Sunday, August 16, 2015

Global Health Immersion: Part 3

It’s 11 AM; the melodic roar of birdsong and jungle creatures is so overwhelming it distracts me from the blinding equatorial sun beating down on my unprotected skin. Thick mahogany trees and draping vines form a dense forest resembling the kinds of images Joseph Conrad or H. Rider Haggard conjured up when they cemented darkest Africa in our minds.  I am in Bwindi National Park in Eastern Uganda, just steps from the Congo, here to see wild mountain gorillas in one of their last remaining natural habitats. 

Ugandan rainforest tree covered in vines and creepers
My party treks for almost two hours before our guide spots the family group.  We are so excited that we don’t realize we are standing in the warpath of safari ants.  The tiny insects scurry up the inside of our pants, into our shirts and down our socks.  They sink their massive jaws into our flesh, drawing blood and screams.  But the creepy, painful encounter only adds to the authenticity of our experience - exploring the jungles of Africa should not be without its danger. 

Safari ants on the march
After dispatching with the ants we finally approach our main target.  Our guide tells us that we can’t get within eight meters of the gorillas because of their susceptibility to human infections; this rule proves to be taken very liberally.  We start on the group’s periphery, but before long the 20 or so males, females, and juveniles begin to move freely all around us.  Within 10 minutes we are completely surrounded by the apes.  At one point we stop to watch the silverback as he feasts on tree roots.  My guide says, “watch him, I can tell he is about to walk right towards you.”  Not 2 minutes go by before the proverbial 800-pound gorilla saunters within arm’s length of me. 

Although I’ve seen gorillas at the zoo and on television, I was not prepared for how human they truly were. Sharing 98.4% of the same genes as us, their faces revealed a haunting spectrum of emotions and expressions.  At times they appeared to play and joke with one another, and even carry out conversations.  The gorillas barely acknowledged our presence but when the odd one would break character and look me in the eyes, I couldn’t help but feel chills.  Deep behind that penetrating gaze was a gentle, sentient soul.

Wild mountain gorillas in Bwindi Impenetrable Forest
Visiting Bwindi was a nice break from Kampala and my work at Twezimbe, but the experience still offered opportunity to widen my grasp of global health and development.  With my knowledgeable driver Sam, the 500 km car ride across Uganda gave us ample time to discuss the changing scenery as well as African politics, tribalism, and inequality. 

The more I learn about Africa, the more I realize how much tribal and colonial history still influence contemporary life here.  When the Europeans colonized Africa, they drew arbitrary borders across a continent home to thousands of independent tribes and ethnic groups.  These new boundaries divided and reordered societies, sometimes pairing mortal enemies within the same state.  In their quest for control, Europeans were quick to exploit indigenous governance systems.  Their manipulation often distorted traditional power balances, exacerbating ethnic tensions still present to this day.  The Hutu-Tutsi genocide in Rwanda is one prime example – the French having empowered the minority Tutsis over the Hutu majority, inciting resentment and distrust between the two ethnic groups that lasted for decades until it came to a head in 1994.

As African colonies transitioned to independence, the heterogeneity of their people and cultures proved a huge challenge to finding solidarity.  Many Africans felt more allegiance to their tribe then their nation, creating conflict when politicians of opposing tribes and backgrounds attempted to exert their power.  

Uganda itself is made up of dozens of tribes, with the Bugandan Kingdom in the central region being the largest.  For centuries Buganda held a monopoly on economic and political might.  The British subsequently used Buganda to govern their new Uganda colony.  After independence, competing Presidents from various tribes slowly dissolved Buganda’s power, and now the various tribal kings are used mostly as political puppets by the central government.  However, ethnic loyalties remain, especially among the Buganda, who seem conflicted by a nostalgia for their past dominance and the hope for a prosperous united Uganda. 

Batwa Pygmies outside Bwindi Impenetrable Forest, one of the many ethnic groups in Uganda
As I drove west out of Buganda, the landscape changed dramatically from verdant, swampy farmland to dry, savannah-like pastures.  Because of its proximity to Lake Victoria, the central region enjoys a moist climate with abundant rainfall and fertile soil.  Traveling west away from the lake, annual rainfall diminishes and the landscape starts to resemble the rolling beige hills of Southern California.  Unlike Bugandans who are subsistence farmers, the people here are cattle herders and pastoralists.  My driver Sam explained to me that owning cattle is a sign of wealth in Uganda, implying that these westerners are richer than their central counterparts. 

The more distance we put between us and Kampala, the more developed the communities became - roads were smoother, schools and public institutions appeared to be in higher abundance, and everything just looked cleaner.  Sam explained to me that this is the region where President Museveni comes from.  Not surprisingly most Bugandans I’ve talked to believe the western regions receive generous favoritism by the President and his cronies.  On the other hand, Sam, a westerner, echoed sentiments I’ve heard from many of his regional compatriots, that western tribes are inherently harder working and ambitious, unlike Bugandans who are still drunk off their prior dominance.  Most of the tribalism I have encountered so far seems to be of this fairly benign nature, between Bugandans and western tribes, and thankfully bereft of any hateful racial rhetoric. 

A sacred Bugandan waterfall, polluted from farm runoff and human waste

On a more somber note, I have realized that there is little purity left to the environment here. In my ten-hour car ride from Kampala to Bwindi, every square foot of usable land seen through my window is repurposed for agriculture, housing, or some other type of commerce.  The iconic wildlife and abundant natural environment I’ve come to associate so closely with Africa is now confined to just a few national parks and preserves.  Every river or pond we pass is sludge-brown and filled with debris. The border of the thick, majestic Bwindi Impenetrable Forest is almost comically abrupt, with villages and crops edging closer and closer like a licentious old man.  Environmental degradation is complete in Uganda, and my gut tells me that most of Africa shares the same fate.

Tuesday, July 21, 2015

Global Health Immersion: Part 2

It’s not often that your expectations are exceeded so completely, but Africa has done nothing but surprise me.  Whether through the adventures, the hospitality, the accommodations, or the work, never would I have imagined so many things to go so right this summer. 

Since my last blog post, I was given the chance to immerse myself in the field of global health and development, working with youth in Uganda’s rural Mpigi district.  Getting on the ground to participate in interventions at the community level was my primary goal for the summer.  I realized that goal, and much more.  My education until now – all the books, lectures, podcasts - only took me so far.  From here the real learning begins.  I feel my own beliefs and assumptions in constant flux, and for a lifelong student it is a sensation I crave.
A group of bodaboda (motorcycle taxi) drivers I interviewed on my first day in the field
As part of its strategy over the next few years, Twezimbe Development Foundation will shift a portion of its focus from broad economic and health development to solving youth specific challenges.  Although Uganda has seen rapid economic growth in the last two decades, an explosive population boom coupled with vast inequality between rural and urban investment has created a dire situation for many of the nation’s young people.  With dwindling opportunity for employment and subpar human development, Uganda runs the risk of disenfranchising an entire generation, paving the way for social strife and potential conflict. 

Over the course of seven days I interviewed 33 groups including secondary school students, teachers, health workers, and various youth professional organizations.  It was an incredible experience, among the most intellectually challenging and rewarding of my graduate education.  Every encounter provided a chance to learn, whether from an hour-long meeting with 25 students to a quick conversation with a staff member in the back of a truck.  I was a sponge, soaking it all in, and resisting any urges to form concrete conclusions. 

My fieldwork began after moving into Madame Amelia Kyambadde’s (Ugandan Minister of Trade and Matron of Twezimbe) country home in Mpigi.  Her house was a beautiful, horseshoe shaped ranch-style that sat on a hill overlooking 40 acres of thriving coffee and banana plantations.  In the mornings the maids opened the doors and windows to invite the warm light and melodic African countryside inside.  I was cooked three meals a day of traditional Ugandan fair, a culinary style heavy on goat meat and starches such as Kasava (like a bland potato) and Matooke (an unsweetened mashed banana).
Walking through Madame Amelia's plantation in Mpigi, Uganda
Although English is the official language, Ugandans living outside of Kampala are much more comfortable speaking one of their native dialects.  Most of my interviews took place with the accompaniment of Bashir (an MC by night and Twezimbe’s Media and PR Officer by day) to translate.  After seeing him perform as a 17 year old MC, Madame was so impressed with his skills that she took him on as a protégé, financing his secondary and university educations and hiring him to work for Twezimbe.  Bashir’s translation skills became essential to completing my work.  He used his MC prowess to warm up the audiences and win over any detractors.  He translated quickly and succinctly, taking diplomatic liberties when his intuition directed.  His verbal agility allowed me to react swiftly and improvise rather than progress down a canned line of questions.   With him as my voice, I was filled with confidence knowing that any stumble or stutter on my part would pass as charisma.

Each morning Bashir and the Twezimbe field offices planned out a full day of meetings with youth groups and health centers.  At 9 AM we’d hop in the Twezimbe 4x4 truck and race across Mpigi’s back roads at the speed of a Dakar Rally competitor.  Our driver Omar claimed to have picked up his appetite for alacrity after seven years of keeping up with Madame’s dizzying political schedule.  My daily routine started to feel like that of a politician’s, with debriefings between events and waving crowds from those who recognized the Twezimbe truck for its ties to Madame.
Me with a village of brick makers

Although the various groups I met with were unique and suffered their own diverse set of challenges, some themes were all too common among the community.  I’ll try to highlight a few of these themes below:

Inadequate Education:

Lack of free and compulsory secondary education has forced many youth to drop out of school.  With little to no skills, these youth are condemned to a life of dangerous, menial work such as bodaboda (motorcycle taxi) driving or brick making.  School dropouts are at higher risk for STIs such as Gonorrhea and HIV.  Young females are at higher risk for teen pregnancy and marriage.  In fact education is considered foundational for reducing population growth, with female literacy and job participation widely considered to be decisive factors in reducing high fertility rates.  

Archaic curriculums and lack of career guidance has ill-prepared many youth for the Ugandan job market.  Based on the British education system and basically unaltered since the 1960’s, the Ugandan school curriculum is too theoretical, training millions of youth for white-collar jobs that don’t exist.  There is a push to emphasize vocational skills and entrepreneurship, training youth to be job creators instead of job seekers.  Unfortunately lack of career guidance has left most youth without any idea which vocations are worth their time and how to go about pursuing them.

Mpigi youth financially unable to attend school, now working as sand miners
Isolation & Fragmentation:

Lack of transportation and Internet has isolated people in the rural communities, preventing expertise sharing and access to wider markets.  This has made it difficult for people to know which jobs, services, and products are in most demand.  One of the most heartbreaking mistakes many make is to sell their land with the belief that life in the city or in some other profession offers more hope.  Agriculture is the backbone of the Ugandan economy, and land here is among the most fertile in the entire world.  It is said that if you have land, you will never starve.  With better guidance on farming techniques, information on crop demands, and access to markets, many farmers could exponentially improve their profits. 

Lack of Access to Capital:

Most youth would like to start their own business or get into farming but lack the capital to begin.  As poor individuals, traditional banks and lenders consider them unserviceable.  Microfinance was designed specifically for the poor, offering loans and banking on a small scale.  Due to lack of education, Internet, and transportation, youth are not sure how to access these lenders. 

Inadequate Public Health:

With poor health both a cause and consequence of poverty, it is hard to imagine any transformative change taking place in Mpigi until the large incidences of HIV, Malaria, malnutrition, and teen pregnancy are remedied.  As preventable challenges, careful planning and coordination on the part of the government could greatly curb these issues.  Yet a few hours spent in Mpigi will reveal that public health care falls far short of need. 

Public health centers in Mpigi, although free of charge to residents, are few in number, and suffer massive medication and staff shortages.  Waiting rooms are insufficient and easily overflow.  Inadequate resources hamstring health education, with insufficient and ununiformed outreach to schools and communities.  Because of lack of transportation, simply getting to a health center is a major challenge.  All of these factors have led to poor health-seeking behavior among Mpigi youth.  Many delay treatment until the later stages of their ailment when treatment becomes more costly and complicated.  Additionally, despite growing awareness, contraception use is still misunderstood and questioned.

Madame Amelia and I

I couldn’t help but think that most of these challenges were only consequences of some deeper issue.  My intuition tells me that so much of the blame lays on the government, that their corruption is stymying the development of infrastructure and public institutions that would help evenly distribute Uganda’s growing wealth.  I also wonder how much good large western aid organizations can do if they are ultimately working through the government and its agents.  Is it possible that they are perpetuating corruption and helping to sustain the status quo?  A little time spent in Kampala will reveal that Western NGOs occupy the richest neighborhoods and pay some of the heftiest salaries in the entire country.  This can’t be efficient use of resources. 

Maybe the answer to transformative change is through small, grassroots organizations such as Twezimbe, with their micro-level, piecemeal interventions.  Their size allows them greater flexibility, accountability, and community buy-in.   They don’t seek broad stroke changes, rather simple, observable and direct objectives: lobbying for a power line to an isolated strip of homes, providing new hoes for a farming cooperative, building a maternity ward in a health center that sees more than 80 births a month.  But of course the question of scale comes up, Mpigi is just one small district in an entire Sub-Saharan region facing similar issues.  In the end I am reminded that if there’s anything to be sure of, it’s that I’m not sure of anything.  All I can do is keep an open mind and continue to learn.