. My husband, Dr. Larry Novak, and I would have yet another month in which to learn, to share and to be stretched.

“For years I had been exposed to lives lived in poverty in El Salvador, and now the poverty of Ugandans was in front of me. Both groups of people work very hard, live quite simple lives, have very little, and yet all are very willing to share whatever they have available.”

For years I had been exposed to lives lived in poverty in El Salvador, and now the poverty of Ugandans was in front of me. Both groups of people work very hard, live quite simple lives, have very little, and yet all are very willing to share whatever they have available. It is this generous, warm, loving spirit that I had quickly grown to love and admire over the many years of working in solidarity with the people of El Salvador. In Mbarara, I found a great similarity in the Ugandans I encountered.

Within a few days of our arrival, I was struck by how comparable life in small Ugandan communities was to what I had known in El Salvador. Familiar sights were latrines positioned behind simple brick and adobe houses; dare-devil-like drivers maneuvering on pot-holed and often unpaved roads; cows rambling in and alongside the roads; people of all ages balancing goods on their heads as they walk beside the roads; bicycles loaded down as wide as the bike is long with bananas, cooking oil, milk cans and building supplies. And all over the country too are advertisements for Coca Cola, Close-Up toothpaste, Kiwi Shoe Polish and Shell.

Two months can seem like an eternity or an inadequate amount of time to really know a situation or community. While my husband volunteered at the Hospital and Medical School, I was able to tap into many resources that afforded me-a non-physician DGH volunteer-the opportunity to engage in a variety of experiences in Mbarara.

DGH has been accompanying the Mbarara University of Science and Technology School of Medicine (MUST) in Uganda for over three years. A small country in Eastern Africa, Uganda is surrounded by the much larger nations of Sudan, Ethiopia and the Democratic Republic of Congo (formerly Zaire). Mbarara University was founded twelve years ago with the express purpose of promoting Community Health, and bringing responsible health care into rural areas. This fits perfectly with DGH's focus. We have been sending medical volunteers to help teach students at MUST, which is located in an area of Uganda where it is difficult to recruit and retain physicians. DGH has recently lent support to three Ugandan physicians who are committed to bringing health care to rural Uganda. These doctors will help train other Ugandan students in the Community-based Primary Health Care approach after their training ends.

My volunteer time at MUST included assisting in weekly "Introduction to Computers" classes. I was also invited to accompany a group of nursing students and their instructor to a presentation of music and traditional dance by a local community AIDS education and support group, TASO (Task Force on AIDS Support Organization). This provided a great opportunity for listening, learning and interaction. All present came away with a better understanding of the disease and its effect on the community. TASO takes the message of HIV/AIDS prevention into rural communities, reaching many young people whose isolation and inability to attend school might otherwise prevent them from receiving some important personal and public health information.

“It was an emotional experience for me when the children in each class stood up to greet me as I entered their classrooms. "Good Morning, Madam," was followed by their singing to me the songs I had taught them during the previous visits.”

Part of my volunteer time in Mbarara was spent accompanying the staff of Hospice Uganda, at its second site in Mbarara (the first located in Kampala, the capital). I had the opportunity to spend a day on the road with one of the nurses, Martha, on the Mobile Hospice Uganda unit. Every Wednesday a driver and nurse venture out in a land rover on a regular route that takes most of the day. The vehicle pulls off to the side of the road at various trading centers (a series of long, low houses and stores strung together every ten minutes or so along the roadway, often with open air markets in front). The waiting patients climb into the back seat of the land rover in turn, engage in a brief consultation with the nurse, after which medications are handed out. Those who can afford to pay do, often in the form of a live chicken, a bag of avocados or a bunch of matooke (hard, green bananas). No one is denied medicine for lack of payment. Regular weekly clinics are scheduled at the Mbarara site, and a full day, once-a-month daycare program is offered for patients, caregivers and/or family members. Besides clinic checkups, support group meetings, socialization, games, activities, and lunch, the day provides a break for the principal caregivers at home.

Uganda's reality is that many infected with HIV resist testing that would confirm or deny their suspicions. A social stigma still accompanies the disease and, up to now, there has been little affordable medicine available for treatment. Thus, there is little incentive to be tested. People with cancer have similar problems. Screenings, like pap tests and mammograms, a routine part of preventative health care in developed countries, are just not routinely available in Uganda. By the time a diagnosis is made, many diseases are in the final stages. Radiation and Chemotherapy treatments are generally unavailable outside the capital (three hours away), but would be too expensive for most anyway. Therefore, as the work of Hospice is becoming more known in Mbarara, it is more common for patients at the hospital to be referred there for support.

Part of my volunteer time was also spent at Primary 1 and Nursery school classes. There the teachers were most interested in learning about schools in the US and in having me teach their students new songs. No books, educational manipulative toys or materials were to be seen. Each child brought a small exercise book from home, and the teacher sharpened each chewed up pencil with a two-edged razor blade before handing it out. Armed with few resources, schools face a huge challenge in educating children eager to learn.

Dr. Larry Novak preparing materials for a health talk at outdoor immunization clinic.

In Uganda, the government proudly offers free primary education to the first four children in every family. Yet at the Uganda Martyrs Primary School, the head master, Betunga Deus, shared this reality: Education is free in rural areas where school communities need not pay for non-existent piped water or electricity; town and city families must pay a fee to subsidize these basic services. The government goal of 1 teacher to 55 students, still waits; this school's reality is 1 to 80. In some rural schools, I was told a teacher could face a classroom with as many as 150 children. Currently there is an average of 1 book for every 5 students (the official national goal is 1 to 3).

In addition, my time there helped strengthen the connection between DGH and the Department of Community Health at MUST. The Chair of the Department of Community Health, Dr. Jerome Kabakyenga, and Gad Ruzaaza, Administrator of Community Based Medical Education and coordinator for its course specific to fourth year medical students, invited us to participate in a required five-week Community Health lecture series for fourth year medical students. Here students learned about the structure of rural Ugandan communities, how food production and preparation affect health, the role of natural healing and medicines, common illnesses in rural areas and the availability of primary preventive health care. While Gad was arranging the logistics for the students' five-week rural site placements, Larry and I went along on day trips to visit various rural centers. These trips were extremely helpful to us in better understanding the different levels of health centers in Uganda, the communities, and the students' field experience possibilities. Toward the end of our stay, we accompanied a group of seven students to Bughoye Teaching Health Center for ten days. This isolated Community Health Center had no regular physician, but provided primary health care through a capable team of health care workers and a midwife. This clinic had been operational for several decades; a newer part of the facility, completed in the late 1990's by the government of Finland, had gone unused due to safety concerns with rebels in the nearby mountains. We were the first group from MUST to use the full complex, which includes comfortable housing for more than twenty volunteers and a furnished house for us as "visiting lecturers." Ugandan soldiers present in the town provided adequate security to the area.

We accompanied the students on daily excursions into the mountains as they learned about protected water supplies, and prenatal care and home births in the homes of TBAs (Traditional Birth Attendants). In addition to seeing patients in the clinic each morning, the students hiked over an hour on several occasions to provide immunizations and informal educational talks to mothers with their babies tied to their backs, gathered under the trees in these communities. We also listened to an HIV infected single parent explain special stresses the disease causes in her life.

Larry and I returned to Mbarara with a mixture of feelings as our time in Uganda drew to a close. On my last visit to the Uganda Martyrs Primary School, I was filled with emotion when the children stood up to greet me. "Good Morning, Madam," was followed by the boys and girls singing to me the songs I had taught them during my previous visits. My heart also swelled as they later, all uniformed but several in bare feet, waved good-bye and sang a farewell song.

The warm, smiling faces of so many Ugandans-both children and adults-are etched in my mind. I don't need photos to remember their love of life, nor are photos necessary to recall the tragedies-five tiny, crying, abandoned babies taken into an orphanage. Most are believed to be HIV infected. I often find myself wondering how many of them are still alive. Suffering, poverty and over-burdened lives must be remembered when I think of the present-day reality in Uganda. But images that remain just as vividly are of people living and working together in an atmosphere of love and friendship. Young and old live in Community, rich with a culture that honors and respects those who came before, as all look together to the future with vision and hope.