We were invited to contribute to the ONE Blog on the lack of access to electricity in Africa. Our entry, “A tale of two babies” can be found here.
When we arrived in Mbarara a year ago, a pair of red-tailed doves made their nest on our balcony. Every morning we woke to their song, da-da-daaa, da-da-da-da, like the guitar measures that start Paul Simon’s Under African Skies. They laid eggs, and took turns protecting them. At altitude, on the equator, we move more quickly through space than we did in San Francisco. The dark, dark night gives way to the brilliant brightness of day with incredible speed, and the animals all wake up. A single drum beat, then the plucking of strings. Under African Skies weaved itself into the morning routine, the lyrics swirling around our heads like boxed milk in dark Ugandan coffee:
Joseph’s face was black as night,
The pale yellow moon shown in his eyes.
His path was marked by the stars in the southern hemisphere,
And he walked his days under African skies.
This is the story of how we begin to remember,
This is the powerful pulsing of love in the vein.
After the dream of falling and calling your name out,
These are the roots of rhythm and the roots of rhythm remain.
One Sunday afternoon, while we were both preparing lectures on the couch, a fluttering of wings caught our attention just in time to see a hawk fly in and steal the entire nest in one fell swoop. There were still birds singing in the mornings, but none of their songs spoke so directly to our experience as that of our doves. We continued to hurl through space, time on its unforgiving march, and as the roots of rhythm faded into the background of more modern morning sounds like boda engines, Graceland played less frequently in our minds and on our iPod. Funny how the daily presence of something is so easily taken for granted as it becomes routine, and the absence over time makes memories fade and meld together. As if to remind us that the roots of rhythm really do remain, a dove recently returned to our little balcony. The tune is slightly different; a variation on the theme, but the sentiment is the same.
We have been here for one orbit of the sun, one full circle of wet and dry seasons, midterms and finals, life and death. As we prepare to leave Mbarara for our close of service conference in Tanzania and our journey home, we reflect on the year and those things, like the red-tailed doves, that we will miss…
Proper greetings. We would never walk into a shop and ask for what we want without first asking about how the morning is going, how the owner slept last night, how the weekend went, how the children are doing, and any thoughts on these strange morning rains. After all, life is about relationships, not accomplishing tasks.
Passion juice. That perfect blend of sweet and tangy that is the passion fruit.
Slow food. Not the smug Bay Area variety that is the purview of rich liberals, but the slow food of a nation where organic, local, and made from scratch are the only choice. This comes with its own set of problems, but it is also a closeness to our food and where it comes from. People know, love, and live with the animals that nourish them. While we did not take up animal husbandry, we did pasteurize our own milk, used the cream to make butter and buttermilk, and the rest to make fresh ricotta cheese.
A real handshake, prolonged and meaningful.
A relaxed approach to time. Time is not something you fight against here, it is something fluid that just happens.
The two handed wave and the smile that goes with it. All ten fingers splayed with open palms facing forward, wrists vigorously shaking with excitement. The smile, truly ear to ear.
A perfect avocado.
Imposing men wearing small pink shirts that say princess without worrying that it will affect their image. There is no self-consciousness in it, no attempt to act cool or put on a front. You don’t need to act tough. Just making a living here is tough enough.
Ugandan babies. With their round faces, full cheeks, big smiles, there are no cuter babies in the world.
The unfaltering gratitude we received from our students just for doing our jobs, and the feeling that we really are making a difference in their lives. Kelly’s nursing students say they are proud to be in nursing school, when just one year ago, they all wished they could be doctors. Ari’s residents say the culture in the department has changed for the better.
Our students have confidence and pride that they didn’t have one year ago. They deserve a good education and a good healthcare system. They are now beginning to believe that too.
We have walked under African skies.
Love powerfully pulses through our veins.
We’ve lived a year we will always remember
A place with many struggles, but a place where humanity remains.
Slowing down, putting relationships first, communicating clearly and concisely, holding hands during a greeting, engaging your community of family and friends for support and guidance. A year in Mbarara has taught us these lessons and more. We are changed people, in small ways. We are better people, in large ways. We like to think we have had a small impact through the friendships we have formed, the patients we have treated, the students we have taught, and the co-workers with whom we have worked side by side. We know they are all leaving a large imprint on us.
We may be returning to San Francisco, but we are leaving a piece of our hearts in Uganda.
We have said it before: all aid is not good aid. This pertains to human capital as well as material goods. Ugandans, in their infinite politeness, will bend over backward to accommodate visitors, and are quite reluctant to criticize them openly. So people come, receive very little feedback on their performance or their impact, and they go. They return home with great knowledge and experience, great stories “from the field,” and great photos of classic textbook pathology, the visiting professional on rounds, and photogenic Uganda. Many are the students and trainees who arrive without supervision and boss the locals around in an apparent attempt to exert control in an otherwise chaotic situation. Many are the researchers who may teach a few sessions but spend limited or no time living the life of a local health care provider. Many are the potential donors who fly business class across oceans and are ushered through both luxury safari and suffering safari to bear witness to the incredible challenges facing people on a daily basis here—some of which could be alleviated with the cost of their airline ticket. And many are the institutional saviors who land at Entebbe with grand plans to create the next “Center of Excellence” in whatever their specialty happens to be, ignoring the fact that we would be better off working toward a Center of Basic Health Care Provision. And let’s face it, there are many good reasons for all of these behaviors: it is easier to send students here than to accept Ugandans in a true exchange, it is easier to conduct research on infectious diseases where they are most prevalent, rich people are more likely to give their money if they see where it is going, and the basics are less sexy than the latest technologies.
As we near the end of a year in Mbarara and mark our second semester finals, we find ourselves reflecting on our form of aid and evaluating not only our performance and impact, but those of other visitors in the patchwork of aid at MUST. Throughout the year, we both became increasingly protective of our students and our university, feeling a sense of ownership for the place. We found ourselves thinking things like, “who are all these muzungus and what do they think they are doing here?” as though we are now fully incorporated and staying forever, which we are not. So we asked one of Ari’s residents for a real local’s perspective on the waves of visitors here to help. Here is what he wrote:
It was one of those very hot afternoons following a high calorie packed Ugandan-style lunch. Classroom dozing was a surety unless the lecturer or the topic was exciting enough for one to stay awake. Luckily enough for us that lazy afternoon, a new set of interesting lecturers had just arrived.
A team of visiting physicians consisting of two Americans and a Brit were the ones running the session. We were preparing for our end of year post graduate exams in Internal Medicine at MUST and in spite our full stomachs, they really made the sessions memorable with a number of bedside teachings and tutorials. These teachings gave us a lot of confidence, which helped us pass our exams. We are grateful that these physicians came to visit at such a time when we needed help.
Sadly, the Brit left after a month, but the Americans were to spend a year with us facilitated by some kind of Peace Corps organization. Fast forward, and I’m writing this post one year from that hot afternoon session which seems only like yesterday. Ari and Heather are the two wonderful Physicians from Obama-land who have graced us with their presence for a year now. To say the least, they have been excellent throughout their stay. We shall surely miss our two friends when they leave.
My institution is blessed with a multitude of visiting doctors and students from various parts of the world and this has benefitted us in many ways. However, there is a downside to everything. Don’t get me wrong here because most of the visitors have been wonderful, but sometimes it becomes unfortunate especially when the visitors are so many that they even outnumber the locals. They instead become a hindrance with ward rounds taking abnormally long hours because of all the discussions and explanations.
Then there is a very small percentage of international medics who come around with the worst colonial attitude ever. This group is really pushy, with a “white man has come to Africa to save the day” kind of attitude. They think they know it all and that their opinions come first. Thankfully, this is only a minority but when it does happen, it can be very difficult to cope with. Just because you’re an infectious disease or something specialist in your country doesn’t make you an automatic expert in another person’s home.
Then there are a category of muzungus who come and can’t absorb the shock of being in an environment that is so resource constrained that there is no CT scan, MRI, ICU or Vancomycin. This particular group angers me, because they think we aren’t doing enough for our patients. They utter the most resource inconsiderate comments and contributions. On reflection I think, “this is our situation, we are happy, if you can’t handle it then go back home to your CT scanners and 300 floor hospitals.”
My department has on the most part benefitted from international doctors. After all, even our head of department is the most amazing “Ugandan-muzungu” ever. The downside to their stay here is small and this depends on the actual individual who has come and cannot be generalized to all visitors.
So there it is, the good, the bad, and the ugly. But just as all aid is not good, nor is it all bad. Some of those trainees forge lasting friendships with Ugandans, and they share ideas while sharing roasted goat at Lord’s Bar. Some of those researchers prove to the world that poor people can adhere to their antiretroviral therapy just as well, if not better, than wealthy people. Or they discover evidenced-based approaches to treating disease in resource limited settings, saving countless lives. Some of those donors are responsible for the professional training of scores of Ugandan health care workers. And some of those institutional saviors differentiate the immediate needs of a place like MUST from their own grand plans, working toward shared goals slowly and respectfully. Visionaries like them helped to build the new cancer clinic that opened last month.
What separates those who hinder from those who augment? Some combination of understanding the local culture, making friends, staying long-term, and listening more than talking. It all sounds simple, but it is not. Staying for the long haul is logistically challenging. There are always ripple effects and unforeseen consequences. And listening is not the same as it was back home. This is really listening, to hear the “Ugandan no”, which can sound for all the world like an emphatic yes unless you’re paying attention. But the local perspective shows that with a little brain, a lot of heart, a closed mouth, and an open ear, true partnership is achievable.
Our friend John visited in March. We met in Rwanda and made our way back to Uganda after a luxurious weekend in clean Kigali. We talked about the similarities and stark differences between the two countries, and about sustainability. Lasting effects are particularly germane given our impending departure for home next month. This week we bring you some of John’s reflections on his trip.
While I was visiting Mbarara, Kelly graciously volunteered me to talk about U.S. work visas with a few of her nursing students. As it turns out, the U.S. offers a particular type of visa specific to nurses. Despite the challenges, costs, and limited duration of the various visas we discussed, they enthusiastically asked about extensions, of getting a green card, or maybe even marrying an American. Both Kelly and Ari interjected with some concern: “But you plan to come back, right?”
“Of course!” They laugh, their answer as light as air, free of any commitment.
They aren’t the only ones who feel this way. There is a significant global concern about “brain drain” —the emigration of trained and intelligent people from a particular country—and this is especially true with regard to the worldwide migration of nursing professionals from developing countries to wealthy ones. In 2008, a joint study by the University of Washington and Makerere University in Kampala alarmingly revealed that 70% of Ugandan nursing students surveyed believed they would be working outside of Uganda within five years. Only 8% intended to remain in Uganda during that same period. Though these surveys do not foretell the future, they do offer some insight into the perceptions and intentions of the next generation of Ugandan nurses. And reality is not far off, because Ugandan medical and nursing schools lose their graduates to countries offering higher incomes and smoother-functioning healthcare systems every year. Doctors and nurses leave for the U.S., the U.K., Kenya, South Africa, and many others. A few years ago, there was an uproar in the Ugandan health community when a sizeable group of senior surgeons were lured to neighboring Rwanda by higher incomes.
Rwanda is a particularly interesting destination, given its recent history. Last month, Rwanda commemorated the twentieth anniversary of perhaps the most unarguable and methodical case of genocide since the Holocaust. Admittedly, before I met up with Ari and Kelly in Kigali, the genocide was all I really knew about the country. Much has been written and filmed about the 800,000 Tutsi and moderate Hutu butchered in just 100 days, and twenty years later it still hangs over much of Rwandan life like a thick fog. At the genocide memorial, recently-discovered bones are still being added to those of 200,000 victims interred beneath massive unmarked concrete slabs in the middle of the capital. A wall of names akin to the American Vietnam Memorial has been a work in progress for the last fifteen years, and still looks several hundred thousand names short. We visited the Nyamata church thirty minutes outside of Kigali, where 15,000 were slaughtered in just one day. The pews inside the church are buried beneath tall stacks of the bloodied clothes of victims, speckled with rays of sunlight that shine through bullet holes scattered across the sheet metal roof. The walls are still spattered with blood, dulled by passing time to brown smears, a grim reminder that this ‘house of God’ once served as the devil’s den. We discuss heading back to Kigali, but decide to pay our respects at nearby Ntarama church, where another 10,000 were killed in a single day. An eerie canopy of ragged, crimson-tinted clothes hangs from the rafters, a tribute to the dead. The bones of the victims are neatly arranged, cracked skulls in long rows like thousands of broken eggshells. The little skulls, those of small children, are particularly heartbreaking. Curiously, we don’t see any other visitors at either of these places, and we wonder if it’s the drive or the destination.
As overwhelming of a display of human misery as the genocide is, Rwanda’s rise from ashes is even more remarkable. President Kagame may be quietly criticized for his repressive regime (which incidentally equates criticism with treason), but he is also widely regarded as one of the most effective leaders in Africa. Rwanda is one of the least corrupt countries on the continent (though this doesn’t stop a policeman from seeking a bribe from our driver for an illegal right turn), and we’re pleasantly surprised to discover that we can walk about safely at night in most areas, which must be unique among African capitals. On the last Saturday of each month, everyone above the age of 18 throughout the entire country participates in umuganda, a series ofmandatory community service activities which might involve planting trees, building houses, cleaning the streets (not that there is much stray garbage—plastic bags have been completely outlawed in Rwanda since 2008). Ten years ago, the government instituted a health insurance program with $2 premiums, which has evolved into a sliding scale charging the poorest just 33 cents to enroll and today provides near-universal coverage to the population. Since that time, life expectancy has increased by ten years and infant mortality has halved. Government officials talk about HIV prevention at every opportunity and provide insecticide-treated bed nets in rural communities. This is in part fueled by more foreign aid per capita than any other African country and a heavy presence of NGOs (the world’s penance for standing idly by during the genocide).
As we cross the border from Rwanda to Uganda, traffic adjusts from right to left, neatly-rowed tea farms give way to thick rainforest, and smoothly-paved, litter-free roads quickly morph into a minefield of potholes and intermittent patches of puddled red earth. Ari and Kelly forewarned of this abrupt transition, and encouraged me to enjoy the smooth ride while it lasted.
Rwanda is an important reminder that one country’s drain is, of course, another country’s gain. Our driver, a kindhearted Ugandan named Lucas, explains that after the genocide he moved to Kigali to find work, squatting for two years in a deserted house left empty after the war. During that time he met his wife, a Ugandan nurse who had also moved to Kigali because of higher nursing incomes than at home. The U.S. too, with nearly one hundred nurses for every ten thousand people, fills gaps in its care system with nurses from countries with one tenth (or less) the nursing saturation. My own parents, a doctor and nurse, left developing countries to come to the U.S. after their training abroad.
These global dynamics provide little comfort to the sick in Uganda, though. Over a few Nile Specials (the local lager), I ask Ari if there’s any chance of simply convincing students to stick around. But the irony of someone with no intention to stay long term, trying to convince someone else to do just that, is not lost on either one of us. Just the other day, he says, one of the best and brightest nursing students he and Kelly have ever seen—anywhere—failed a course that will set her training back six months. He suspects that she was flunked by a more senior nurse who felt that her own job might be threatened by this rising star. He hopes the student will decide to repeat the course with resolve, but fears that these sorts of systemic issues will continue to frustrate her until she decides to seek another profession, or perhaps take her talents elsewhere. Soberly, he explains the simple success he hopes for: that he might have a lasting, positive effect on even just one or two students, who maybe take a run at developing one of the programmatic changes he’s trying to put in place, and that over time this might help build local capacity for health education and patient care, even if he never gets to see it.
Towards the end of my six-hour drive to Entebbe airport, my driver asks how I like Uganda. I tell him it is one of the most amazing places I’ve ever seen, and that I wish I could stay longer. “So you are going to come back?” he asks with a smile. “I hope to” I reply, and I do, but he laughs anyway.
Living paycheck to paycheck, praying that the government is actually able to pay your salary this month. Hoping there has not been extortion of funds or corruption–again. Paying school fees to the same government that has not paid you in two months so that your 9-year-old can get a public school education. Unable to get a credit card because affordable interest rates are non-existent. No Amazon, no PayPal, no eBay. Forced to pay exorbitant fees for money transfers. Hoping you don’t get sick because hospital bills are fee for service—if you don’t have the cash, you can’t get care. But you get sick, because the power is out and spoils your food, the water is contaminated with bacteria and parasites, and mosquitoes carry malaria. And you are forced to beg for money from friends and family in order to get the care you need—or you just don’t get care, and you get sicker.
Life is hard in Uganda. Uganda is not unique to the harsh realities of government inefficiencies and corruption, poor education, bad water, and bad health care, but we have been immersed in this beautiful country with these lovely people who are living in this harsh world for almost a year now. We have befriended many. We have listened to their stories, commiserated with their losses, and been lifted by their triumphs. The people we have met here are truly some of the most resilient people we will ever meet. We would like to introduce you to a few of our friends and students. Their names have been changed to protect their privacy, but their stories are very real.
Meet Natalie. At the age of 27, Natalie entered University, about 8 years later than most of her peers. Her father died when she was in 6th grade, and her mother was unable to get a job to support her three children. Natalie dropped out of school after 7th grade and got a job cooking and cleaning at a secondary school. After 5 years of working there, the headmistress noticed something in Natalie and invited her to join the school, as a student, waiving the school fees. Natalie worked her way through 10th grade, excelled in all her classes, and qualified for A-Levels (advanced levels of high school that enable students to apply for university). Her employer, seeing her potential for success, told Natalie to stop working and paid her tuition. Natalie excelled on her A-level examinations, qualified for a government scholarship, and is now one of the top students at MUST. This year will bring a challenge–she and her boyfriend are expecting their first child in October, but Natalie’s mother has refused to accept the boyfriend as a suitable husband since he practices a different religion. But Natalie refuses to be defeated. She is moving in with her boyfriend who will support their new little family as she completes her university education. She is continuing to work on the relationship with her mother. She stands tall, has a beautiful smile and calming disposition. She will be a wonderful mother.
Meet Georgia. Georgia presents herself with confidence, sass, and intelligence. She is extremely bright, quick, well spoken, and always well dressed. She wanders around campus with a gaggle of friends, always laughing, chatting with boys, and enjoying life. But behind her confident exterior is a girl with a challenging past. Both of Georgia’s parents died when she was in primary school. She and her brother were taken in by her caring uncle who manages to support his niece and nephew, in addition to four children of his own. But it is a constant struggle. Every semester Georgia waits, fearing that her uncle won’t be able to pay for her school fees this term. If fees aren’t paid, even if the student is short the equivalent of five dollars, students are unable to sit for their final examinations and they are forced to fail their classes and repeat the entire semester. Georgia has a dream to complete undergraduate education and eventually apply for a post-graduate degree. She has big dreams for herself, but worries that financially she won’t be able to accomplish these dreams. Still, she studies hard, plays hard, and maintains a poised disposition. She doesn’t share her struggles with her friends, as she doesn’t want them to feel sorry for her. She pushes herself to succeed.
Meet Jonathan. Jonathan is here at MUST, living hours away from his wife and four small children. He wants an education. He wants to advance in his career. This is the only school that offers the degree he needs. He worked hard for years before starting university, saving for school fees. But the university increased its tuition and fees this semester, and Jonathan was short about $400, which is the equivalent of 1-2 months of work. His wife is working two jobs to support their four children at home. They have no savings. There is no credit. Jonathan called his friends, family, neighbors, asking for help. In the end, he was still short $100. He has worked so hard, sacrificed so much, with a dream of advanced education. $100 was all he needed, but he had no other options. We were able to find the money for him, and he accepted the scholarship with tears in his eyes, so thankful for what, in the end, is so little to us, but so much for him and his future.
When life is continually a battle, when money is always a struggle, when health is so precarious, it is no wonder that many people stop trying all together. If every time you rushed to resuscitate a patient, your patient dies because there is no oxygen in the hospital, would you continue to rush? If every time you work hard to earn enough for school fees, the school increases its tuition so you have to forfeit the semester even though you put in the work for the past 17 weeks, would you continue trying to obtain that education? What if that education didn’t guarantee you a job at the end? Would you want to work hard in a job that six times a year fails to pay your salary? We don’t know if we would. Yet, we have met so many people who, in spite of these hardships, in the presence of this chaos, somehow maintain their drive and continue to push, learn, and persevere. People who will not give up until their dreams are obtained. People who want better—for themselves, for their families, and for Uganda.
We didn’t know what resilience truly meant until coming here, but all these stories—and there are many—prove that it is both within and without. These students are lucky. They had the critical combination of inner strength and drive with outside support at just the right time. These students are the pillars of tomorrow’s Uganda, and their tales prove that under the extraordinary pressure of life here, they may bend, but they won’t break.
Amplified sound fills the air: voices on mobile loudspeakers announcing the latest club opening, the call to prayer, a Michael Jackson re-release featuring Akon. Mixed with the clamber of giant storks outside our window, the jingle of empty beer bottles on flat-bed trucks making their way to the Nile brewery for a filling of golden lager, and the clang of the same trucks over our beloved speed bumps, Mbarara starts to feel like the inside of a giant dome. Maybe those perfect African skies really are too good to be true. Maybe they are really just paintings to thinly veil the massive speaker sets aimed inward. Orien’s belt really a line of tweeters the size of Boeing 747s, tuned perfectly to play the high pitched howls of the small dogs and roosters. Cumulus clouds really subwoofers like small planets, pounding out the cacophony of an equatorial beat.
For all that noise, Ugandans are a quiet people. A gross generalization, of course, but stereotypes come from somewhere, and this one comes from constantly straining to hear the person standing directly in front of you. Yet it is with no sense of irony that people describe a raucous night on the town as making noise. As in, “let’s meet up and make noise tonight.” It used to strike a funny chord, the idea of quiet people making a dent in the 140 decibel background. But through a process of overly analytical interpretation, this southwestern Ugandan colloquialism has gradually taken on new meanings. First, making noise was an expression of frustration with the challenges of life and work, an escape from the quiet grind of needy students and dying patients. Next, making noise morphed into a rebellion. Not an escape at all, but a middle finger to all that oppresses, a way to stand tall and proud and loud. Finally, the familiar phrase turned into something transcendent—a contrapuntal crescendo independent of, but in perfect harmony with, the M-Town dome of sound. It is music.
Throughout our time here in Mbarara, the tempo and amplitude of our own making noise has slowly increased. Figuratively, we are making noise with ideas while finding harmony in the broader symphony. And literally, we are making music. We are not the composers, nor the conductors, but hope to inspire a band-mate or two to play more than a military march in common time. We have evolved a bit from our days of bucket drumming on the pediatric ward. Mary now has a Fender guitar, and Ari has a cowhide drum from the royal drum-makers on Kampala road. We even have a theme song: Hidden Ones, by Missy Higgins.
“There is a choice. You can follow the leader. Or use your voice. Cause this will just keep up till we make a loud noise. And the hidden ones speak up.”
Mary and Kelly first sang this song at a dinner party for the Nursing Faculty. These words, sung aloud to a group of Ugandan nurses, suddenly took on a much deeper meaning than any of us had anticipated. It is a song about finding your voice, standing up for what you think is right, and making change in the world. It’s about education, commitment, exchange of ideas, and finding your own internal leadership. It is a song that signifies the reasons why we are here: to help our students and faculty push for what they think is right in their country; for better education and for better health; and to bring out their hidden voices so that they demand change in their own world. We are here to help them make some noise.
Sometimes an idea takes root and we land a power chord. Sometimes we’re just plain off key, in need of a capo wielding guitarist with perfect pitch to bring us back. We play andante (walking pace, a moderate tempo) or vivace (very lively, up tempo), sometimes adagissimo (very, very slow). But always affetuoso (with affect), with good intention, and with extreme pride in the community we have joined.
As a coda to the movement of this year, and as a way to make a different type of noise himself, Ari was invited to rap a verse on the latest track from Shaay, a football friend with a local music career. After some discussion of possible socially progressive lyrics, Dr. Shaay (his MC name) announced that the song would be about a hot Arab girl, with a chorus in Luganda that essentially says how hot she is and how her skin looks like gold. Not quite the socially progressive message originally in mind, but tried and true hip-hop, and given the Jewish heritage, it could be seen as bridge building. The next discussion was about MC names, which turns out to be incredibly challenging. Shaay sings the introduction with the name “American Ari”, which Ari’s brother Eric pronounced the worst MC name in history. Jewganda and Dr. Dreidel were both on the table, but the Jew reference is a bit obscure here. There are a number of websites (myrapname.com, flocabulary.com, etc) that offer assistance in selecting the perfect MC name. You enter some basic information, click on a button that says something like “yo mama”, and there it is, your new rap name. Manic Ari A Hitman, AH Pimp Crush, and Four Letter Word were a few options. Then there is always the random approach, like calling yourself Carne Asada or Zebra Foot. But on the local music scene, your real name with a twist works best. So this week we bring you the world debut of Arab Gal (Omuwarabu) by Dr. Shaay, featuring Ray Signature and Ari B.
Enjoy the song. Try to find some deeper meaning within. And go, find your voice, and make some noise.
This week we bring you reflections by Tom Lippi:
The arrival on our digital doorstep of Kelly and Ari’s blogs is always a welcome event, and we read them with relish, amazement, pride, and concern. Always mixed feelings, to be honest.
You can’t help it when you read something like,
“We pay the school fees for a friend’s child, then spend the same amount on imported cream cheese so we can make a cheesecake and delicious frosting for our cinnamon rolls at Easter brunch. We watch the wards fill to overflowing, diagnose terminal illness, pronounce dead, then sit poolside drinking rum cocktails out of pineapples while the sun sets over the savannah. It is a world of extremes, hard to make sense of.”
So how do we read that? The English teacher in me wants to reward the wonderful writing, rich in details, laced with irony. But of course the source of the irony is painful experience, hard to read. How hard to live? And so the parent in me, and this is always one of my responses to every blog, wants to waggle a finger at them and order them to come home right this minute. Just what do you kids think you are doing? And when I consider that, I am reminded they’re not kids at all. What they have seen and done, the work they do, the world they live in, try to make sense of…They are older and wiser than I.
Yeah, mixed feelings…
We scan the pictures. The food looks good, in particular that calorie and cash heavy cheesecake…And so do they, in the company of friends and fellow adventurers, at home, in a way. They gather for a Passover Seder, for Easter brunch. They’ve made it like home, which is nice, and a comfort. After each blog or conversation we always say “they look good. They sound good…” and we hope it as much as we mean it. Truthfully, to me they always look a little thin, a little tired. Not surprising. But beaming Ari looks great behind his Ray Bans, basking in the sun, and Kelly, brandishing her luscious-looking cinnamon rolls, smiles proudly. Her eyes have a spark in them, inextinguishable. Together they celebrate “holidays symbolic of spring, remembrance, the circle of life. And sacrifice… Passover and Easter remind us of all that we have, and all that others don’t, but also that joy and sacrifice are not mutually exclusive.” See what I mean? Older, and wiser…
So how do we read the Easter story? It’s complicated, of course, but let me offer one reading, (with a little help from Dylan Thomas) and inspired by the work Kelly and Ari—and good people everywhere like them—are doing, everyday, often against awfully formidable odds. Easter says, “Death has no dominion…” Nor do disease, despair, bigotry, repression, hatred. Easter says that the essence of the human spirit, illuminated by some divine spark, inextinguishable, is to be good, and to do good. As our wise children write, “You just need to act.”
Spring’s coming here, too. I’m planting stuff, looking for signs of life—sprouting beans, red leaf lettuce, tomatoes (planted, as always, too early, too optimistically…), basil, and my new king of crops, kale. We look forward to cooking and sharing meals in a new kitchen with a soon to be reunited family. Spring, Easter, will finally arrive when Kelly and Ari are home.
It was a religious week in Mbarara. We had a Seder in the expat compound on the second night of Passover, retelling the story of Exodus, a celebration of freedom. This on the 20th anniversary of the Rwandan genocide, with ongoing civil war in the Democratic Republic of Congo that occasionally spills refugees and rebels alike over the border. The Central African Republic continues to rip at its religious seams, Christians killing Muslims in retaliation for Seleka militia killing Christians, in retaliation for, in retalitation for…
Then came Easter, following on the coattails of Passover like the crucifixion followed the last supper. Freedom from slavery and persecution on Tuesday, rebirth and purity on Sunday, both holidays symbolic of spring, remembrance, the circle of life. And sacrifice. The sacrificial lamb, the sacrifice of the firstborn Egyptians, Jesus’ sacrifice for the sins of others. A rooster appeared on the compound last week, pecking around the lawn and fattening itself in preparation for his ultimate sacrifice.
A recent replay of “Animal Sacrifice” on NPR’s This American Life starts with a discussion of the historical shift in major monotheistic religion from sacrifice to prayer, from deeds to thoughts. We are not suggesting a return of animal sacrifice, but all these age old traditions and ideals seem to have left so many without freedom. Freedom from persecution, from poverty, hunger, and disease. Good intentions are necessary but not sufficient for good outcomes. Action is key.
What have we sacrificed? We like to think of our being here as walking the walk, dedicating our hard earned skill sets to the betterment of a place we had never even heard of two years ago. And we are certainly acting on our good intents. But we are, at the same time, enjoying life’s luxuries. The contrast between great need and great luxury is not unique to Africa, but our proximity to both can be overwhelming, and it is hard to make sense of the extremes in this crazy world.
We ate matzo ball soup while a young man with a treatable head injury languished in the Emergency Ward after a motorcycle accident because his family couldn’t afford the ICU. Last month we visited the genocide memorial in Kigali with our friend John. We saw churches still stained with the blood of murdered children, then we ate sushi and met a group of friends at a swank nightclub overlooking the rebuilt capital. We pay the school fees for a friend’s child, then spend the same amount on imported cream cheese so we can make a cheesecake and delicious frosting for our cinnamon rolls at Easter brunch. We watch the wards fill to overflowing, diagnose terminal illness, pronounce dead, then sit poolside drinking rum cocktails out of pineapples while the sun sets over the savannah.
It is a world of extremes, hard to make sense of. Passover and Easter remind us of all that we have, and all that others don’t, but also that joy and sacrifice are not mutually exclusive. People often say “I couldn’t do what you’re doing,” give us praise for the apparent sacrifice we have made to be here. But we live well. You don’t need to uproot and move across the world to act on good intent. You just need to act.
Everything grows in Uganda. Spit a seed from a slice of watermelon into the dirt in front of your house, and a seedling will spring from that fertile soil in weeks. We once passed a control burn on a Friday, and on Sunday new grass had begun to grow, bright green shoots in charred earth. That extreme fertility transfers to the people of Uganda as well. Uganda ranks among the top three nations in the world for fertility, with an average of 6.2 children per woman (Unicef, 2011). You see babies everywhere. Moms walk down the road, carrying heavy baskets of fruit or charcoal on their heads with an infant strapped to their backs. Babies sleep in the hospital beds of their sick moms who have no choice but to bring them along while they are receiving care. Babies take care of other babies while parents work, clean, cook, and birth more babies—it is extremely common to see a 2 or 3 year old carrying his baby brother or sister on his or her back while mom is busy caring for the household. While in the United States we expect our infants to hold up their heads around 3 months, crawl around 9 months, and walk around 12-15 months, here it is normal to see a 9 month-old walking around, stable, with their older siblings. In fact, it’s abnormal not to walk by your first birthday. When the average lifespan is 52, and momma is too busy to carry you around, you have to get on with it.
What contributes to the high fertility rate of Uganda? Will this number continue to rise or will it fall? I decided to poll my class of 30 nursing students, ranging in ages from 21 to 35 years old, to get their views on sexual health, contraception, and fertility in Uganda. The results were fascinating and enlightening:
1) How many children do you want to have in total: 3.65
2) How many children does your mother have: 5.9
Already, in one generation of educated males and females, there is a marked decline in the number of children desired versus number of children their parents raised.
3) Why do you think Uganda has one of the highest fertility rates in the world?
Ugandan woman are extremely fertile.
There is prestige in number of children.
There is no education about family planning methods.
Lack of education and low literacy lead to more pregnancy
Infant mortality rates are high
And my personal favorite…
There are no jobs for people in Uganda so everyone have too much time for sex and production.
4) Do you think this number will continue to rise or will it fall?
Most felt the fertility rates will go down due to two main factors:
Education of girls
Sensitization of family planning methods countrywide
I was impressed by the insight and candor of my students. They named the key factors that have been found to correlate with fertility rates in Sub-Sahara Africa: women’s education and lack of access or understanding about family planning and contraceptives. Countless studies have shown the importance of educating girls. Educated girls marry later in life and have fewer children. Educated girls are less likely to die in pregnancy and childbirth. Education brings better incomes, less abuse, and overall, better lives for women and children (Worldbank, 2004). So that seems pretty clear—educate girls and fertility rates and overall health will improve. But what about access to, or understanding of, contraception? Walking around campus, we see signs promoting family planning methods and contraception. The government clinics are supposed to offer all forms of contraception, from birth control pills to injectables (like Depo) to IUDs. However, recent data collection demonstrated that more than 4 in 10 births in Uganda are unplanned and Ugandan woman give birth to nearly two more children than they desire (Ugandan Demographic and Health Survey, 2011). So, obviously, access to contraception and understanding about contraception is not as widespread as it should be.
I asked my students about this discrepancy. Aside from the lack of actual medicine, does anything else influence this? My students are the current and future health care workers of Uganda. They are the nurses that will provide the counseling and education about family planning methods to the population. They will be staffing the clinics and the hospitals; they will be birthing the babies and treating the sick infants. The “sensitization of family planning methods” throughout Uganda will depend on them. What is their opinion about why woman are having more babies than they want to?
Their answers were surprising and, in truth, a bit concerning at times:
Sexual health is not discussed in school. Period.
Parents do not discuss sex with their children. Period.
… so if school isn’t talking about sex and contraceptives AND parents aren’t talking about sex and contraceptives AND computers, internet access, and televisions are scarce, especially in rural Uganda, where are people getting their information? Ideally, from a well-educated health care worker in a well-stocked clinic who greets you with an open mind and non-judgmentally explains your options for family planning. But, unfortunately, many of the health care workers themselves have opinions about who should receive contraception. Although it is against the law NOT to offer contraceptives to women, a recent survey in Uganda showed that many nurses and health care workers will not offer contraception advice to unmarried females, especially adolescents. And often, patients themselves, especially unwed adolescent patients, are hesitant to talk about their need for contraception for fear of being judged or ridiculed.
Myths about contraception and pregnancy also permeate society, even among educated health care workers.
For example, in my class, predominant myths included:
Birth control pills cause infertility.
Birth control pills cause abortions.
If you do not become pregnant by the time you are 24, you will develop cervical cancer.
You can only be on birth control for maximum two years or your will develop problems.
These myths were believed to be true by my highly educated group of students, 12 of them practicing nurses. If they believe these myths and are the most educated people in the country, what does everyone else believe?
The churches, mainly of Christian varieties, also greatly influence opinions about contraception.
I was asked:
Isn’t contraception use bad, especially among Christians, since it causes abortions?
My priest told us in Church on Friday that birth control pills cause abortions. Is this true?
Now this was a bit challenging to address. Being from the liberal bubble of the Bay Area, we rarely think about the interplay of religion and medicine. Science is science. Religion is religion. But Christianity is huge in Uganda, and there is no separation between church, medicine, and the government. To understand why the Christian Right argues that birth control causes abortions, I had to turn to trusty Google. And, of course, it comes down to the good ol’ argument about when life begins. Science says pregnancy begins at implantation. Conservative Christianity says pregnancy begins at fertilization. Some (a small minority) contraceptive methods prevent implantation after fertilization. Thus, if you believe that life begins before implantation and contraception may prevent implantation, then contraception may be against your religion. I couldn’t, nor should I, argue about the beginning of life, but I had to find a way to teach about the science without causing religious offense.
In the end, as with most things, talking about the myths led to greater understanding about the issues. By giving students the scientific facts about sex and contraception, they are now better able to educate their patients about family planning. These future nurses reached an agreement with me: although they may have their own religious views about contraception, to be an effective, unbiased health care provider, they must give patients the facts and allow them to make their own informed decisions about contraception.
This was the first “sex talk” the majority of my students had ever had. They are adult university students.
We are living in the fruit basket of Africa. The mangos and avocados that fall in buckets into the tall grasses of our yard remind us of the power and beauty of fertility. Yet so much fruit lies there to waste, rotting in the sun, crowded out by neighboring plants without a chance to take root and grow. We need to plant the seed of education. We will still grow, just not in numbers.