Current Issues with Uganda (IMHO)

Today’s your lucky day, as I’m bringing the James Rodriguez double-whammy of blog posts. This post will consist of an update on what I’ve been doing at TASO, the struggle with HIV in Uganda, and my personal thoughts about the matter. This is a rather long post, so get some popcorn or coffee or something to keep you engaged.

This past week, I’ve worked in a variety of clinics, done some lab work, and ventured out into the “field.” Two Fridays past, I was placed in the TB clinic. TB is common amongst HIV patients because active TB leads to decreased CD4 cell counts and increased viral load of HIV. Thus it is common for HIV patients to contract TB, as the diseases go hand in hand. The clinic is hosted outside, to avoid housing the highly contagious disease indoors. Patients with TB are given masks when talking with clinicians (who also wear masks). The typical conversation between patient and clinician consists of symptoms experienced and duration of them, HIV status, and administering drugs to the patient. A patient infected with TB is put on medication for 2 months, and is then required to come in for a follow-up visit. If the patient is still sick, they are given a stronger antibiotic and the process repeats itself. Being able to shadow the clinician taught me that most clients are unaware of how to take care of themselves and really depend on TASO to supply them with care. The only downside to this clinic (and most others) is that most of the clients know Luganda or other local languages (English is the official language of Uganda, with Luganda being commonly spoken; there are 63 tribes in Uganda, each with their own language, ultimately translating to me not understanding anyone). I usually have to ask for a translation after each client.

This past Tuesday, I was fortunate to work at the Prevention of Mother To Child Transmission (PMTCT) clinic. Probably the most interesting fact I learned was that if an HIV positive mother takes ARV’s before delivering her child, the baby will be born HIV negative. After the birth, the child is frequently tested during breastfeeding, in which the mother still takes ARVs; but if the child can make it past the point of breastfeeding, roughly 6 months to a year after birth, the mother-to-child transmission will be eliminated. These checkups are a surefire way of preventing HIV transmission. The only problem is that not all mothers take ARVs or come into TASO or a hospital for a birth. The clinician I was with informed me that this is not due entirely to laziness, but simply access to hospitals or monetary issues. Some mothers live too far away from hospitals to come in for delivery or they don’t have access to transportation, so they just give birth in their homes. It is crucial that after birth, mothers continue taking ARVs and that they come in so clinics can monitor their children. Scanning through TASO’s logs showed me that any child who was brought in timely remained HIV negative. Babies who were HIV positive had always been brought in much later than 6 weeks, usually ranging from 6-10 months. The clinician in charge of the PMTCT department was very optimistic about eliminating mother-to-child transmission and I agree that the methods TASO uses are on track to reach that goal. The problem now lies in being able to see all HIV positive mothers in a timely manner.

This past Thursday, I had the opportunity to venture out in the field, approximately an hour north of TASO. I went with a small convoy that consisted of a lab technician, two counselors, a pharmacist, and several other interns. We set up shop at an abandoned looking house, but it must have been the center of the village as 50 or so patients were congregated there. The patient flow was as follows: a patient receives their file and waits for blood to be drawn to determine their CD4 count. The patient then talks to a counselor about how they are doing and if any problems have arised regarding treatment, general health, etc. Lastly, the patients visit the pharmacist who doles out medications. I was to assist the lab tech in drawing blood, a technique I had never learned and had only seen done a handful of times in the past three weeks. I was quickly shown how to prep the needle, and collect samples, though it was up to me to find the veins and determine how far to push the needle in. Beginner’s luck got me through the first five patients, but then some bigger patients came and I had a hard time finding the veins (we constricted their upper arm to increase blood flow and enlarge the veins, but it is still hard to find them on a larger patient!) After poking around several patients arms in futile attempts, I was told I can rest if I was feeling tired, an excuse I was some-what happy to take. I wanted to help as much as I could to levy the burden of the other lab tech, but I think I was doing more harm to the patients at that point. I will provide pictures the next time I draw blood! I ended up assisting in prepping needles and mixing samples as they were taken for the rest of the afternoon. This excursion taught me I have to work on my bleeding technique, but also that there are a ton of people without ready access to hospitals or clinics. As a group, we treated 50 patients in roughly 3.5 hours. It would take a much larger convoy and much more time to fully treat everybody in need that can’t come to TASO.

Now that I’ve been here for three weeks, I’m starting to understand why HIV is so prevalent. The short answer is that the issue is very complex and multi-faced. All areas of life and the government contribute to the structural violence that supports HIV. I’m going to attempt to detail the long answer, but even my description may change in the coming weeks as I learn more. So you have been warned.

Uganda is not the worst country in terms of HIV prevalence. Approximately 1.3 million Ugandans out of 35 million live with HIV/AIDS, but HIV prevalence has risen from 6.4% to 7.3% in the past five years. Initially, I had thought HIV prevalence was so high because of children not being educated about the disease or safe sex practices. This is sort of the problem, as children aren’t learning their ABC’s, but the reason is due to their absence in schools. The main problem stems from families and poverty (NB: I don’t have statistics to back up the following claims, but only the stories of staff and other interns at TASO, all who’ve grown up in Uganda). The average Ugandan family contains five to ten kids. Already this is a financial burden on families in terms of food, clothing, books, etc. Uganda is a country still facing gender equality challenges. A husband or brother beats a wife or sister for “acting out of line”. As a result, families can decay quickly and easily, and often one parent, or sometimes both, abandons their children, leaving them to fend for themselves. Children will attend school, which is free, but even school poses problems. Most Ugandan schools are boarding schools, so the students live there. They are fed, dressed and kept in line. Most of the school systems are run-downed and don’t have enough supplies for students. Teachers are few and far between, and those at school are underpaid. Working a somewhat unrewarding job in their eyes, teachers carry a short fuse and often lash out, physically and verbally, to students who make small errors. Just this week, NTV Uganda, the local news station, reported two stories of students being sent to hospitals because their teachers bludgeoned them almost to death.

School in Uganda is nowhere near as nurturing and supportive as American schools. It’s no wonder that 29% of students finish primary school (or 7^th grade), a statistic reported by NTV. There is no real reinforcement or teacher organization to keep students in school, so students can leave at will. There is still more educations after primary school, and I would guess that less than 20% of students make it to the end of University. That means there is more than 80% of Ugandan students uneducated, and unable to obtain well-paying (or any) jobs. As a result, life becomes a game of survival. Boys will become truck drivers or fishermen, and girls will fall prey to prostitution, both being rather reckless jobs that easily succumb to HIV, all in the hopes of getting enough money for food. Once a person has contracted HIV, they seek to be put on ARVs immediately. ARVs can extend the life of an HIV positive patient for 30 or more years; as a result, people don’t care whether they get HIV or not, as they know they can still live for a fairly long time afterwards. TASO gives out ARVs for free, but ironically, ARVs have stimulated the prevalence of HIV. HIV positive patients will then get married, have 5-10 kids, some of which are HIV positive, and the vicious cycle continues.

As you can see, there are several persistent problems: the inability to establish gender equality, and limit physical violence by the police, and the inability to improve schooling and retention of students. I have come to appreciate my family more in the past three weeks, even though I have not seen them, because they really supported me and guided me through childhood, instilling a drive in me to be the best in whatever I do. That love and support is common amongst most American families but absent from most Ugandan families. Ugandan kids don’t receive a hug or toy when they’re upset. They’re told to suck it up or get beat. The lack of emotional care leads to the plummeting spiral of hopes of becoming well-set later in life. Children fail to develop self-confidence and ultimately try to determine how to survive instead of prosper. If physical and verbal abuses are the cause, then shouldn’t the police be informed so they can handle the situation accordingly? They should, but they aren’t because they are hardly around. Ugandan police fail to enforce the law, and instead, take bribes whenever the catch someone in the wrong, sadly because they are hardly paid. The police force is corrupt and is not provided a reason or incentive for carrying out their jobs like their American counterparts do. If the police force is shitty, who’s to blame then?

Yoweri Museveni has been president for 28 years, and shows no sign of stepping down soon. In his early years, he was regarded highly for introducing order into Uganda by establishing courts, and uniting the country from Idi Amin’s reign of terror in the 1970s. But now, the recent budget for the upcoming year has questioned Ugandans' faith in the president. The Ugandan budget for the 2014/2015 fiscal year came out two weeks ago; approximately 38.4 million US dollars, or 8.4% of the 14 trillion Ush budget was allocated to healthcare, specifically HIV treatment for 100,000 patients. The only problem is that same amount was allocated in last year’s budget, and 190,000 cases of HIV were reported this year. There is no way anyone can reasonably expect all HIV patients to receive treatment; the budget for healthcare needs to be increased by at least 50-100%, or up to 15% from 8.4% of the budget, so that the rate of treating patients exceeds the rate of new cases. Regarding education, 11.9% of the budget was allocated to schools, specifically to increasing the salary of teachers by 15-20%. While that is a step in the right direction, the schools themselves are not being directly enhanced, meaning supplies may be scarce. There was no clear funding directed specifically at the police force, but Museveni decreed that defense and security were the most concerning issues for the budget, despite the fact that Uganda is currently at war with no other country.

But there is a bigger problem at hand between Museveni and the Western world. In February of this year, Museveni signed the Uganda Anti-Homosexuality Act. The law criminalizes same-sex relations domestically, and internationally, as Ugandans who engage in same-sex relations outside of the country can be extradited for punishments. Additionally, individuals, companies, NGOs, etc., can be punished for supporting LGBT rights. As you can imagine, some countries would condemn this kind of behavior. Just a few weeks ago, the USA passed sanctions against Uganda, as a form of protest, which ban Ugandan officials from entering the US, and cuts funding to military cooperation and to HIV/AIDS NGOs. In addition, Sweden, Norway, and the World Bank have suspended funds, which total about $140 million US dollars to further protest the laws. Bear in mind that 67% of Uganda’s HIV response is internationally funded, so these protests really exacerbate the already tiny healthcare budget. Museveni has retained his stance about the laws and has even criticized the Western world for bullying Uganda to act in accordance with their morals. He also stated that Uganda will look for other means to find money to replace the slashed funds, but I have no clue where he could pull out so much money.

Did you get all that? As you can see, money to improve decaying sectors of Ugandan life is scarce, and the recent sanctions do not make life any easier for Ugandans. In my honest opinion, Museveni needs to take this matter seriously and try to find a way to alleviate tension with these other countries.  More importantly, he needs to think about whether the anti-gay laws are going to ultimately hurt Ugandans rather than help them. Musevini is like the Western world's stubborn little brother; he stands by his beliefs despite other countries telling him otherwise. Uganda needs money to help reduce the prevalence of HIV/AIDS, and Museveni will deny it because he feels like he is being bullied. While I respect his decision to remain firm in his beliefs, I think that he needs to realize that his country at this time in history needs help. Whether the anti-gay laws are right or not is a different question, and one I’m not going to delve into, but it is foolish for anyone to think Uganda will improve medically without the aid it was already receiving.

I will continue bopping around different departments of TASO this week. Thanks to my mom’s connections through Merck Research Labs, I also hope to talk to some people at the CDC and other social NGOs about HIV prevalence and learn more about how areas can be tightened up. Hopefully, you now have a better idea of how different sectors directly contribute to HIV cases and the areas that need to be improved upon. I will try to expand upon these ideas and current measures being taken in future posts, but if you have any questions, let me know. Thanks for reading!