Clinic Challenges & The Importance of a Local Voice

I (and most people I know working in international development) have always struggled to figure out what my role should be as a foreigner. It is a very sensitive issue – how to avoid imposing your own norms, how to avoid creating a system of dependency, how to ensure you are not taking away opportunities from local people. I do believe I can play a role (otherwise I wouldn’t be here), but that is why I have always been most interested in capacity building – supporting others to help them grow their skills, create their own opportunities, take on greater leadership roles, increase their resources. Even still, there are limits on what I can accomplish as an outsider.

One of my main roles here is to support communities that have chosen to implement a health clinic as their Spark project. I am working to support their management, finance, and sustainability. This objective has been exceedingly difficult. In communities with such limited financial resources, developing a realistic sustainability plan can seem impossible. Communities need to figure out a way to pay for a qualified nurse, a clinical officer (to register the clinic and supervise), a Village Health Team member to do record-keeping and education, medicine and other medical supplies, stationery, cleaning supplies, and more. Their monthly budget is usually around US$120.
 
Finding qualified medical professionals within their budget has proven to be particularly challenging. We have struggled with nurses quitting after short terms due to low pay and long distances and sometimes not even being able to identify a qualified nurse to begin with who would accept the salary. For instance, the nurse in one of our communities that first opened its clinic two months ago quit within a couple short weeks on the job. Even when he was there, he was not the most reliable person – often showing up late and sometimes not coming at all, citing transportation as a major issue. After he quit, the clinic had to close until they could find someone new, which was no easy task.
 
Moreover, the community wanted to find someone who would work 5 days a week (they were previously only open for 3 days a week) because they felt that the low patient numbers during the first month were due to the limited working days. If finding someone to work for 3 days a week on their budgeted salary was difficult, finding someone to work 5 days would be impossible. Nevertheless, we do not make decisions for the community, so while we warned them of the difficulties of finding someone willing to work 5 days a week, we agreed that we would wait until someone was identified and discuss salary and work days at that point.
 
The former nurse identified a potential candidate to take over for him while the community also identified two people for the nursing role. My co-fellow Tracy interviewed all of them (she’s the one who actually has a health background and is a trained nurse). She was impressed by the person identified by the previous nurse, but the other two identified by the community turned out to be nursing assistants rather than accredited nurses. Nursing assistants cannot legally run clinics in Uganda. After some debate, the community agreed to hire the qualified nurse to work 3 days a week, but they still wanted to hire one of the nursing assistants as well to keep the clinic open 5 days a week, meaning two days of operating illegally each week and an additional person to factor into the already overly tight budget.
 
This put us in a difficult position. The community always gets to make all of its own decisions. We do not put any conditions on them so we could not force their hand. I attempted to discuss the implications of their choice with them, but nothing I said caused their view to budge. Next Tracy tried. I though that her being a Ugandan might make it easier for her to get through to them, but we still had no luck. We knew going in that this conversation was going to be difficult, so we had also invited Wilson, the chairman of a nearby community that is implementing a health clinic project, to share his experiences. Now I don’t know all of what he said since he was speaking in Lugisu and different people kept getting up to leave the room to discuss things in private outside, but by the time he was done, the community agreed that they should have a qualified nurse working 3 days per week. I asked them what changed – they said that they now understood the legal and budget concerns of their original plan.
 
Something that the community could not hear or fully grasp when coming from a foreigner or even when it came from a Ugandan who was still an outsider in this community, could be conveyed tactfully from a local person with whom they could relate. If Wilson had not been there, I am confident that the community would currently be moving forward with a nursing assistant running the clinic 5 days a week and that their budget would not be sustainable. Wilson was able to help them see what would best serve their ultimate goals. And me? My biggest role was simply facilitating their meeting and I am completely comfortable with that. Ultimately that’s a huge part of what Spark does – it brings people together in a forum where they can harness their collective power, knowledge, and skills to solve problems and reach their self-identified objectives.
 
Err sorry for the lack of pictures in this post – apparently I haven’t been very good about getting photos at the clinics. Here’s the one photo I have. It is one of the community’s clinics with the management committee and the former GHC fellows posing in front. I will try to get more clinic photos soon!

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What I’m Actually Doing Here & Experiences From a Muslim Community

So I suppose I haven’t yet talked much about the organization I am working for or what I am actually doing here. My organization, Spark, has a community-driven model for development – pretty much as community-driven as it gets. We work with local communities to facilitate a process in which the communities work together to identify a top goal, objective, and ultimately a pathway (project) that will best serve their needs. Spark then provides a small grant for the communities to begin implementation and provides support throughout the implementation process and two years post-implementation to ensure that the project is still sustainable and that it continues to meet the community’s goals. We do not impose anything – the community has full ownership of the project.

A large part of my role here involves developing new tools and activities with our team to better support our partner communities who have selected a goal of increasing their incomes. These should be activities that are not pushing the communities in any particular direction, but that help the communities think through different factors that may be relevant as they make decisions. So far, these activities include a mapping exercise, discussion questions, evidence-gathering activities, financial analysis, and more. I have been working with one of our facilitators, Lilian, to test some of these out in a community that is currently going through this process.

One community where we have been testing several of these activities out over the course of a few weeks is Bunabigubo, a primarily Muslim community. Many people may expect a Muslim community to be especially conservative due to prominent stereotypes and how Muslims are often portrayed in the media. This has never been my experience interacting with Muslims, however, and this community is no different. If anything, it is noticeably less conservative than many of our other communities. In fact, one of the first things I noticed, before I knew anything about the community, was how many women were present at the community meeting. There was quite a good turn-out overall – over 50 people. At least 40 of them were women. They were not shy either. The women participated in every aspect and took the lead on many of the discussions.

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For homework one day, we asked a group to brainstorm, among other things, how gender roles may impact their project. We asked them to think about things like what tend to be male-dominated activities or female-dominated activities and who generally controls the money in the household. During our next visit, one of the ladies presented what her group had discussed. She noted that there are certain activities that some may perceive to be “male” activities such as bricklaying, but then she pointed to the closest brick structure. “Women built that,” she said. In fact, she said women are engaged in every type of activity in the community – there is nothing that women cannot do.

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She went on to address the question regarding who controls the money in households. She talked about how, in her household, they combine their money and decide on how it should be spent together. At this point, a man chimed in. He had something to clarify. It does not work like that in all households, he said. In some, the money is split and the man is given a small portion to cover his agricultural expenses. The woman controls the rest. He claimed this is because if the man is given more money, the family might not see it again – the woman is usually better at managing expenses. Another man now spoke up to agree and to explain this is why they hope that a woman will take charge of the financials for their project.

At the end of my first visit, the women wanted to end with a certain activity. It involved a little hip shaking at the end (very scandalous, I know). The men were not comfortable participating or witnessing the activity so they waited behind (it was explained to me as they would not be comfortable seeing their daughters move like that in front of both them and their son-in-laws). Meanwhile, the ladies had a blast chanting and moving around. A male American intern was also around and he witnessed their activity. To him, the interaction was a sign of how conservative the community was due to the men’s discomfort, but I did not see it that way. The women wanted to do something that the men were uncomfortable witnessing, they did it, and they had a great time. The men did not try to stop them. The women were not told it was inappropriate. All decisions and feelings were respected.

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I hear so often from people who have generally never interacted with many Muslims that it is an incredibly oppressive religion towards women, that men control women’s actions, that they silence women, that they control all of the household decisions and finances, and that they shame and disrespect women. This has never been my experience. That is not to say everything is perfect. I still think women are given a much larger burden in terms of household responsibilities and taking care of children in many of the communities that I have seen. Nevertheless, the Muslims I have encountered have often had a more liberal, egalitarian, and balanced perspective than many other groups and certainly much more so than they are perceived to have by the media and majority of the US. In fact, I think quite a few Christian, Jewish, Atheist, Agnostic, fill in the blank, communities could learn quite a lot about gender equality from Bunabigubo and some of the other Muslim communities I have encountered. So here is my earnest plea to please not judge members of any group based on stereotypes or media portrayals – particularly when you have very little experience interacting with anyone from that group yourself!

On a complete irrelevant note, I visited another waterfall last weekend (Sipi Falls – the big tourist destination around here). I figure I can’t make all my posts about hikes to waterfalls, but I couldn’t resist sharing a little taste. Parts of this hike may have been even more treacherous than the last. It involved a very rickety ladder build of old nails and logs that went down at approximately a 90 degree angle. Before we began, our guide warned us that the side rails were broken so we should not hold on there, that it was even longer than it looked, and that it was very slippery (we were doing this hike right after a rain). About half way down, he warned us to avoid a certain step since the nail had come loose. We all managed to survive though and the view was incredible! I am still very sore from all the hiking three days later though…

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A Perfect Saturday

Just behind my house is a beautiful mountain range. It makes for a great view from almost anywhere in town. The closer you look, the more waterfalls you see, but there is one that is particularly eye-catching. Last Saturday my co-fellow Tracy, her boyfriend Andrew, and I decided to attempt to hike up to it. We left on foot from our house and started on a windy road toward the mountain.

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Can you see the waterfall way up there? That’s where we’re headed.

At first it seemed quite easy – it was a large dirt path, easy to walk along that weaved through a small town with a few little shops scattered along the way selling vegetables, eggs, oil. Soon enough though, our legs starting becoming all too aware of the upwards slope. For some reason, the waterfall, which we could see from a distance, didn’t seem to be getting any closer.

Starting to get a little more tired

After 45 minutes or so or so of this, we needed a short break and sat down in the grass to relax while a gaggle of small children started laughing and speaking to us. The only problem, is none of us speak Lugisu. Once we recouped a little energy, we set off again. Eventually the main road we were following appeared to be diverging from our goal of the waterfall, but an even steeper and narrower path through a corn field seemed like it might be the right option. Luckily there was a young boy there, maybe 7 years old, who spoke English and knew the way. He very kindly offered to take us there. Unfortunately I was never really able to understand his name despite him telling me about three times…
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Our guide!

The path got steeper and Tracy, Andrew, and I were all out of breath. Our young guide, however, did not seem to be experiencing any difficulty. We eventually got to a clearing where we had a great view of the waterfall. It was where the primary school for this community was located, which was nicely painted with some friendly moral and health reminders lining the walls such as “Virginity is healthy,” “AIDS has no cure,” and “Early sex is bad.” Might not be how I would choose to decorate a primary school, but I suppose at least the messages were clear.
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Next to the primary school

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Some of the school’s lovely reminders

Our guide seemed to think this was the destination we were hoping for, but we asked if it was possible to get to where the water falls down. We could hear some water from this point so, while we were already quite tired, we figured it couldn’t be too far and it seemed like the path had flattened out from the steep slope. Boy were we wrong. After 30 more minutes or so of huffing and puffing up the mountain, a young man, probably around 17 years old, joined us to make sure we found the right route. At this point, it was essentially a path that went straight up via jagged rocks. We asked how far we were from the falls. We were not prepared for the answer: 45 minutes. Ugandan time. I knew by now that, if anything, this was an under-estimate. We collapsed down on the rocks. Could we really continue like this for at least 45 more minutes? I don’t think any of us were confident, but we had also come too far to give up at this point.
*Insert photo of treacherous trail here*
(We were all too focused on not falling down the mountain to be taking photos at this point :P)

On we go. The steep rock path in the mountain not so slowly transitioned into batting our way through dense vegetation on a still steep and windy dirt path that sat a few edges from from an increasingly steep cliff edge. We continued on grasping to plants and rocks, hoping the rocks on which we jumped or clasped were securely set in the soil. We were doing fairly well (with a few breaks to catch our breath) until we got to a point where there was a rock jutting out over a reasonably sized whole in the path. We were so close at this point. I could almost feel the mist of the water. We couldn’t turn back now. Deep breath. Don’t look down. Hug the rock. Step over. Done. Made it to the other side.
Passed all the major obstacles - almost there!

Passed all the major obstacles – almost there!

A few more slippery climbs and we were there! At the pool just below the beautiful waterfall.

Celebrating our accomplishment 🙂

The mist felt so refreshing. The scenery was jaw-droppingly gorgeous. I was so proud – we came, we saw, we conquered! I was also in disbelief as I looked down upon Mbale town – how on earth did we come from all the way down there? I spotted the primary school where we first stopped – it was so far below! When first looking at the waterfall from the bottom, I thought there was a cell tower right in front of it. I looked down now and saw that same cell tower. From this perspective, it seemed like it was all the way back in Mbale town.
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See that town way down there? That’s where we started.

After soaking up the cool air, the view, and our accomplishment, we decided to begin the journey back down, trying not to think about how we would navigate the steep slopes in reverse (if you’re curious, completing part of the decent in a seated position proved useful). We asked the young man who accompanied us how often he came up here. His answer? Every. day. He went up there (actually a little higher) nearly every single day to gather grass for his cow. If I were in his position, I’m pretty sure my cow would have died a long time ago (and quite possibly me along with it!). It certainly puts things in perspective.
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This is where the young man gathered grass for his cow

As we continued downwards, several young people passed us along the way, running and hopping all the way down as if it were nothing more than a staircase or hallway, while I very carefully measured every step (and still tripped more times than I can count). Neither our 7-year-old guide, nor the young man who accompanied us, nor any of the people we encountered along the way (old or young) ever seemed to even be out of breath. Did I mention that our young guide rolled a tire along with him for the entirety of this journey as if it was nothing but a different location to play?
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Our guide rolling his tire on the way down

When we eventually made it down to the main road, we gave our guides a small monetary gift to thank them for showing us the way (and keeping us alive) and continued on the still long way back to Mbale. The rest of our journey was peppered with regular shouts of “Muzungu” from the kids we passed. For some reason, they sadly never seemed as interested in greeting my two companions. One brave young soul reached out her hand to great me. The moment I accepted her greeting and took her hand, out of the woodwork came about a dozen other small children running towards me to say that they too touched the Muzungu. I continued for a few minutes with them all holding on to me wherever they could reach while they shouted on an endless loop “Muzungu, how are you?” and finally “Muzungu, bye!”
Juste a small taste of the number of greetings I received

Juste a small taste of the number of greetings I received

Luckily Mbale town slowly came back into our sights just as I felt as if my legs were going to give out. I think the only thing that kept me moving at that point was the promise of a cold beer once we arrived. We somehow made it back to the house to shower and then headed out to treat ourselves to a major (but well earned) splurge at the local resort hotel. Mind you, by splurge I do mean approximately US$10 for a large pizza and two double beers 😉
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Mmmmm!

So… a Saturday well spent! Although it may take a little while before I’m ready to commit to that hike again…. I’ll just need some visitors to motivate me (*hint hint*)!

Whoops – nearly a month has already flown by!

I meant to start this blog earlier and write about all my initial experiences. I really did. Somehow four weeks have already melted away since I arrived in Uganda and it never happened. Oh well, I guess I was just too busy experiencing new things, starting a new job, and adapting to a new culture.

I’m not really sure where to go from here, I meant to write about my training at Yale before leaving, my first impressions upon arrival, the organization I’m working for (Spark MicroGrants), my onboarding at my new job, and my first community visits. There’s so much that has already happened that I don’t think I can catch up. Let me just try to share a few of the highlights:

Attending the launch of a community project

Women dancing                    hike down to makutano

The community selected a boda boda (motorcycle taxi) project in which they used their grant money to purchase two boda bodas and hire drivers. The project should help provide much needed revenue to their community as well as help connect them to other areas. It is a very remote community – to get there we had to take a matatu (shared mini van) for about an hour followed by a boda for another hour or so through windy mountain roads. When we got as close as we could with the boda to the community, we were met with singing and dancing by many of the women who led us on a little hike down to their village. They rolled out the red carpet (and by that I mean laid down palm leaves) and sang and danced the whole way down. While the event went on a little longer (and by a little longer, I mean a LOT longer) than expected, their excitement and pride was palpable. I can’t wait to see how the project does over the next few months and visit again soon.

Testing out a new activity in a community

Mapping Activity                  presenting map

A big part of my job here is to develop tools and resources to support communities who are developing income-generating projects. One of the activities that I have been working with our team to develop is a specific mapping of the communities in which community members physically map out all the current resources in their community that may be relevant when determining objectives to achieve the goal of increased incomes. We tested this out for the first time recently in one of our new communities. The community really seemed to understand the worth of the activity and it did appear to unearth some new, relevant information that may help inform their objective setting and ultimate project choice. Apart from the actual results, the best part was seeing community members working together so well and to see women being so involved. Women were often taking the lead (and to be honest, the groups that were predominantly women came up with some of the best and most comprehensive maps!), but were also displaying such wonderful collaboration – happily passing the marker amongst themselves so everyone could participate. Community-building is one of the main goals of Spark (possibly considered even more important than the actual results of their projects) and it was so wonderful to see this community exemplifying that value.

The boda rides up in the mountains

Boda riding          Boda waterfall

I NEVER thought I would say this. The first time I road a boda (motorcycle taxi), I was clenching onto the back for dear life and counting down the time until I could get off. As I’ve gotten more and more used to the acceleration and turns, however, I’ve become more and more comfortable. Now, instead of keeping my eyes glued to the road in front of me, I can appreciate the scenery around me. And it is breathtaking. Winding through the mountains, surrounded by greenery, fields, and more waterfalls than I can count, with a soft wind blowing on me is nothing short of magical. It is in these moments that I am in awe of my life and so very contented to be doing what I’m doing. A boda ride after the rain on the muddy and slippery roads, however, is a whole other scenario. Don’t expect me to be swooning about those experiences any time soon.

Visiting Jinja

Nile River             nile river 2

A week ago, I want to catch up with some other Global Health Corps (GHC) fellows in the town Jinja. This was perfect for me as it is about the half-way point between Kampala (where most fellows are based) and me in Mbale. The transit there was surprisingly smooth and only took two hours. It is a gorgeous community right on the source of the Nile River. About 10 of us ended up going and it was wonderful. The river looked more like a lake and was beautiful. We hiked down a steep, slippery path to a rope swing and everyone jumped into the Nile for a swim. We went on a sunset canoe ride and then out for the night to a bar for drinks and dancing. It was so refreshing (even after only 2 weeks in Mbale) to have time to swim, relax, and spend some time with the other fellows.

Other experiences so far have included: going to a club in Mbale to celebrate a colleague’s birthday (yes, we do have a club. We even have two!), drinks at the local resorts that have beautiful views of the mountains, awkward name games in the office upon arrival that ended in me needing to jump around trying to depict a “crazy cabbage,” having two teenage girls joining me for a portion of my jog (while wearing skirts and flip-flops) and taking photos of me, candlelight cooking, having a swarm of small children in one of our communities come up and suddenly all begin petting my head (apparently upon the command of one of the mother’s to go touch the muzungu (foreigner) hair), and hiking up to a beautiful waterfall on my way home from the field one day.

There’s so much more, but I think that’s all I can share for now. I promise to try to actually maintain this space both to share with others and, really, for myself to be sure to remember this experience.

Until next time!