Childhood Illness Group Reflection

Academics

In contrast to all the packed-in schedules that we followed together, our group was given two free days, one to relax and spend leisure time together and the other to conduct independent research in our own theme groups. This was a great experience for a lot us, as it was the first time where we were forced to use public transportation (taxis that were mini-vans) to get around places.  On the first free day, many of us went to church in the morning and then to the recreational center for a great swimming session.  Some of us went to the spa and received pedicures and massages to receive the long-awaited rejuvenating moment for all the fatigue that had accumulated in the past two weeks. For dinner, many of us found our way to the “most American restaurant”- Mish Mash – to grab a burger or grilled chicken in the midst of the amazing live music the restaurant had. On the second day, all of us split into our theme groups and conducted independent research. Pediatric HIV group encountered a group of teenagers who sang together to sensitize the community to bring down the stigma of HIV, and for sure, it was an inspiring experience they shared with the group. The Orphans and Vulnerable Children group traveled 140km to get to the orphanage sponsored by Vision for Africa, only to be shocked by the “palace” that these orphans lived in, not to mention the jungle gym and the nice clinic they had. It was very encouraging to hear that many orphans are in good hands and are being helped to be molded into sociable adults.  

On Monday, January 21^st we continued gathering information for our independent study. We first spoke to a specialist in the field of Child and Maternal Public Health, of Makerere University. She discussed many of the interrelated factors that are currently impeding the treatment of childhood illnesses. More specifically, she described the poor attitude of health workers, denial of research, lack of accountability and quality control, desensitization, and the improper allocation of health sector funds. Furthermore she stated that a major problem was the vertical approach to health care. An example of a vertical approach occurs when donors want to give all their money to treat just one illness; despite their benevolent intentions, donors are not improving Uganda’s health sector in a broad sense. She stated that Uganda could solve this problem by following a horizontal approach instead. For instance, Uganda could put their donor funds towards improving the general health care package and making certain that all Ugandans have access this packed, rather towards improving the state of just one disease. Ultimately she suggested that a lack of agreement over which healthcare approach to implement was the underlying interference to her solution.

 

Later on we spoke to a pharmaceutical technician and dispenser at the Mulago Private Patient Pharmacy. Moses revealed many interferences that exist in the healthcare sector. He stated that there is too much bureaucracy and health has become political. He also shared his opinion on the Ministry of Health, an institution he believes is corrupt. He also showed us that there is frustration at all levels of the health system. Patients become frustrated with him when medicine is out of stock. (Three times throughout our interview with him, patients were sent away to a different pharmacy because the Private Patient Pharmacy no longer had a particular medication.) His boss becomes frustrated when he asks for the funds to order more of these fast-moving drugs. Finally he himself becomes frustrated because he is the middleman; his patients attack him and his boss neither appreciates nor understands him. Despite all this frustration, people have generally remained complacent; they give up and accept the system as what it is. No one is channeling this frustration towards effecting positive change. There is a general lack of faith and inspiration. It seems that many of the people we have interview throughout this process are merely waiting for a savior, someone who can get rid of the old system and start from scratch.

 

Tuesday we figured out the direction for our final project and created our presentation. We chose to emphasize seven of the interviews we conducted at either Rakai or Kampala. For each interview, we focused on a healthcare problem, a possible solution and an interfering factor that is preventing the problem from being solved.

Reflection

                Before our reflection session, we were able to listen to a fascinating story about Daniela and her friend Ibra of how they got into a dangerous situation with gangster kids and were able to get away unharmed, wallets untouched and funny as it sounds, escorted by these gangsters back to their hotel. Simply by horsing around with the kids, Daniela and her friend Ibra were able to change the atmosphere that diffused the situation to an enjoyable atmosphere from a stern one. After all, “Kids are kids and just kids.” Realizing the power of one’s reaction that can completely change the situation from a dangerous one to an enjoyable situation truly fascinated us.

                On our free day, many of us went to a spa and others went to a recreational swimming pool. While reflecting on the day later on, we discovered that some of us were uncomfortable going to the expensive spa and fancy restaurant. Although group members had different opinions, we all agreed that it is better to open up about our personal comfort levels so that compromises can be made and our time can be spent together. One colleague observed that one’s ability to compromise reflects how much one is willing to find comfort in places outside one’s comfort zone.

                An important question asked in the reflection session was what people wanted to get out of the last five days of our trip. This question ushered in a premature goodbye atmosphere, causing members to make rosy comments and concluding remarks about the trip. The most appropriate phrase to describe our expectations may just be “carpe diem,” to spend and live each day like it is our last, so that we will have no regrets when leaving Uganda, with everlasting friendships and unforgettable memories to cherish forever.

Mental Health Group Reflection

Since returning to Kampala last week, the Mental Health group, comprised of Molly, Raphael, and Alex, has been collecting information and observations to present to the Makerere and JHU faculty on Wednesday.  On Friday, January 18, we visited the Makerere University – Johns Hopkins University Research Collaboration Center (MU-JHU). We learned about the services provided by MU-JHU to help HIV+ pregnant mothers prevent HIV transmission to their unborn children. The doctor who spoke to us at MU-JHU is greatly involved with the antenatal ward at Mulago Hospital and was willing to give us an extensive tour of this unit. Through this tour, we learned how the HIV testing is performed on site for rapid results, that there is counseling available for mothers and adolescents who are trying to understand their infection status, and the various types of medications administered to HIV+ women who want to prevent mother-to-child transmission.

Mental Health Group (from left: Alex, Raphael, and Molly)

After this very eventful morning, the Mental Health group had the opportunity to visit the Psychiatric Ward at Mulago Hospital to compare their past experience of rural psychiatric services to an extensive psychiatric unit in an urban setting. We were able to talk to a psychiatric clinical officer who provided us with a different perspective of mental health issues regarding volume of patients, services offered, and treatment plans.

The following day, Saturday, January 19, all JHU and Makerere students travelled to a water and sanitation treatment facility in Kampala. There we learned the steps and processes required to convert toxic water in Lake Victoria to safe, useable water in homes in the surrounding districts in Uganda. Most of the JHU students were able to compare what they learned in their previous public health courses regarding the successive steps of water sanitation and treatment in the US to that of Kampala, Uganda. Shortly after returning from the water treatment plant, a Ugandan Member of Parliament (MP) discussed his successful attempt at election and current term issues and plans. One major problem face is governmental corruption, which he believes will stall long term development in Uganda if not addressed.

That evening, the Mental Health group engaged the group in a reflection session to discuss the events of both the current and previous day. We first gathered opinions on the groups feeling toward the MP. Many thought he was inspiring, courageous, genuine and brave because of the obstacles he had to face in attaining his position. Another topic of discussion was that demonstrations are often effective in enacting change, but should not be used exclusively as solutions in all situations. Then we discussed our experience at the water treatment plant the previous day. Many flaws were obvious, including the contamination of the potable water after traveling through the pipes to the homes and the suggestion to boil the tap water to ensure purity even after chlorination. These issues are not foreign to some locations in the US. For example, in Baltimore there are still lead pipes carrying water to homes, which also makes the water treatment process inefficient.

The mental health group then shared their findings with everyone, including the comparisons between Kalisizo in rural Rakai and urban Mulago in urban Kampala and witchcraft and traditional medicine as compared to western medicine. At Kalisizo Hospital we discovered that there is only one psychiatrist who mainly deals with HIV related mental illness. He is the first psychiatrist at the hospital and has been working there for the past three years. He mentioned that the incidence of autism in children is only one per year. This is much different from what we found at Mulago Hospital in Kampala where the practicing psychiatrist in the established psychiatric ward diagnoses upwards of 60 children a year with autism. Based on our comparisons between the two facilities, we questioned the group about other similarities and differences they may have noticed. Students believed there was overcrowding, long waiting times, and lack of clean supplies, sterilization, and privacy at both Kalisizo and Mulago. However, students were aware of the greater availability of technology and resources at Mulago as compared to Kalisizo.

Psychiatric Ward at Mulago Hospital in Kampala

Another topic of discussion that arose was the stigma associated with mental health treatment. The Luganda word “mulalu” translates in English to “crazy,” “mad,” or “mentally ill.” This may be a contributing factor to mental health stigma in Ugandan society. Although the association of crazy behavior with mental health is apparent in Uganda, many American students also admitted to stigmatizing those with a mental disorder as crazed.

A major mental health issue we have discovered thus far is the high prevalence of witchcraft and traditional medicine in Uganda to treat ill patients. During the past two weeks, we have had the opportunity to compare not only urban and rural mental health facilities, but also the comparison among witch doctors, traditional healers, and psychiatrists. We found that many mentally ill patients prefer to first seek out witchcraft or traditional medicine techniques to treat their affliction and only visit a hospital as a last resort after spending all their money and giving away all their cattle as payment for treatment.

To gather more information on the practice of witchcraft, we explored the village around Mulago Hospital. Although we did not have the opportunity to meet with a witch doctor, we spoke with a couple of people who provided us with insightful information. One man explained how his aunt took her convulsing son to a witch doctor for treatment. After many unsuccessful debt producing visits, she decided to bring her child to the hospital for treatment where he was diagnosed with epilepsy and effectively treated. Another woman explained that she was a Christian believer and felt uncomfortable speaking about the witch doctor because of stigma.

     Our group is having an information-packed experience learning about the different types of techniques and settings used to treat mental health in Uganda. We are looking forward to presenting our findings and observations to the Makerere and JHU faculties on Wednesday.

Pediatric HIV Group Reflection

Academic:

The Pediatric HIV group (Toni, Anastasia, and Victoria) have had much exposure to HIV/AIDS in the classroom, but the opportunity to observe and interact with those closely working with the disease was indispensable in expanding their knowledge. When first going out to explore HIV/AIDS in Uganda, we were all thrilled to have the opportunity to study the disease in a place with such a high prevalence; however, we didn’t realize the similarities we could draw, despite our cultural differences. From talking to health professionals to researchers, we were not only able to learn more about this widespread disease in Uganda, but were also able to create parallels within our own country. As related to Baltimore, the quality of care is directly related to your income as well as your place of residence, specifically comparing rural and urban areas.

Pediatric HIV Group exploring Kampala

               When beginning to learn about HIV/AIDS, we realized that the disease is highly stigmatized in Southern Uganda because the social implications for having such a disease are associated with promiscuity and immorality to mention but a few. This social stigma has put major health access restraints on children who have inherited the disease. In Uganda, Pediatric HIV is predominantly transmitted from a pregnant mother who is HIV positive during birth or through breastfeeding. The overall health of HIV positive children is highly influenced by the disease; it weakens their immune systems and makes them increasingly more vulnerable to common diseases such as malaria, diarrhea and pneumonia. Because social stigma is such a concern, women sometimes hide their child’s status, not disclosing it to teachers, doctors or even fathers due to fear of discrimination, which directly affects a child’s ability to get the proper care. This was evident when we visited the pediatric ward at Kalisizo Hospital in Rakai. Rakai is a rural district of Uganda, which has had a high prevalence of HIV/AIDS. We were astonished to learn that although every child was required to be tested for HIV before treatment, some mothers would deny their status or even leave the hospital to seek traditional medicine. There was also a lack of drugs and a shortage of staff throughout the hospital. This hospital was unlike any we had ever seen:  the undivided beds in the wards and healthy children playing amongst those in critical condition were disheartening. It was an overwhelming day after seeing the major advancements and research being done by the U.S. donor-run Rakai Health Sciences Program (RHSP) a few blocks away. Since the creation of the RHSP in 1988, it has had major strides in managing the HIV/AIDS epidemic. We were astonished to see how this program’s research and involvement in the community has been wildly beneficial in more ways than providing proper health care. Through our visits with our homestay families, we were able to see the respect and value the Rakai residents had for the RHSP. Some of our host families were employed by the program for 20 years, and others were grateful for the free and easily accessible treatment their families received. Through our independent study, we found out that the key aspects of managing such a debilitating disease include education that this disease can happen to anyone, proper treatment through administering drugs and offering counseling, and encouraging prevention through contraception use. By looking at such a rural area’s advancements in HIV/AIDS treatment and prevention, we were able to see the progress that can be done. This however, is not indicative of all rural areas of Uganda. A rural village called Toruwu, which we visited earlier in our trip, was a better representation of the discrepancy of care between rural and urban settings. From brief visits with the families that lived there, we found out that the nearest health facility was in Mulago, which is 15 km away. Many children with HIV are usually unable to get the proper medical care because many are either orphaned or abandoning them with grandparents who are physically unable to walk these distances. Despite the lacking care in the rural areas, there are increasing advancements in the city, which shows how far this country has come in decreasing the prevalence of HIV/AIDS.

After visiting Kalisizo hospital, we got a chance to experience pediatric health care at Mulago hospital situated in Kampala district, an urban center. Mulago hospital is one of the national referral hospitals in Uganda, it receives patients from different parts of the country that come for treatment for various kinds of diseases. At Mulago hospital, we visited a foundation created by Makerere University and Johns Hopkins University entitled MU-JHU that was set up to improve the health status of families living with HIV or affected by it. This foundation has carried out research concerning HIV/AIDS which has provided information on how best to prevent the HIV epidemic especially in the area of mother to child transmission; it has also set up a community based approach in controlling and handling HIV so that HIV no longer becomes an individual issue but a community issue. This has been done by encouraging HIV positive individuals to come with their partners for testing and counseling and by providing treatment and health care for all HIV positive individuals in a family. The information from the research carried by the foundation was instrumental regarding treatment options for prevention of mother to child transmission of HIV/AIDS.

Poster at Kalisizo Hospital

Reflection:

                Earlier that day before our reflection session, the group returned to the Ndere Cultural Center from our safari adventure at Lake Mburu National Park. That afternoon, Dr. Fred Ssengoba, a faculty member from Makere University School of Public Health came to speak to us about his work with health systems. He introduced the six building blocks of a health system: governance, finance, service delivery, workforce, medical products, and information systems. Based on the findings from an assessment he conducted in 2010, he pointed out the variety of issues associated with each building block, but despite the resource constraints in Uganda, the overall service delivery is performing reasonably well. The problem with service delivery is that it is heavily affected by the failures from the other five building blocks. While there are numerous issues in the Ugandan health system, Dr. Ssengoba left us with a positive outlook by reflecting on how many micro changes have occurred over the past eighty years, which resulted in improved health, such as mandated immunization in children.

                We began our reflection session with an activity to gage the group’s knowledge on HIV/AIDS. We read aloud ten HIV/AIDS related statements and asked the group to clarify whether they were myth or fact. Overall, the group was able to correctly determine which statements were true and vice versa. We then asked the group to reflect on their reaction if an immediate family member were suddenly diagnosed with HIV. A few members of the group shared personal experiences of dealing with close family members and friends who were diagnosed with the HIV. It was inspiring to hear their stories, which helped place the group into the personal aspect of the disease. After our reflection question, we shared with the group the development of our research through the site visits and interviews. We ended our session with a light hearted bonding activity, where we each picked a random question out of a hat and had to answer it. Would you eat a bucket of live crickets for $40,000?

Orphans and Vulnerable Children Group Reflection

              One of the first challenges that the Orphans and Vulnerable Children (OVC) subgroup encountered was the complexity of the topic, making it a broad and challenging subject to cover entirely. Because vulnerable children can also mean children that are disabled or have a poor quality of life, we decided to focus upon orphans, child-headed families, and children that have lost one parent to HIV/AIDS in order to narrow our search. Our approach was to coordinate with organizations that focus on the aiding of OVCs in both rural and urban communities. In our first two weeks in Uganda, we have been extremely fortunate to speak with and explore organizations such as the Rakai Aids Information Network (RAIN), Kalongo Widow and Orphans’ Project, a prominent babies home in urban Uganda, and a remand home in urban Uganda. Through our experiences with these organizations, we have decided to focus on education, healthcare, quality of life, and the impact of organizations on the lives of OVCs. Throughout the next week, we hope to continue to gather information from urban organizations, medical institutions, and orphanages within Kampala.

                Investigating our topic over the past week, our group has explored many facets of OVCs. Visiting with RAIN and the Kalongo Widow and Orphans’ Project in Rakai gave us some fascinating insight into the lives of OVCs. For example, we were shocked at the lack of involvement of the government in the case of OVCs. Though the Ugandan government provides Universal Primary Education (UPE), we learned that merely providing schools and teachers was not enough. Both RAIN and the Widow and Orphans’ Project had to provide scholastic materials, clothes, food, and even shelter for OVCs. We were also surprised to learn that though the government does provide some universal secondary education, it is only for those who meet high academic standards, a difficult feat for orphans who attend low-quality primary schools and face hardships that other students may not. We also learned some astonishing statistics. Out of the 34.5 million people living in Uganda, 52% are under the age of 18; of these youth, 11.5% are orphans.

                Two days ago, the JHU/MakSPH students had the opportunity to visit a babies home and remand home within the city of Kampala, allowing us to further explore our topic. The babies home, an orphanage for abandoned children under the age of four, is geared towards finding a permanent home for these children, locally and internationally. Within the home they are taught, provided meals, and cared for by staff, affectionately termed ‘mamas’. If a child in the home is not adopted by the age of four, they are transferred to a home specialized towards older children. Our time spent at the babies home consisted of touring the home, shadowing classes, helping with grounds work and laundry, and playing with kids. The remand home provided a stark contrast from the babies home. A center for youth aged 12-17 who have been arrested and are awaiting trial, the remand home’s efforts are meant to reform the behavior of these youth and assist them through their trial. The facility, meant to accommodate 142 youth, was overcapacity, housing 184 youth. JHU/MakSPH students were surprised at the close living quarters and lack of necessities. Through interviews with the social workers and warden, we learned that a large number of the youth there were OVCs. A social worker explained that many OVCs are forced to commit crimes in order to provide for themselves, younger siblings, or older relatives. Our goal there was to interact with thirty of these youth through activities and discussion, getting to know them individually.

Later that night our group led a reflection session focusing on the day’s activities. We discussed the impact that we had on the babies and youth earlier that day as well as the ethical dilemmas we encountered at the babies home, remand home, and while investigating our independent study topics. The majority of students had mixed feelings about their contributions towards these youth. Leading off of that, the first topic that we discussed was whether we had done more service or harm in our short time volunteering at the babies home and remand home. Many students felt guilty volunteering for one day because they felt the experience was geared more towards their academics than helping the youth. Students also felt disappointed with the remand home because they believed that they could not make a significant impact.  One term that was discussed by everyone during the reflection session was ‘Poverty Tourism’. This term refers to the act of seeking out experiences or lifestyles in underdeveloped countries that a traveler may not otherwise see. In the session, we decided that, as students, our experience did not classify as Poverty Tourism because our intentions were well-meaning and the purpose was academic.

In the next week, our group is eager to explore more urban areas, learning about OVCs in the process. On our independent study day, we are excited to visit an orphanage geared towards children older than the age of four. We cannot wait to compare and contrast our findings with those from the rural areas as well as the babies home and remand home. Hopefully, we’ll gain much more insight into the condition of orphans and vulnerable children in Uganda.

A member of the OVC group interacting with an orphan at TORUWU

Water and Sanitation Group Reflection

The three students that created this post comprise the Water and Sanitation group and are Wesley and Brittany, who study at Johns Hopkins University and Norman, from the Makerere University School of Public Health.

After a week of cold-water bucket baths, squatting over latrines, and hiking to retrieve water, a warm shower is no longer something to be taken for granted. For the three week period of our independent study in Uganda, our group has chosen a focus on the Water and Sanitation subtopics of clean water, waste water, and solid waste during our experiences in Kampala, Rakai, and Lake Mburo.

What We Found Surprising

An interesting topic arose during the homestay in Rakai, regarding access to clean water. One of the homestay families owned a Biological Sanitation Tank (Biosan). Forty of these tanks had been donated by the Rotary Club to institutions and homes in the Kalisizo area. These systems work by using sand to filter contained water as well as a biofilm to destroy other environmental contaminants. Initially we perceived this to be a brilliant public health initiative. However, upon questioning a health inspector about the project, he was not convinced that this technology has been very effective. He brought up many different problems that come with the tanks including their requirement of a great deal of upkeep and understanding of function. When residents do not know how to properly use the tanks, mold growth can become dangerous to health. The inspector was insistent that encouraging the consistent use of the widely-understood practice of boiling water was the safest and most effective method for assuring safe water within the broader population.

In spite of the awareness of safe waste water and hygiene practices in many communities, there have been behavioral limitations. An example: despite the prevalence of many latrine facilities in different communities, open defecation is still frequently practiced, often near usable facilities and community water sources. Although many accessible technological solutions exist, the most basic preventive hygiene practice, washing hands, before the preparation of food and communication with other individuals following the use of latrine facilities, is still insufficiently practiced, contributing to many preventable illnesses.

Solid waste is consumer waste (garbage that does not include waste water or fecal matter). Within many communities there is a challenge surrounding solid waste infrastructure regarding accessibility, convenience, and effectiveness. The inspector familiarized us to one of the many methods citizens follow to rid their homes of solid waste: local dumping sites. It was very interesting to learn about the actual compliance with the trash collection services, and how this can significantly impact the daily structure of the sanitation system. The widespread prevalence of trash burning amongst institutions and families is an emphasis of the inadequacies of the governmentally-sanctioned local sanitation system. This independent practice has great potential to have negative effects on air quality due to the release of particulate matter, impacting the health of people in local communities.

The Protected Spring Project in the Rakai Community

Rakai’s residents expressed the desire for the Hopkins-Makerere Program to help protect a spring that many rely on for water. A protected spring greatly improves the quality of water that members of the community receive as it reduces the contamination of water sources from environmental pollutants.  Many of the families in the area are forced to walk over two kilometers in order to reach a safe water source. The protection of this spring has enabled greater accessibility of safer water to the local community, reducing the distance that families have to travel to access protected water sources. Our participation in this project was primarily to purchase and transport materials, supporting the work of the engineers and community members who actually completed the construction of the protected spring. Although there were individuals who could complete the task, they lacked the human-power to move the many rocks and bricks that were going to be used. Our twenty-four person team was able to move these materials down the steep slope leading to the well in three hours, greatly assisting in the process of completing the project.

Reflection of Our Progress

Since the beginning of this experience, we have realized that our assessment of water and sanitation does not simply have to be limited to discrepancies amongst rural and urban areas. The disparities that exist are even prominent within individual communities. This realization has been prominent through our visitation of different communities in Uganda, witnessing the resources that are accessible to residents of different socioeconomic groups and nearby institutions. Our visitation of the Health and Sanitation Inspection Office of the Kalisizo Town Council helped us identify that there are many simple solutions to improving water and sanitation that have been frequently underutilized. Boiling water, washing hands, frequent bathing, and proper use of latrines remain effective hygiene practices that protect the health of families. The widespread use of rainfall water tanks amongst private and public institutions also supports that the modernization of traditional methods can have an important impact on improving access to safe water. As we continue to gather information before the completion of our presentation, we have an interest in continuing to explore economic disparities that exist within the Kampala community. Rather than trying to immediately define the theme of the project before our research is complete, we have realized that information can be gathered through every experience and will use this principle to guide us during the rest of our study.

Postnatal Care Group Reflection

Academics

During the time in the Rakai District of Uganda, the Maternal Health Post Natal Group acquired a lot of information about standard of care in the town of Kalisizo regarding how most rural women seek post natal care. First we were directed to the Kalisizo Hosptial where we had a fruitful discussion with a midwife in charge of the antenatal care for HIV positive pregnant women. Her extensive knowledge about the entire birthing process provided our group with an inordinate amount of basic information from which a lot of our further questions were drawn. What our group was struck by at the hospital, and mentioned by the midwife, was the very apparent lack of adequate facilities and supplies. As a result of the relatively small number of beds, lack of privacy screens, and an insufficient number of staff members to take care of the maternity ward, the new mothers only stay in the ward for one to two days after delivery (barring complications with delivery).

Another major issue regarding post natal care in rural Rakai is the lack of support given by the fathers.  According to all of the sources we talked to, the absence of the fathers in the post natal process in comparison to what is typical in the United States significantly contributes to the mother’s deficiency in seeking post natal care. According to a researcher of the Rakai Health Sciences Program, many women do not seek adequate post natal care because they believe it unnecessary to pursue more care unless the mother feels abnormal. This is perpetuated by some of the fathers’ lack of support of postnatal care by not providing transportation money to the hospital for care. In addition many fathers do not respect the recovery period the mother needs after giving birth. During the six weeks after giving birth it is advised to abstain from sexual intercourse in order for the mother to heal properly; however, it is all too common that fathers do not abide by this recommendation. Without attending the birth and hearing the initial post natal instructions, many do not believe the information relayed by the wife as it goes against traditional beliefs. The outcome often involves some sort of domestic violence or abandonment of the family.

Both ANC and PNC groups at the Kalisizo Hospital

Another prevalent issue in post natal health is family planning. The birth rate is very high in rural Uganda, and many mothers opt to pursue family planning in order to control the growth of their families. However, this goes against traditional beliefs, and many times women choose to obtain birth control without telling their spouses. The main form of contraceptive chosen by rural women is the "injectable", which is virtually undetectable and it is only administered every three months. A midwife that we interviewed who runs a private clinic claims that on Saturday market days, over fifty women visit her office seeking the injectable contraceptive. Furthermore, we brought up the issue of family planning to four mothers from the village in Rakai in order to obtain their perspective on family planning. When questioned if they choose to control their family growth as well as the method of preference, three out of the four admitted to using the injectable. The major reason why the injectable is preferred over other methods such as daily tablets is the discreetness and longevity that the system affords: since one injection lasts an average of three months, there is less opportunity for a husband to find out. As such, the women feel they are less likely to be subjected to undesirable consequences such as domestic violence.

Our findings at Rakai seemed to be contrary to what is advisable. This is because it is considered to be a supportive gesture for a husband to accompany his wife to the health center for postnatal care; but this was not the case. We found out that this has been due to traditions which may control a person’s decisions and ignorance which prevents a person from knowing the impact of postnatal care on the good health of a mother and her newly born baby.

Reflection Session:

Part of the student’s activities at Rakai was taking part in a community project as a way of contributing to community development. Access to clean water for domestic use is a problem in many parts of Rakai. This is due to long distance to the clean water sources or few clean water sources. We took part in the construction of a protected well. This would provide easy access to clean water for the people of Rakai. We conducted a reflection session to inform our peers about the developments in our project and gain insight as to their opinions about this community service project.

Working on the well as a team

Our first question for the reflection session was how the students felt about physically taking part in the community development project or if they felt that providing the necessary funds or hiring highly qualified  personnel to take up the project would be more fruitful. After our discussion we conclude that physically taking part was more meaningful. This is because we had interacted with the community members on a deeper level through family homestays and doing this project would have a great impact on their families and in Rakai as a whole. Taking part in it would also permanently leave the memory of the students among the Rakai people.

Our second question was the people’s preference between seeking healthcare from a public health facility versus seeking healthcare from a private health facility. There were different views about this. Some students preferred the public health facilities for various reasons for instance the presence of well qualified personnel and the provision of services at an affordable cost. Those who prefered the private health facilities did so because provision of services was quick and the quality of service provided was better compared to the public health facilities. This is in terms of how the staff treated the patients. In general most people preferred to seek healthcare from private health facilities.

Antenatal Care Group Reflection

Reflection:

                This Wednesday we had our first group led reflection session, with the antenatal group as the facilitators (Abby, Belinda, and Mary).  We first pulled from our homestay experiences, topics which varied from any struggles that were faced that first night and how incorporated we felt by our hosts, to the efforts put forward by our families. 

We transitioned to a discussion about the ethics of working with patients, and the confidentiality that each person has the right to maintain.  The topic of HIV disclosure was one which had varying opinions.  When is the right time to tell a partner or child?  If a couple is discordant, where the wife is HIV positive but the husband is HIV negative, how would one go about sharing this information?  How is a researcher able to move forward with a participant, knowing that he/she may not disclose an HIV positive status with a partner?    

The ethical discussion was left with the thought of how people felt touring the hospital at Kalisizo.  The interesting thing about this experience was that although the students were there to investigate our topics and see different wards, patients’ were laying before us, experiencing real life pain and discomfort.  When we thought about the tour from the patient’s perspective, it made us feel a bit uncomfortable, as if we were invading the patient’s privacy.  During one of today’s interactions, a student was even invited to witness the birth of a child.  This experience brought up uncomfortable ethical issues, but allowed us to gain perspective on healthcare in Uganda.

                Today the three of us met with healthcare professionals at Kalisizo Hospital, a private clinic, and Rakai Health Sciences Project. All three shared with us the different aspects of antenatal care in Uganda, challenges for women in obtaining antenatal care, and frustrations that healthcare providers face. One of the biggest challenges brought up was the lack of available transportation for women to get to healthcare facilities. Women who cannot afford the time or money to get to a hospital or clinic often do not receive any antenatal care and deliver at their homes, with a traditional birth attendant.

              Transportation challenges exist even for those able to reach the hospital or clinic. Women with complicated pregnancies are often referred to regional hospitals for ultrasounds and other care unavailable at the smaller health centers. (In Uganda, the health centers are national, regional, and local hospitals, and health centers are rated on a scale of two to four, a four being the highest standard of care. Kalisizo Hospital is a level 4 health center.) The procedures the women are referred for may also be too expensive or the woman may be unable to be away from home long enough to receive them. 

Billboard promoting access to health care

           Even at the level 4 health center, there was an obvious lack of resources and funding to care for the large number of women wishing to receive care. One service Kalisizo did provide, was the access to what is called “Mother Kit”.  This included 3 pairs of gloves, soap, cord ligature, polythene bags, a razor blade and an infant immunization card.  Mosquito Nets are also provided, which are all given gratis. We also found that HIV testing for pregnant women is compulsory nationwide before receiving care.  HIV positive women are given appropriate counseling and care to prevent the passing of HIV to the fetus.

          Male involvement is also an issue in receiving proper antenatal care. Oftentimes men are entirely uninvolved in the pregnancy, delivery, and postnatal care. A midwife at Kalisizo Hospital cited the need for more education, especially for men and in rural areas, to teach people the importance of proper antenatal, delivery, and postnatal care.

Antenatal facilities at Kalisizo Hospital

          For our group, there were many surprises during our day in the field. First, we were interested to learn that HIV testing is mandated nationwide at health centers in Uganda for all pregnant women. Our initial reactions were all positive, because an HIV-positive mother would be directed to appropriate care, but with more reflection we realized the test could be a deterrent for some women. All three health professionals we spoke with brought up problems including women who don’t want to be tested or receive the results of the test, or women who might not return to the health center after being tested. We were also surprised by the general lack of resources, both in terms of the women’s challenges with transportation and finances and the health facilities’ lack of appropriate physical supplies (e.g. curtains between beds, ultrasounds) and their process of referral for more complex care that made it even harder for the women to receive the care they need. Finally, we were very interested in the role men play in antenatal care here. As in the United States, men in Uganda are less likely to visit health centers than women. It was still surprising to hear accounts of men who refused to provide their wives with transportation to a health center, even for delivery, or men who were generally completely uninvolved in their wives’ health during pregnancy. We’re looking forward to learning more about these topics as we continue to explore antenatal health in Uganda.

  

"So when do they turn the lights on?"

          Today is the second day of the homestay and all of the JHU/MakSPH students could not feel more at home. Two days ago the students met their new "mama" and "tata" as well as their loving brothers and sisters. Many of the families have taken to addressing the students as their own children. Some of the young children in the family have never seen "bazungu," or white foreigners, before, so the first interactions were quite fascinating. For instance, students have shared experiences of young children who cried when seeing "bazungu" for the first time. After two days, the children have begun interacting with the JHU/MakSPH students by sharing music from our different cultures and dancing to the tunes. 

             Many students have had very heartfelt experiences with their families which we had the chance to share with each other in a group reflection yesterday. One student had an experience where, as he was sneezing just due to allergies, the 12 year old house-brother offered him local medicine thinking he had the flu.  Nothing could have made the student feel more at home. 

            The MakSPH students have had quite the entertaining time watching the JHU students adapt to the homestay. Many of the JHU students have never used a latrine or taken a bucket bath. Thankfully, most of the MakSPH students were able to demonstrate the techniques for their homestay colleagues. One MakSPH student had the courage to get in front of the whole group and teach a bucket bath step-by-step.  The first day was a tough adjustment for the JHU students, as evidenced by Dom's reaction to his home's lack of electricity: "So when do they turn the lights on?". The MakSPH students felt more comfortable with the living situation than the JHU students did, but all the students felt the expected awkwardness that comes with living in another family's home.  The second day has proven to be easier, and we expect that by the end of the homestay we will be so comfortable it will be hard to leave.

Meeting our families!

            The JHU/MakSPH students were fortunate enough to go on a tour of the Rakai Health Science Program (RHSP). While at the Rakai Health Science Project laboratories,the JHU/MakSPH students were able to physically see some equipment like the safety devices and huge freezers that are used to keep samples since 1988. They had never seen these before.

            Today the students are breaking off into small groups to research their independent topics in the area around the Rakai Health Sciences Program.  Students are headed to the Kalisizo Hospital, Uganda Cares (an organization working with HIV positive patients), Rakai AIDS Information Network (RAIN), Kalisizo Town Council, and the RHSP Counseling Center.  The students had a chance to ask questions regarding their topics to local experts.  Getting out into the community was a great way for the students to expand their knowledge about their topics, sometimes gaining a perspective different from that which they expected.  

        

TORUWU

Today we headed to Kikaji Training of Rural Women in Uganda, or TORUWU.  It is a fantastic program that teaches rural Ugandan women different crafts (basket weaving, bag making, wine brewing etc.), with the intention of giving them skills that can earn them money.  The Center also serves as a middle man between the craftswomen and the consumers, finding them markets where they can sell their products.  We spent an amazing day here getting a chance to interact with these women and learn their stories.

Basket woven by the women at Toruwu.

We were greeted with fanfare.  Meaning, a marching band greeted us at the entrance to the Center and walked us to the buildings.  Along the way the JHU/MakSPH students had fun dancing and interacting with the local children.  During the performance, the band played "The Lion Sleeps Tonight" from the Lion King, and we had a cross cultural experience when both groups started singing and dancing and having a blast.To add to the cross cultural experience, the band played both the American National Anthem as well as the Ugandan National Anthem.

Watching the youth group band perform

The first part of the day was spent in groups touring various homes in which the women working for the center do their crafts.  They invited us into their homes and showed us how they do the weaving and answered any questions we had about their work.  We then reconvened for lunch and delicious wine prepared at the Center with oranges, pineapple, and passion fruit.

We then moved into a very interesting discussion with Makerere Students, JHU students, and members of the youth group answering anonymous questions about each others cultures.  JHU students enjoyed learning about the Ugandan's take on the American system of government.

Interesting questions were brought up in the discussion

The day concluded with a dance performance by the youth groups accompanied by the band playing traditional African drums.  Some of the JHU/MakSPH students had the opportunity to show off some moves.  After purchasing some crafts made by the women, the students boarded the bus (sad to leave) and headed back to Ndere.

The whole group loved their time at the Kikaji Center learning about different cultures and getting to interact closely with these amazing women.  We are getting to bed early, packed and ready to head off to the Rakai Village tomorrow.

The whole group with the women at the center

Day One.

After roughly 26 hours of travel door to door, the JHU student group finally touched ground in Entebbe, Uganda.  Three stop-overs, countless movies, and an hour long bus ride we arrived at the Ndere Center in Kampala at 1 AM Ugandan time with a meal awaiting us.  Not knowing which way was up we settled down to our midnight feast and tried to beat the jet-lag.

In the morning, the Makerere and JHU students finally met in person in the dorms at the Ndere Center.  In order to merge the two groups, we did a bunch of team-building exercises that ranged from thought provoking discussions about what we wanted to gain from this trip, to flipping a group member upside down blindfolded. The team building helped us as we braved Owino Market for a scavenger hunt.

Team building

Owino Market

We were tasked with finding a variety of items including a funny t-shirt, fruit we have never seen before, and a large pair of shoes.  We even tried our hand at bargaining with the merchants, some faring better than others. Emerging from the bustling market after two hours we headed back to the Center.

Displaying our finds

Trying new types of fruit

At night we got to view the amazing drum show at the Ndere Center.  We sat down to 4 hours of dancing and performing, while educating us about the different regions in the country.  We even got to join the dancers on stage for a little traditional dancing. This first day was action packed and the entire group is looking forward to a good nights sleep before tomorrow's adventure remembering that we are 8 hours ahead of our parents and all prices must be divided by 2,700 shillings.

Jamming

Pre-departure Orientation at Baltimore Intl. Hostel

After two days of orienting activities, it's time to depart for Uganda via Amsterdam. There were humorous and sobering moments that prepared us for what we'll see and experience in Uganda. You'd be surprised how much you can learn from a tent pole, a horseshoe discussion, a Necklaces meet Headbands game, and a day-trip to Baltimore's Lexington Market. We also had a lecture from Ms. Lin Lin Aung, an expert discussant from International Youth Foundation, where she works on the YouthMap Uganda project. Most importantly, we met the Ugandan partner students via Skype! (see a few photos below)

 Dom and Ellie Skype with their Ugandan partner 

 Molly and Alex use the BIH piano bench for their Skype session

 BIH was a great retreat for students to reflect and do research before departure

Students hard at work finding articles related to their topics

 BIH has lots of provocative art--we fell in love with the big ballerina

One last group photo before we depart!