A Day in the Life

Last Thursday marked the conclusion of our work in the villages. This
week, we will be compiling data and creating documents summarizing the
effect of the intervention and results obtained from surveys, focus
groups, and assessments. (More on focus groups and assessments later).
That means that until Friday, we will be locked up in the MMHF offices
working away on our computers looking at a whole bunch of words and
numbers…

I will take a break, however, to share some stuff about daily life in Mbarara.
The team from Duke Engage, whom I did not introduce earlier, is a
group of 10 Duke undergraduate students; 3 rising seniors (Paul,
Jesse, and David), four rising juniors (Naima, Gregory, Eddie, Josh
and me), and 2 rising sophomores (Marquise and Alex); and two on-site
coordinators hired by Duke Engage (Jacques and Peter). Yes, this does
mean that out of the 12 team members, there are only three girls.
However, the group is actually quite diverse. The group includes every
major race in the USA, a variety of family backgrounds, different
majors, and very unique personalities, each contributing to the
dynamics and grooviness of the group. I feel pretty lucky to have been
able to get to know a lot of the team over the past few weeks, and I
am sure that a lot of long-lasting friendships have been fostered.

Tank Hill Hostel entrance at sunset

The aforementioned team has been living in Tank Hill Hostel during the
last 8 weeks that we have been living in Mbarara. Like I mentioned in
an early entry, the hostel usually houses students from Mbarara
University of Science and Technology, but classes are not currently
going on because the students are on break so we have essentially been
the only ones in the hostel for a long time, with a handful of other
people here and there. It is a fairly large hostel, but luckily we all
live in the same area of the hostel, with all but two of the boys
living on the first floor and the girls living on the second floor. We
have been fortunate enough to get our own rooms – although I should
note that after an unfortunate event involving Marquise waking up with
a grasshopper on her face during the first week, the other two girls
moved her bed to Naima's room and they are now roommates. Otherwise,
each room has two cement desks built into the wall, a bed, and two
small built in closets. Additionally, you will find a mosquito net
over each bed. Also, every room has a window, which is nice, and
Naima's room has a balcony.

In addition to our bedrooms, Gordon, the hostel manager, has allowed
us to keep a fridge in a spare room and a large table, forming a sort
of common room and fruit storage place – if you were to walk in there
now, you would find a fridge stocked with drinks and snacks, as well
as a table with about 5 pineapples and a couple of papayas on it, and
an enormous bag of passion fruit. These three fruits I just mentioned
and also bananas and mangos compose our entire selection of fruits
during this trip. There is also a fruit called jackfruit, but most of
us find it pretty unpleasant, and some have described its smell as "a
cantaloupe that was carried under someone's armpit for hours."
Speaking of meals, the hostel has a nice dining room with many plastic
tables and chairs and a couple of small TVs that are constantly tuned
into National Television or the news channel. We eat breakfast and
dinner in the hostel every day, unless we decide to go out for dinner,
maybe once a week. Breakfast involves one of the following: chapatti,
a flat tortilla-like bread; green onion omelette; sweet bread muffin;
white bread with butter and honey; or samosas, and is accompanied by
either fresh pineapple or papaya, and always taken with either black
garden tea, hot milk, or African tea, which is the black tea brewed in
hot milk. Dinner is buffet-style where rice, matooke (mashed
plantain-like things), cabbage, and beans are always offered and a
couple of other options are rotated daily, such as chickpeas, g-nut
sauce (a mushy sauce made of ground up g-nuts, a small, local,
purplish nut that tastes a lot like peanuts when raw), Irish potatoes,
spaghetti, and on good days, avocado, roasted beef or goat chunks, and
chicken in a broth. Otherwise, the options do not vary at all. I end
up eating rice, beans, and cabbage on most days because I don't really
like most of the other common options. As for drinks, we get to choose
one 300ml of the soda of our choice for dinner every night. In
addition to Coca Cola, 7up, Pepsi, Sprite, Mountain Dew, and Orange
Fanta, Uganda is keen on a couple of other sodas, including Citrus
Fanta, Passion Fruit Fanta, Mirinda Orange (like Fanta), Mirinda
Pineapple, Mirinda Fruity (berries), Krest (bitter lemon, and Stoney
(ginger-flavored soda – much stronger than ginger ale, very strong on
the ginger…). Of course, there is also bottled water.

Gregory and Naima participating in two different conversations after dinner (you can also see two empty bottles of Fanta)

As for personal hygiene, each floor of the hostel has community
showers, sinks, and toilets. The water is in fact, cold, so I have
become very accustomed to compartmentalizing my body sections and
showering one part at a time so as to avoid being under a cold stream
for long periods of time. The toilets upstairs are Western-style, but
downstairs they are latrines in the ground, so the boys have learned
to live with that. Otherwise, everything is pretty good. Occasionally
we find a spider, fly, bee, moth, cockroach, gecko, or two in the
showers and stalls when we check them before entering, but things
actually are a lot better than the first two weeks when giant
grasshoppers were dominating the hallways and bathrooms. One insect
complaint I do have, though, is that there is a never ending
population of ants all over the hostel – they generally mind their own
business, unless you regretfully leave a little bit of food out or
even a crumb on the ground. It is amazing, but in less than 30 minutes
ants will smell that out and mobilize to go and collect the goodies,
so by the time you get back to your room there is an entire line of
ants with an unidentifiable entry point into your room (sometimes its
electrical outlets, or other random holes in the walls). Additionally,
ants will get in your laptop and come out when you turn it on and it
heats up, and they are also a big fan of dirty clothes. Oh, and you
have to hang your toothbrush and toothpaste from a clothes hanger in
your closet if you don't want the ants to get to it.

Speaking of dirty clothes, the hostel has staff that washes our
clothes once a week, except for our underwear, which we wash ourselves
in plastic bins with powdered detergent in any of the community
laundry rooms on each floor. The clothes and sheets they wash are
dried in the sun on clothes lines that are set up on a small lawn
behind the hostel.

This entry is getting very long so I will continue later… I hope this
provided some insight into daily life in Mbarara…

Surveys, Focus Groups, and Assessments

A couple of entries ago, I outlined what our work in the field Monday
– Thursday has been and how we have been involved in the Safe
Motherhood program that has been providing free antenatal health care
services to rural women in the surrounding villages of Mbarara through
the Mayanja Memorial Hospital Foundation. With the next few entries, I
want to share more details about some of the other work we have been
doing simultaneously.

Baseline Survey

One component of this Duke Engage Project is a survey that we have
designed and put together for the purpose of learning more about the
women whom we are serving and to identify some of their biggest needs.
It has been translated into the local language, Runyankole. The
information we gather from it will help us and the foundation to
improve and tailor future interventions to help more women and do so
more effectively by targeting key issues in their communities.
Additionally, good data may also help us and the foundation acquire
grants and other financial support from various organizations.

The first section of the survey contains basic questions about a
woman's demographics - age, residence, and education. There are also
many questions on her reproductive history, family life and assets,
occupation, and accessibility to water. Then there is a section on
antenatal care, which asks about the woman's prior healthcare
experiences during pregnancy, what sort of information she received
during any prior antenatal care visits, if she has ever had one, the
drugs she may have taken during pregnancy, how much she would be
willing to pay for an ultrasound scan, and the challenges she
perceives in obtaining or reaching any antenatal care. The following
section is about the delivery and health of the child she gave birth
to prior to her current pregnancy (if applicable). Next is a section
on malaria, which assesses the woman's knowledge of the disease, its
diagnosis, and precautions that can be taken to protect oneself from
getting malaria. The final section asks a woman about family planning,
her preferences on the size and timing of her family, family planning
methods, and a few questions on who makes family planning and other
healthcare decisions in the family.

Our subjects are randomly selected from the women who come to receive
services from the intervention. They are then approached by a
surveyor, who would be one of the four local university students who
speak the local language and have been told how to give the survey.


Bob and Becky, two MUST students who administer surveys, chatting with Gregory, one of the Duke Team who managed survey work for the day.

The first step is telling the woman how she was selected, what the
survey is for, and then she is asked if she is interested in
participating. If she agrees, a very detailed consent script is read,
and if she still wants to participate, the survey is administered,
after determining that she is eligible (she must be at least 12 weeks
pregnant). As recompense, when the survey is over, the woman is moved
to the front of the line to receive the services she came for, and
like every woman who comes to the intervention, she receives a
mosquito bed net at the end of the day to protect her and her fetus.

Once the surveys are administered, students not going into the field
the next day enter the responses into a large database designed using
the EpiInfo software. We are actually having them entered into two
databases so that we compare them later and check the original paper
copy in case there are discrepancies.

The Nile

So this past weekend I took one of the most exciting day trips EVER.

Panorama of the Nile River

It began Friday. After a day of work and meetings at the Mayanja Memorial Foundation offices, all but a few of us from the Duke Engage team grabbed our things and headed to the bus station in the Mbarara town center, where we loaded a Swift Safaris bus to Kampala, the capital. The buses usually don’t leave until they fill up and we were just in time to board the latest one – which meant a few of us, myself included, where stuck sitting in the very back row of a coach bus. For anyone who has ever experienced such a treat, then you know that with every speed bump you fly about 1 foot in the air… in Uganda, you multiply that times 3 considering the quality of the roads.

After a 6 hour bus ride, we arrived in Kampala at night and Dr. Mugerwa, who happened to be in town, picked us up and drove us to where we were staying, Backpackers. It is a cute hostel full of mostly American, European, and Canadian youngsters and a few NGOs/tourists. We stayed in a dormitory room with maybe 8 bunk beds…we just laid our stuff on any empty beds, and at night we ran into some other people sleeping in beds around us. There is a common bathroom and showers, and some of the beds have pillows – overall I would say it’s sufficiently clean and very, very affordable. And they make really good food – I had a grilled cheese sandwich and it was the most satisfying dinner ever.

The next morning at around 7am, a shuttle from the Nile River Explorers, the rafting and adventure company that two friends of the group also doing Duke Engage in Uganda chose for the day’s activities, picked us up from the hostel and took us to Jinja, a town approximately an hour and a half from Kampala. In addition to being the home of Nile Breweries, the town is located beside the source of the Nile, which comes out of Lake Victoria. Not too far from the source, the Nile has a series of rapids ranging from Class 2 to Class 5 rapids. From my understanding, quite a few companies exist that make use of the river and offer whitewater rafting, kayaking, bungee jumping, and other activities, but the Class 5 rafting full day trip is supposed to be one of the best in the world. When we got to Jinja, the shuttle took us to the main offices of the Nile River Explorers, and we signed in to our reservation. The company provided a good breakfast, briefed us, and then gave us life jackets and helmets, and we got on another shuttle which took us to the launch site. There we divided into teams of about 8 and a guide for one raft, and began our amazing journey.

I have never been rafting before, but after this amazing experience I expect I will not be easily impressed. We spent over 5 hours in the water, at times tackling rapids with names such as “Silverback,” “50/50” (as in a 50% chance we would flip over), “Chop Suey,” and others, and then at some points we were just paddling in smooth water. While our crew was pretty lucky and did not flip over on many of the most treacherous rapids, we purposely flipped on one of the last rapids, and then were completely dominated by the very last rapid that the company takes you through. While flipping over and struggling to hold on to the side of the raft with one hand and a wooden paddle with the other is pretty difficult, particularly during the few startling seconds that you find yourself completely submerged in water and looking for a way out from under the raft, falling in can be sort of fun. The water was at a perfectly cool temperature, and usually rapids are followed by still water so there is time to recuperate and get everybody back on the raft. At one point, the guides let us just swim around in some of the calmer parts of the river. Something cool about the calm time is that the company has figured out how to feed people during the day so as to make full day trips on the river (which cover a distance of 30 km) possible. The company has a gear boat that leads all the raft crew, and strapped to it are bags full of pineapple and biscuits that they distribute to us around lunch time while we are on calm water, in addition to first aid equipment, repair kits, extra equipment, and air pumps. As for our thirst, we just drank the Nile water. And impressively enough, no one in our group got sick from it. While there were a couple of bumps and scrapes and helmets crashing, everyone came out of the majestic Nile in one piece. At the end of the trip, the company puts you back on some other shuttles and they drive you to their campsite, where you can stay the night for a very cheap price in addition to the included barbecue which we all partake in – which was composed of grilled chicken, pork, and a myriad of fantastic sides to accompany the feast. Oh, it also included two free beers. We of course chose Nile Special beers, which cost the same as the other most common beers in Uganda but come in 500ml bottles.

We returned to Kampala after dinner via the company shuttle, and that night a few of us met some peers in Backpackers and we went out with them to a club/bar/hostel called Iguana Lodge, and we danced the night away on a small dance floor with a surprising number of foreigners. The next day, we went to the mall in Kampala and bought a variety of small things ranging from souvenirs/handicrafts, books, Chinese food, and gelato. Yes, gelato. Only in Kampala…

Our Work

Unfortunately, I have failed to write in this blog frequently, but now that I have the time and dedication, I want to share more about our work here.

If you remember my first entry about the Safe Motherhood Program, then you know that the team of Duke Engage students here (10 of us, ranging from incoming sophomores to seniors) spent the first week of work assisting in the Safe Motherhood intervention that provided free antenatal care services, such as physical examinations, sonograms, and drugs, to mothers from the Mbarara municipality who were able to come to the private clinic at Mayanja Memorial Hospital during the week. The next week we began a longer leg of the program, which will not be completed until the end of July. These last few weeks we (the Duke Engage students, a few paid students from Mbarara University of Science and Technology, and Mayanja Memorial Hospital and Foundation staff) have been taking the intervention's services to government-run health centers in rural areas around Mbarara. Each week, we visit a different health center every day; on Mondays we go to Kashongi, Tuesdays to Kikyenke, Wednesdays to Rubindi, (all of which are about an hour and a half away from Mbarara town center) and on Thursdays we go to Kikagate, which is the furthest one, requiring about a 3 hour drive on very poor dirt roads (the town happens to be right next to the Tanzanian border).


The health centers we visit are designated as health center III's by the Ugandan Ministry of Health. My understanding is that they are supposed to be equipped to handle common diseases such as malaria and STIs by providing free drugs and treatment by a couple of nurses, HIV counseling, family planning, antenatal care check-ups (basic minimum, not including sonograms) minor emergencies, and uncomplicated deliveries usually managed by a midwife. Anything they cannot handle they usually refer to higher level health centers or regional referral hospitals (also government-funded). The health centers are usually two buildings: one building has a large room with maybe 10 beds, a small lab room, and a wash room, then the other has a small pharmacy, an office space or two, and some more beds, maybe a labour ward.
A typical day in these health centers, "in the field" as we say, is as follows: first, pregnant mothers arrive at the clinic in the morning and wait for the team to arrive (we leave Mbarara town at around 8:45 am except on Thursdays, when we leave at 7:30). In the first weeks we got upwards of 100 women on some days, but more recently the number is about 50 per day. The women come from the area served by the health center, and while some live a 5 minute walk away, we have spoken to some who have walked 4 hours (an extraordinary feat for a pregnant woman). Then as the ultrasound tech and the rest of the team (6 students each day and frequently also one of the on-site coordinators) get the different stations set up, a team nurse or midwife will gather the women outside and deliver a health education talk, where she tells mothers about pregnancy, the possible complications they may see, the danger of not seeking healthcare if these complications arise, and the importance of delivering at a health center. I believe sometimes she also mentions family planning methods, prevention of mother to child transmission of HIV, and nutrition.


Then the mothers are registered by one of the MUST students or another staff member (actually for the most part I believe mothers have been registered prior to the talk), two students set up a station where we measure the women's blood pressure, height, and weight, two others assist the nurse in setting up a bed where she does physical exams, and two others assist the ultrasound tech in setting up a bed where a portable ultrasound machine allows the intervention to provide the mothers with a sonogram examination. Then once the health education talk is over, the mothers proceed to get in line for the services.


Once they pass through every station, they check out at the bed net table, where if they do not own a mosquito bednet to prevent them from getting malaria through mosquito bites while they sleep, they receive one for free. The nets they receive are provided by the funds raised by the Progressive Health Partnership, the student organization at Duke which began the foundation for this Duke Engage project.
Almost every mother who comes to the intervention brings with her a mother's health passport or antenatal card which the health workers give them and their formats are standarized by the ministry of health with blanks and charts to fill in about their personal health record and their antenatal care visit results. If they don't have these, they will usually have thin notebooks where we write down their results throughout the day. They will usually also bring a purse with personal items and will almost always bring a ketenge, a large piece of cloth with multiple purposes. When they go through the blood pressure/weight/height station, we record the measurements in their books or cards. Then they get in line to see the midwife/nurse. She performs palpitations (meaning she feels around on their bellies and wombs) and determines the position of the baby, estimates the gestational age, listens for the fetal heartbeat, and predicts any complications. She also prescribes antenatal drugs including iron and folic acid supplements, drugs that can both prevent and treat malaria during pregnancy, antibiotics, and deworming tablets, and examines the inside of the mother's eyelids to see if she may be anaemic. Then the mother is seen by the ultrasound tech, who determines the health of the maternal organs, liquor amii, the position and echo grade change of the placenta, the position of the fetus, the femur length, gestational age, and expected date of delivery. If the child is an embryo, slightly different information is gathered, and if it is a multiple pregnancy then she determines how many placentas and sacs are present and information for each fetus. If the mother requests it, she may be able to determine the sex of the fetus by checking to see if a scrotum is present, but unlike in the US, most of these mothers have never had an ultrasound examination, so they are not usually shown the screen so that they can see the baby, nor do they get a print out of their child. The results are recorded on a special form and given to the mother, as is done in the physical examination, and some of the information is entered into large registers for the nurses' personal records.


I mentioned that all the students help set up in the morning, but during the day in the field not
all students are always assisting in record keeping, blood pressure/weight/height measurements, and moving women along. Two students each day are responsible for conducting a focus group with a different group and type of community members each week, and two are engaged in conducting an assessment out in the community in the homes of mothers who we had seen in the prior week. One of the students who assists directly in the intervention simultaneously administrates the MUST students who conduct the survey that we developed in order to do a baseline assessment of the antenatal health and related subjects of the community, which we hope to use in the future to guide future programming. I will explain the details of these three projects more in a future entry, because they are a large component of the work the team is doing here.


When the day is done, usually because a) we have seen all the mothers who came, 2) we run out of battery power for the ultrasound and the power is out in the building, or 3) we run out of bed nets (which only happened recently). Then we pack up all our stuff and ride back to the hostel, usually arriving at around 6 pm.
The rest of the team, 4 students each day, who do not go into the field, spend the day shadowing at two hospitals. Two students will spend the morning doing rounds with the doctors at Mayanja Memorial Hospital. Two others observe the labour ward and surgery at Mbarara Referral Hospital, and after lunch the four students will work back at the hostel entering data and completing other tasks, usually on the computer, related to the project. We rotate every day, so for example I spend Mondays at MMH, Tuesdays in Kikyenke Health Center III conducting a focus group, Wednesdays in Rubindi supervising surveys, and Thursdays at Mbarara Referral. On a Friday like today, most of us go to the Mayanja Memorial Foundation Offices and have meetings to debrief on the results we gathered during the week from our three side projects, enter data from surveys into our database, compile notes from focus groups, discuss the scripts for the next week's focus groups, and work out any problems we want to discuss. On a day like today, we will work for a half day and then begin our weekend journey - this weekend we are going to a town called Jinja, which is next to the source of the Nile River. We will be lodging in Kampala, the capital of Uganda, and on Saturday morning we will be picked up and driven to Jinja (approx. an hour away) and we will spend the entire day on the Nile. I am excited about the trip to Kampala - we will be riding on a public bus.

Thanks for reading, and once again, I will write more about the project after I get back from the Nile....

Queen Elizabeth National Park

Cottages at Kingfisher Lodge, where we spent two nights during our visit to QE.

One of many buffalo at QE

Pelicans and other birds at QE

One of the many adult elephants getting a drink from the channel in Queen Elizabeth National Park

Three baboons on the road through QE

A herd of Ugandan kob in the park

Adult elephant feeding at QE
Male kob at sunrise

Mgahinga National Park

Pictures from Mgahinga National Park

Two of the three mountains at Mgahinga NP

The third mountain, named "Old Man's Teeth" in the local language.

Half of the crew on the hike/climb up to the gorge at Mgahinga ... which was about a 7 hour "walk," as they called it.

The team stops for a break at a clearing on the way to the gorge. On this trip, almost all of the Duke Engage team plus a couple of our community partner staff members spent 2 nights in Kisoro, the nearest town to the national park, and engaged in both the gorge walk and a visit to a cave formerly used by the Batwa tribe (pygmies) as a living space. I didn't get pictures of the cave walk, but others did. Sorry!

Paul looks for birds or possibly monkeys in one of two bamboo forests on the way to the gorge.

Lake Mburo National Park

For now, I only have time to upload some pictures from a couple of our weekend excursions into amazing parts of Uganda...next time I get a good opportunity to use the internet, I will go into detail about the work we have been doing here =).


Ankole cattle on the way to Lake Mburo

Hippopotamus in Lake Mburo

Papyrus in the swamps of Lake Mburo

Me on a boat in Lake Mburo

African Fish Eagle at Lake Mburo

Black-faced vervet monkey at Lake Mburo NP

Can't remember the name of this antelope relative...

Isn't he cute?

A herd of impalas at Lake Mburo NP

Zebra running away at Lake Mburo NP

Me and a warthog by Lake Mburo

The dock at Lake Mburo NP

The landscape on the way to Lake Mburo NP

A plantation of matooke (relative to the plantain) on the road to Lake Mburo NP