I met Christine through other CHAI staff and hired her in January to clean my apartment twice a week. I didn’t expect her to have such a huge influence on my time here in Uganda.

Christine is a single mom of three. Her daughter Ruth is 12 and is consistently the top of her class at a nice boarding school in town. One of my colleague pays for Ruth's school fees. I generally don’t support organizations that are based on a sponsorship model because I don’t think they’re addressing the root of the issue and can also have many unexpected consequences based on the way they select beneficiaries. However, how can I argue with the fact that Ruth is better off because Christine receives money to pay her school fees?

Sometime in February, I found out that Christine started a school in Pader, about 6 hours north of Kampala. I was confused. How did she start a school? She doesn’t have a lot of money, and I know she’s physically in Kampala because she comes to my apartment to clean each week. My colleagues also didn’t know what to make of the news. My first instinct was to learn more and figure out how I could help. However, I also understood why my colleague (the one who supports Ruth’s school fees) was skeptical. Why was Christine opening up a school to benefit other children when she can’t individually support her own children and their education costs? Those that had given Christine money over the years to build a garden and open a restaurant weren’t totally sure where that money went. 

While I had my doubts, I figured I should go talk to Christine in-person instead of speculating. The Sunday after I heard the news, I stopped by Christine’s house. How did she do it? Was the school functional? Who was running it? How many students were there? I dutifully came prepared with a list of questions that I quickly forgot about. 

Christine told me about how she, as a primary school dropout, knew first hand how difficult it was to make a life for herself and her family. She didn’t want others from her hometown to face the same fate. Many families in Pader could only support their children (and likely only a couple of them at that) through primary school. The secondary school fees were just too steep so children instead helped out around the house. I told Christine I wanted to help, but I was careful not to commit to anything. She gave me the contact of the school’s head teacher, Godfrey, who was able to tell me a bit more about the number of students, current operational costs, etc. 

Timing seemed to be in our favor. I was headed up north to do some field work in Gulu and I told Christine that if she would meet me there, I would travel with her to Pader to see the school for myself. If I could better understand what was happening and what the biggest needs were, then I’d know what to do.

When we arrived in Pader, Christine was eager to show me her room, which she shares with her sister, Brenda, who lives in Pader full time. Brenda runs the restaurant which some of my colleagues’ money went towards. At the time of my visit, Brenda was in Gulu tending to some health issues. The restaurant, which Christine only trusts Brenda to run, was therefore closed for the time being. 

Godfrey, the head teacher, came to meet us shortly after our arrival and we headed over to the school. To be honest, I wasn’t expecting much. I had prepared myself to be disappointed. But instead, Christine and Godfrey eagerly showed me around the school There are two large classrooms, a main office, and a staff rest area. The building used to be occupied by World Vision, which has decreased its presence in the region. Christine has paid the lease through the end of the year. 

The school had a sign and a stamp. These were two things that wouldn’t have been at the top of my list of necessarily expenditures, but they are items that give the school a sense of legitimacy and permanence. 
They needed more books, money to fix up the latrine which wasn’t yet functional, chairs for the classroom which were currently on loan from Christine’s restaurant, and enough money each month to pay their teachers. The list wasn’t long and besides the teachers’ salaries, wouldn’t really cost that much. But, a nagging voice in my head yelled “sustainability! This needs to be sustainable!!!”

​I walked away from the school feeling excited for Godfrey, Christine, and the community. This was a huge need. Pader Secondary School was offering a quality education (all the teachers had degrees) at about a fifth of the cost of other schools in town. Do I support education? Yes. Do I believe it’s a necessity for all children? Yes. Do I believe education is of utmost importance in a country like Uganda with a growing birth rate and young population? Yes.

So, what was holding me back from calling my friends and family and throwing a few hundred dollars at a good cause? After all, I had seen it with my own eyes, run through my list of 30 or so questions, and talked to some of the staff members. This was real. It wasn’t just a ruse to get a few extra bucks from some naive muzungus. 

The situation, however, didn’t align with what I believed at the time. I wanted the school to have a long-term plan. I didn’t want to feel like what I could do was just a short-term solution until I inevitably left the country. So, I tried brainstorming. I made a list of NGOs within the region that might be willing to donate time, money, and skills. I reached out to some Duke Engage students who had worked in Uganda over the past few years - maybe some of them were looking for a gap year before the “real world” hit. I talked to my Ugandan colleagues to figure out what I needed to know and how they thought I could help. I grappled with the fact that education might not be an area that is sustainable. It’s not a business, I thought. Our public education system in the United States is funded by taxpayers and private schools cost an arm and a leg. I couldn’t name a school in the states that was sustaining itself by selling produce from its own garden, so why should I expect that here? 

The end of March came around and Christine called asking for an advance on her salary so she could pay the teachers. She had similar requests of some of my colleagues that she also worked for. None of us said no. 

But, I knew I wouldn’t be here each month to help out. Eventually, some of us would say no. It wasn’t sustainable. So, I turned my efforts to capacity building. My Ugandan colleague, Brenda, knew of a woman who had started a successful and sustainable school in Kampala. I sent an email, explained the situation, and she agreed to meet. Christine, Brenda, and I went to meet her one week in April. She spoke of the hours she spent at the internet cafe doing research about how to run a school, sending emails to any organization she thought might want to help, etc. While she had some good ideas for us, her success story was heavily reliant on the urban location of her school and her strong English abilities. She talked about how she went from having two computers to a lab full of them. Pader Secondary School doesn’t even have a latrine. Or power. We’re a few steps behind that. Nonetheless, she had some great ideas and proved to Christine that a Ugandan woman with goals, could set out to achieve them. She told us that every student is an idea, so we should talk to our students. She reminded us that Uganda’s land is fertile, and we shouldn’t forget what is at our hands and feet (and usually free). 

Yes yes...I'm still actually working over here in Uganda...thought it might be time to give you all a work-related update :)

​CHAI is supporting the Ministry of Health pilot a 9 month rapid antibody test as part of the EID (early infant diagnosis) testing algorithm. The goal is to identify HIV+ infants as soon as possible so they can start on treatment immediately. 

Currently, the guidelines say that healthcare workers should do a 1st DNA PCR (polymerase chain reaction)at 6 weeks and then a 2nd DNA PCR 6 weeks after the mother stops breastfeeding (usually just over a year). While the infants are young, they carry maternal antibodies, so the tests look at an infant's DNA directly. At or after 18 months, infants will be given a rapid antibody test which is the same test an adult would receive. 

Rapid tests are cheaper and easier to perform compared to DNA PCR tests which require removal of hemoglobin from the blood in order to obtain leukocytes from which purified genomic DNA is isolated. While facilities can perform their own rapid tests, DNA PCR test samples are collected at the facilities, delivered by hub riders to the local post office and run in the central lab in Kampala. The turn around time (TAT) for results is approximately 2 weeks. While the TAT has decreased over the past few years thanks to some hard work from our labs team, any TAT at all increases the risk of mothers and caregivers not coming back to pick up their results.
 
Introducing a 9 month test between the 1st and 2nd DNA PCR would help identify exposed infants who seroconvert (basically means they weren't showing signs of the virus but now are) after a negative 1st DNA PCR. Additionally, there have been some studies showing that maternal antibodies usually clear by 9-12 months (though they can remain until 18 months and in mothers who continue to breast feed). Lastly, the uptake of the measles vaccine, which is administered at 9 months, is around 95% in Uganda, so the hope is to capitalize on the fact that mothers are bringing their children to the facilities already.
 
The pilot will help us gain insights into the operational challenges we will encounter (and yes, there will be many) so that we can apply lessons learned to the scale-up process. We trained healthcare workers in February and are doing some data collection right now so hopefully we'll see strong uptake of the 9 month test!

Here are the current (left) and proposed (right) testing algorithms in case you're interested.

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?!?!
 

There's been a lot of buzz about Priscilla Chan and Mark Zuckerberg's letter to their newborn daughter where they commit to donating 99% of their Facebook shares. The comments from Melinda Gates, Gavin Newsom, Richard Barth, and many more seem to echo the sentiment that I had when reading the letter. More or less that...this is awesome, it may encourage similar people to do the same, and will really make a positive impact for our global community.

My curiosity led to looking up some of the organizations that the Chan Zuckerberg Initiative has supported (well...not officially on behalf of CZI until now I suppose). They are largely focused around education and healthcare (not surprising given Priscilla Chan's background and work), which, given my interests and experience made learning about these organizations really interesting. 

​Then I came across this Guardian article that challenged me to think more critically about the impact of not only western philanthropy but also the work that I, and many of the folks I'm meeting here in Kampala are doing and the system we are supporting. 

Since being here, I've met lots of interesting people and have started to have some great conversations around this topic. I've been going back to some of the reading I did in college around international development (like Escobar's thoughts around the "Problematization of Poverty") now that I'm interacting with this space more personally. 

I'm not sure I have any coherent opinions to share yet (would love to hear yours!), but general observations include:

• The young adult population in Kampala is extremely well educated
• There are a lot of international development organizations (many faith-based) here - in addition to a handful of smaller organizations, I pass by the IOM and UN buildings (one of the many) on my way to work
• Every foreigner I've met so far in Kampala is working in the development space (solar energy, education, global health).
• At the CHAI Uganda office, over half our staff (including the Country Director) is Ugandan. While this is celebrated, I don't get the notion that this is extremely unique to CHAI - a few of the young Ugandans I've met are also working at social businesses or aid organizations.