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Election day is tomorrow and things have been getting crazy in Kampala, so I have retreated to nearby Kenya.
I am hanging out at Diani Beach for a few days and it's beautiful and so relaxing. There's nothing like falling asleep to the sound of crashing ocean waves. I'm getting some dives in and will try my hand at kite surfing before I head to Nairobi for the weekend. Updates and photos will come on the soon-to-appear Kenya page!  Another highlight of the Sipi trip was brewing our own coffee. While I’m not a coffee drinker, I was excited to see the local coffee production process and the end product was actually really good! I drank the whole cup, Zea would’ve been proud. :) We started in Mangusho’s garden where he grows coffee beans. They’re Arabica which means they have 2 beans per berry (is it a berry?) instead of 3 beans, which would be Robusta and apparently not as good. Once the plants grow in his garden, he replants the seedlings in little bags for each to grow on their own. They grow in the shade of banana trees which is perfect for them because it keeps them out of direct sunlight. The elevation at Sipi is also ideal for good coffee plants. Melissa may have to help jog my memory on this, but I think they then grow for another 9 months before they’re ready to be planted in the soil to grown into larger trees. Mangusho showed us a coffee tree that his grandfather planted years ago – he’s carrying on a family tradition. Legend goes that that was the first coffee tree in Sipi!
It takes 4 weeks to dry the beans, so we jumped over that part of the process. Once you have the dry beans, you need to remove the husk. While you can do this by hand, as you can imagine, that is very tedious and time consuming. So we used a wooden mortar and pestle. It’s important that the mortar is really deep so the beans don’t escape. Once our arms were too tired to continue, Mangusho took a plate and artfully separated the beans from the husks. We’re now ready to roast the beans! I had no idea that the difference between light, medium, and dark roast is simply how long you roast them for…so self-explanatory haha. At Mangusho’s suggestion, we decided on a medium roast. The beans crackle a little kind of like the early stages of cooking popcorn on the stove. It smelled great! Once they were ready, we let the beans cool on a banana leaf. Mangusho had us try the beans – they were pretty tasty. Definitely really flavorful. I feel like describing the taste of coffee is similar to describing the taste of wine, so I’ll continue to steer clear of both.
Ina, Melissa, and I took my car, yet to be named, on a little road trip to Sipi Falls in January. Without traffic and with good roads, it would probably be a 4 and a half hour drive. But, the 190 mile journey took us about 6 hours on the way there and 8 on the way back because we hit some bad traffic coming back to Kampala. We stopped at Mbale Resort Hotel for a late lunch on our way up. There’s a nice pool that you can eat by and the food was pretty good, and cheap by Kampala standards. The roads to Mbale are pretty nice (just need to keep an eye out for all the speed bumps) and it’s just the last 45 mins or so from Mbale to Sipi that are full of potholes. Crow’s Nest is a really popular budget option and has a great view of the falls. But Lacam Lodge, where we stayed, includes all meals (and they're great) so once you factor in food costs, at $25 a night, I would highly recommend it. We stayed in their dorms, but they also have nicer bandas that have their own bathrooms and outdoor seating area. You can also arrange all your activities through the lodge. Our amazing guide, Manugsho “Steve” Martin took us on a 4-5 hour hike of the three main falls in the area. I’ll let the photos speak for themselves. The following morning, we checked out Mangusho’s favorite waterfall before hitting the road and heading back to Kampala.  Mangusho (which means “elephant”) is half Kenyan and half Ugandan. His dad was a Masai warrior but unfortunately killed by poachers when Mangusho was young. Soon after, Manugsho, his mom and brothers moved back to Sipi, the home of his mom’s tribe, the Sabine.
Before he turned 18, Manugsho participated in the male circumcision ceremony which is a pivotal right of passage. In Kenya, this ritual is done in private with only males present, but in Uganda, the ceremony is a huge public gathering and celebration. Teenage males will spend the year prior to their circumcision building themselves a home close to their parents. Once they have “proven themselves” they will live on their own, but it’s important to still be closely their families. As a well educated son of a warrior, Mangusho was chosen to go first. During the ceremony, the males are not supposed to flinch or cry - their faces are even painted so it’s very obvious if they do. Those that don’t make it through the circumcision are publicly shunned (I think they’re actually given slashes on their arm so it’s visible to everyone) and likely will never have a family. We asked Mangusho what he would do if he had sons - would he circumsize them in the hospital or have them endure the same pain he went through? He said that for safety, he would prefer the hospital but because the male circumcision ceremony is such a big part of Sabine culture, he would want them to participate in the ritual. We loved learning about Mangusho’s life and would highly recommend him as a guide!! Sipi is beautiful and relaxing - perfect for a 3 day weekend getaway. With more time, I would have loved to climb Mt. Elgon which we could see in the distance. Wanale Ridge in Mbale is also supposed to be really great.  Family Planning register and some ARVs After a 1:45 AM wake-up call to watch the Superbowl, I spent the day at Buwama Health Center III.
I am working to support a National Technical Support Supervision where members of the MOH and other IPs are visiting about 100 facilities across the country. We have a 30+ page questionnaire that we go through at each site to understand to extent at which facilities are using nationally provided tools, supplies, and recommended patient flow / patient care processes. We then wrap up the visit by debriefing with the available facility staff and developing an action plan with owners and deadlines (#PMOmg). So far, I’ve been to five facilities and it’s been incredibly eye opening. It’s easy to back up pilot recommendations or national roll-out strategies with some data, but actually seeing how things are done (or not done) on the ground has provided invaluable context to the work I’m doing. The quantitative and (potentially more impactful) qualitative data we are collecting will be compiled and shared with DHOs (district health officers) nationally in the coming months. The first two facilities we went to were doing a great job. The staff was engaged, open to our suggestions, and seemed to be doing all they could to provide high quality care to the large volume of patients that arrived each day. While that was awesome to see, it almost discouraged me a bit about the strengthening work we are doing. It made me feel like without hiring a lot more staff and building more rooms to see patients, we’re grasping at straws hoping we get lucky that the infants or children we test are from the frequently cited unidentified HIV+ population. The third facility, which was pretty rural, was not performing at the same standards at all. Their in-charge seemed detached and unaware of all the problems in his facility. The majority patients they were able to identify were not being retained on ART treatment. My program manager tried to express the gravity of this situation by explaining that the poor healthcare and follow-up services would have a much greater impact on the surrounding villages than they may think. The CD4 cells of those who take 1st line ARVs and then stop after a few months or even a few years, will mutate and become resistant to the drugs. That means that if the patient starts the same treatment regimen again, the drugs will not be as successful in suppressing the virus. The next step would be to put the patient on 2nd line ARVs, but the side effects are much worse. There are 3rd line ARVs but they are not available in Uganda as PEPFAR does not support them. All that being said, having poor retention rates for those initiated on care, means that there are HIV+ people in the local community who are not virally suppressed and likely spreading HIV to other people. Those people are getting a mutated strain of HIV that is already resistant to treatment – so if and when they seek treatment, it will not be as successful. That discussion was disheartening and reenergizing at the same time. It showed me firsthand that there is so much work to be done. But, it also made me think about what challenges we’re addressing in our work which are mainly process based (testing at more entry points, following-up with patients via SMS / phone calls / home visits, etc.) versus some of the underlying systematic challenges. At the facility I just discussed, the core issue seemed to be the staff. My team told me that basically the in-charge was linked to a MP (member of parliament) which essentially made him (and his two sons he employed to work there) untouchable. Because the community is small and rural, it’s likely most other folks are closely connected as well rendering them untouchable and it’s hard to incentivize people from other areas to move there to work there. But what if we paid health care workers more? In most cases, they already work for close to nothing and meanwhile we are paying MOH staff to come to meetings. For example, last Friday CHAI hosted a meeting about a new testing algorithm that’s being proposed and every government official in attendance received transport reimbursement (even if coming from Kampala) as well as ~$40USD. Apparently, one of the more recent PEPFAR grants tried to ban the payment of per diems to MOH officials since…it’s their job…but that had to be removed as no one would show up to the important meetings. In the same meeting, someone made a comment about all the efforts around follow-up initiatives. He said that the way we are talking about follow-up assumes that forgetfulness is the reason why mothers are not coming back with their children for treatment. However, we are ignoring that many of these patients don’t live close to facilities and transport costs are high (and if the wait is long, they may have to go home without being seen that day). Perhaps we need to instead hire more VHTs (village health teams) to engage communities and bring treatment to the patient instead of vice versa. On a lighter note, at Buwama today, I saw the newest born baby I’ve ever seen! I remember growing up always visiting my new cousins a day or two after they’re born, but I was sitting in the maternity ward going through some registers when Brenda, one of my colleagues, and I heard a baby crying from the labor suite across the room from us! I had no idea anything was going on because apparently mothers are not allowed to make noise during labor. About 15-20 minutes later, the midwife slowly walked the new mother out and let her rest on a cot in the room. Then another woman brought out the baby for its first feeding! There was no privacy at all, not even curtains. We were sitting maybe 10 feet from her and the door of the room led outside so people were coming in and out frequently. Brenda says she’ll stay there for a night or two before she’s discharged to go home. She had a small suitcase with her with some blankets and clothing. It reminded me of this article another colleague shared last week. What a jarring juxtaposition at the inequity of services and resources mothers-to-be face across the world. As if that isn’t enough…mothers usually will come to the maternity ward when they are in labor…mode of transportation: BODA?!?! It looks like the NRM has been handing out 50,000 UGX notes (about $15 USD) as they've traveled around the country hosting rallies. Museveni, the incumbent, has been arriving to some rallies by helicopter which allows him to cut down on travel time a lot. He has a full entourage of yellow trucks with open beds and huge speaker systems and busses that are used to bring people from more remote areas. Apparently the man you see in the photo above, was beat up badly soon after that photo went viral since people knew he had so much cash on him.
Elections are on the 18th and I'm heading to Kenya for the week to escape the potential (and likely) craziness that will ensue. I'll spend a few days hanging out at Diani Beach before spending the weekend in Nairobi hanging out with Kristy and Hannah - can't wait! The 2016 Ugandan presidential elections are in just over two weeks and we’ve somehow timed our site visits perfectly with some presidential rallies happening in a few small towns in Central Uganda. After a long day at the field, we returned to our hotel to see a campaign handing out cold hard cash for votes.
How much do you think it costs to buy a vote? Let’s play! Price is right rules. Answer to come in my next post! Bonus points to those who want to comment about how much it costs to buy an American vote these days… In the meantime, I thought I’d share some other cost of living snippets of life so far here in Uganda. Rent: $100-500 per bedroom per month
Plastic soda bottle: 60 cents
Curious about other costs? Let me know! My general observations is that “stuff” isn’t as cheap as you might think, probably because most of it is imported. However, food and then time / labor costs are pretty low. An example of this is that taxis and private hires all charge only on distance and not time. Given the Kampala traffic, this was surprising to me. A short, cheap ride could last 5 minutes or 20 minutes depending on the time of day, but it’d cost you the same amount. The culture here is very relaxed when it comes to time. Meetings unapologetically start or end late…or just get cancelled after you’ve already arrived. We once told data collectors to come pick up their money and materials for field visits and then due to some bank delays made them wait around THREE hours before we starting handing things out. While I was anxious and embarrassed leaving them to sit around the office waiting, I don’t think we got one complaint or question about when things would get started. That was insane to me and I’ve realized I place such a high value on time – both my own but also respecting others’ time. This probably stems from all the hours I “wasted” sitting alone waiting at the Millbrae BART station…just kidding Mom. |
AuthorI'm eager to learn about the world around me and find that travel (and food) is one of my favorite ways in which to do so. 
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