Uganda 2022

Without courage, the act of collecting skills and knowledge can become a kind of waiting. Waiting to get better, waiting to get ready. Waiting for conditions to improve. Waiting for the path to reveal itself. Waiting for someone to give you permission. In sum: Not acting.”

  • Ashish Goel

Global health has been a passion of mine since my undergrad years, and a trip to Nepal in 2008 played a large role in my career path. Ironically, my current trip to Uganda started out as a vacation, supporting my mom and her PICC program (Photography Inspiring Children in Conservation). I started exploring local health organizations and thought it may be interesting to meet with a few people and discuss community health needs, considering opportunities for the future. This quickly developed into multiple immediate opportunities including holding a clinic in the remote village of Rwenshama, and working with local surgeons at Bwindi Community Hospital. With the trip expanding by the day, Goel’s quote hit home.

It is time to step forward out of the comfort of waiting – waiting to get better, to get ready, or for conditions to improve. Time to design the path rather than waiting for the path to reveal itself. Time to act. I accepted these opportunities and started planning quickly as possible. Part of being able to step forward and act comes from letting go of the image I had in my head of what a “medical mission” looked like, and forming a new image rooted in the values and priorities I wanted the trip to reflect. The ultimate priority for me was respecting the local culture, understanding that I have much to learn from the local community’s practices, and gaining a deeper understanding of their needs. Only after immersing myself in their lives and being curious without judgment would I be able to see if and how I can humbly fit into the puzzle of effecting sustainable change.

Reflecting on these values allowed me to see that there is no reason to wait until I have a mission team formed and a complete plan developed; in fact this would go directly against my goals. The decision to act now comes from seeing that the path forward is through curiosity, humility, and an open mind.

Rwenshama

Nested far in the depths of Uganda, at the edge of Queen Elizabeth National Park and the bank of Lake Edward, the Banyabutumbi are proud, beautiful, and resilient people. After 20 hours of flying and 10 hours in the back of an off-road vehicle navigating bumpy terrain (“the Ugandan massage!” our driver joked), we rolled onto the small main street of Rwenshama. Barefooted children ran along the side of the car waving with large smiles. The air was surprisingly cool and heavy with humidity suggesting impending storm, and was penetrated with a subtle smell of fish. We pulled into the Genesis Beach Resort, not beachside nor resort, but the nicest accommodation and central attraction of the town. Our local contacts Frank and Akiikih greeted us with the warmest welcome, and despite being halfway around the world I immediately felt at home.

Children in Rwenshama

Genesis Beach Resort in Rwenshama

As we set off on foot though the field behind our lodge for dinner, an intense darkness set in, and a heavy rain poured down. Deep rumbling thunder and bright lightning filled the sky. As I became lost in a feeling of freedom and adventure, an arm suddenly shot out in front of me “Eschere!” someone yelled as I snapped back to reality (Hippo, as was translated for us). Then quietly,  “Let’s go this way instead.” As hard as I strained my eyes, I couldn’t see the hippo in the deep darkness. Heart pounding, I followed our local friends who guided us safely to Akiikihi’s house.

Hippopotamus tracks

I would see many more wild animals during my stay here. Bordering the national park, the Banyabutumbi live in close proximity to animals including hippos, elephants, water buffalo and hyenas. This causes many difficulties to the community as the animals destroy any attempt at growing crops, and often wreck havoc on their homes. Unlike other communities in Uganda that border national parks, Rwenshama does not receive any assistance from park revenues. In addition, few tourists reach this part of Uganda, and when they do most do not stop in Rwenshama, so there is little economic stimulus from tourism. Despite not receiving any benefit from protecting these animals, there is an underlying level of respect and attempt to build peaceful coexistence. During my stay I learned to spot hyena eye glow in the flashlight, to recognize the chanting and clatter of pots that scare an elephant away from the huts, and to patiently keep an eye on multiple hippos to find a safe crossing on the path. When I cartwheeled with children on the soccer field we kept a respectful distance from wild water buffalo who casually shared the space and watched us with a bored affect.

A hippo behind our lodge

Note the water buffalo in the background

That night, after safely making it through our first of many hippo encounters, Akiikih’s family welcomed us with a warm meal and we became acquainted over a feast of fresh tilapia, potatoes and rice, Matoke, vegetables, and soup, with an unrelenting rain pounding on the tin roof.

Frank welcoming us in Akiikih’s house

Dinner with fish fresh from Lake Edward

Conversation under the storm

The rain had cleared by the next morning, and a warm sunshine poured over the village. A tour of Queen Elizabeth National Park allowed us to see the local wildlife including lions and elephants without the adrenaline from the night before. We then got to meet the BACHO (Banyabutumbi Cultural Heritage Organization) children. BACHO is a local, Sahaya supported organization that is doing excellent work in their community. Their projects are far-reaching, however one large component is supporting orphans, many with HIV, with food, housing and education, and giving them a supportive community through BACHO. As we approached the BACHO housing, dozens of children poured out for our welcome. The patter of feet in the dry dirt caused tiny clouds of dust to rise up, settling on their bare legs and tattered clothing. But the light from their smiles and laughter outshone all. A small girl, no more than three, grabbed my hand and led me forward. She was more serious than the other children, and her eyes looked weathered beyond her years. 

As they led us into their yard, the BACHO children and elders broke into their traditional welcome song. In the midst of the dancing, singing and beats of the drum, the surroundings melted away and the only thing that remained was pure, exuberant joy emanating from each person within the circle.

Akiikih dancing with a BACHO elder

The afternoon was spent with the children excitedly engaged with the PICC program. I used this opportunity to meet with Amon, the community nurse. We discussed the most pressing health issues in the village, mainly HIV, malaria, and jiggers (tungiasis infection). The nearest hospital and outpatient clinics are a 2-3 hour drive from the community. The children do not have means of transport from this remote village, and hiring a driver regularly is cost prohibitive even with the excellent support from Sahaya. Walking or using a motorbike is not a possibility as the national park must be crossed, and the risk of a predatory animal attack is too great. Therefore, access to even basic healthcare is extremely difficult, and the majority of the community has unknown HIV status. Parents die young, leaving child headed households.

“K”  is a well spoken, hard-working student, talented artist, and member of the BACHO football club. At 17, he is also the head of his 6-sibling family and is responsible for providing for his younger siblings. K spent over two days with our group, learning photography and taking part in our activities. Not once did he mention his living situation or need for assistance. He was always cheerful, humble, and pitching in wherever he could. When his artistic talent was applauded and he was asked about plans after school, his silence spoke loudly. There is only the reality of now, surviving the insurmountable challenges of daily life, and protecting his family.

“K” working on his photography skills

In many families, children may not go to school due to hunger. While education and healthcare are valued, the basic need for food to think and function overshadows all. As Frank put it, “food is the first medicine.”

Musculoskeletal deformities fall lower on the list of pressing needs in the community, but make a tough life even harder for these children. I identified three clubfoot deformities on this day, and while it would normally be a relief for a mother to hear that this is a treatable condition, it is not much of a relief if you cannot access the care. The Ugandan Sustainable Clubfoot Care Project has done excellent work systematically expanding education and access to ponseti casting in Uganda, however in a community as remote as Rwenshama, the nurse had not heard of the condition before. I provided him with the knowledge to identify clubfoot, but access to care still remains the limiting factor.

A BACHO child with clubfoot deformity

The following day I was able to visit the clinic with Amon. This consisted of a front room with a sparsely stocked medication shelf, and two small beds in a back room. As I unloaded a suitcase with over the counter medications and vitamins, I knew the stark reality of the limited effect this would have. Sustainable change and access to a full clinic is needed.

Rwenshama clinic

The issue that I hope we may have been able to make a tangible change with during this trip is tungiasis. Tungiasis (sand fleas, or “jiggers” as known locally) are a common problem in Rwenshama, and can lead to significant morbidity. The common local practice is to use a needle sanitized in a fire to pick out the burrowed flea. This is concerning for spread of transmissible disease, and can also lead to secondary bacterial infection or injury.  A randomized, controlled field study in Madagascar showed that twice daily application of Zanzarin, a plant-based repellent, was highly effective in preventing Tungiasis infection and helping to reverse active infections (1). While Zanzarin is no longer on the market, its main ingredients are readily available over the counter (coconut oil, jojoba oil, and aloe vera) (2). After using a Costco sized tub of coconut oil and buying Target out of jojoba oil, I was able to create a large batch of prophylactic oil to take with me. The BACHO leaders were very receptive to the use of this oil, and felt that regular use could be implemented with education and sensitization within the community. The most promising aspect is that these ingredients can be locally sourced so that this prophylaxis and treatment can be continued after our departure.

Tungiasis, or “jiggers”

Mixing Tungiasis prophylaxis

Applying oil

Community education

That afternoon we played out on the field with the children. A generous donation from the Quakes outfitted the entire Sahaya BACHO football team with new gear. The boys were most excited about the gloves, as they had never had these before, and the soccer balls as an elephant had recently trampled their ball. The younger children hung off of our arms wanting selfies, and knew just how to ham it up for the camera. I tried a cartwheel to see how the kids would respond, and suddenly had ten children flipping, cartwheeling, and breakdancing beside me. We all soaked up these small moments; the surroundings and poverty momentarily disappeared and the children played with youthful joy.

BACHO children

Sahaya BACHO football team

When we returned to the Genesis, we realized that we had unintentionally started a town-wide party by purchasing gas for the generator. We returned to find a DJ blaring music, beer flowing, and a dance party in the courtyard. We joined in and partied late into the night. Partway through, the BACHO children showed up and had a special dance presentation for my cousin’s birthday, which was followed by a long procession of speeches and festivities. After he and his girlfriend were formally celebrated we laughed that we were pretty sure they were just unknowingly married in the Genesis courtyard.

Genesis Beach Resort Party

On our third and last morning in Rwenshama, we had a final family breakfast at Akiikih’s house. I reflected on the first evening where we sat at this table amidst the thunder and lightning. So much had passed in such a short time, and I felt more connected to a community than I would have thought possible in two days.

Bwindi

That afternoon we set off for Bwindi. As we climbed higher and higher on rocky roads, the air became crisper and fresher. The greenery became more dense and lush, and birds chirped alongside the road. We were warmly greeted by our friends Mushamba and Shivan at the new (and gorgeous!) Rafiki guest house.

Sahaya Rafiki Guest House in Bwindi

Sahaya Rafiki Guest House

A tour of the town the next day revealed clean streets and busy shops fueled by a thriving tourism business from the nearby Bwindi Impenetrable National Forest. In contrast to Rwenshama, here the neighboring towns receive a small portion of the revenues from the national forest. In addition to more job opportunities from tourism, this helps stimulate the economy. Due to this, a larger focus is able to be placed in the community on education, empowerment of women and girls, and encouraging a passion for art in youth.

Bwindi

We were fortunate enough to have the opportunity to gorilla trek in the national forest. The beauty of the natural environment and strength of the gorillas was awe-inspiring. The gorillas are habituated to humans, and were completely relaxed in our presence. I will never forget locking eyes with a silverback gorilla. I quickly glanced down in submission, but was able to keep watching him through my camera. The moment of connection was incredibly powerful. 

On Monday I started at the Bwindi Community Hospital. I met with Eunice who is an orthopedic officer, which is similar to a physician assistant with three years of postgraduate training. Eunice manages the orthopedic clinic and inpatients, and assists the general surgeon on surgeries. The hospital does not currently have an orthopedic surgeon on staff, so the general surgeon manages the fractures he can and refers out the more complex cases. The closest hospital for referral is in Kampala which is about 10 hours away. Eunice and I saw many patients that day, from a 3-day old with clubfoot to an 81 year old with post traumatic arthritis. We triaged patients into conservative care, operative care at a later date when more supplies can be brought in, and one patient for surgery this trip.

“S” is a man in his 40s who sustained an open tibial and fibular fracture 5 months ago during a motorbike accident. The fracture had not healed well and he had a large residual deformity. Given that he had an extensive free flap on the leg from the time of the accident, the surgical approaches were limited and more complex. After we talked for a long while, he chose to proceed with surgery which we scheduled for the next day. 

Picking out instruments to sterilize for the case

On the day of surgery we slipped on rain boots and scrubbed in the sink with a bar of soap, after which we were fitted with well-worn cloth surgical gowns and gloves a few sizes too big. With the heat of the OR, heavy lead, and the occlusive cloth gown I immediately began sweating through my scrubs. The case was very challenging due to both the deformity and extensive scar tissue, as well as navigating the differences in available OR instrumentation and resources. In the end we were able to achieve a good outcome and I am optimistic that S will continue to do well in his post-operative course. I am very thankful for the opportunity to operate in this setting, and will humbly carry many lessons forward from this case.

The last day was spent sightseeing with family and enjoying resting at the lodge. I could have easily stayed here another few weeks – and was somewhat jealous when I heard that a family of 10 gorillas visited the lodge the day after I left! More reason to come back soon.

As I set off for the airport the next day, I was somewhat dreading the 21 hours of flying ahead of me. The first flight was a quick, 1 hr trip from the Kihihi airstrip to Entebbe International Airport. I told myself that at least the first leg would be fun on the small cessna plane.

Kihihi Airstrip

Little did I know that I would be the only passenger on the flight – and my pilots were awesome! I had a VIP flight and had the time of my life flying with two strangers – now friends – over Uganda. It was the perfect way to end the trip.

In an expansion from the earlier quote, in his book “Drawing on Courage,” Goel wrote about four key stages when taking a leap:

  1. The fear that blocks you
  2. The values that bolster you
  3. The moment of action
  4. The change that ensues

In a whirlwind of two weeks pursuing healthcare in rural Uganda, I have gone through the first three, and am now focused on the fourth and most important: the change that ensues. As I reflect on the trip and continue communication with the local community leaders, multiple projects are coming into view for both Rwenshama and Bwindi.

Please reach out if you have any interest in participating in projects in-person or remotely. These communities have conquered insurmountable odds and have produced incredible improvements with limited resources using determination and ingenuity. They in no way need “saving” or western influence. My goal is solely to use our access to resources, grants, and technology to connect the communities to opportunities and education that otherwise may not be available to them. WIth a little support, the possibilities are endless.

1: https://doi.org/10.1371/journal.pntd.0002426

2: https://emedicine.medscape.com/article/231037-treatment#d10