It’s been a busy month (eek!) since I last sat down to write. As I type away in my cozy little home, rainy season deluge in full effect, reflections from the past several weeks are flooding in. Get ready for a rambler!
Uganda’s health workers face huge challenges.
Over the past several weeks, Mary and I have been conducting site visits to hospitals enrolled in Save the Mothers’ Mother Baby Friendly Hospital Initiative (MBFHI) to evaluate their progress and assess ongoing needs.
We arrived at Kawolo Hospital, about an hour from Mukono in Buikwe District, only to find that two midwives had been taken away in handcuffs the previous night after a mother had perished in childbirth. This is an unfortunately, all too common occurrence in Uganda – both the death and the arrests.
Now, technically speaking, this is not legal. Health workers can’t be detained unless a pathology report completed by a trained professional (which is not a police officer) determines the cause of death to be criminal medical negligence. But these health workers don’t know their rights and are not empowered to speak up against this kind of injustice. So, rather than being counseled and supported through the trauma of losing a patient, these midwives were carted off to the local police station. (They’ve since been released and the Resident District Commissioner was magically replaced, but this problem and its insidious effects persist).
Here’s where we come in. In partnership with an awesome local NGO called Barefoot Law – a group of lawyers who provide low- or no-cost legal education and advocacy across Uganda – we’re putting together a legal clinic for the health workers and administrators of Kawolo Hospital. They will spend a day learning about their rights as health workers, as employees, and as individuals. They’ll learn the definition of medical negligence and the basics of criminal law and liability. And hopefully, they’ll leave the session feeling way more empowered to advocate for themselves and protect one another against injustice.
On top of this wholly demoralizing debacle, the health workers at Kawolo (and every other hospital we visited) are dealing with a severe shortage of basic supplies like gauze, gloves, and sutures; miniscule and sometimes nonexistent (in government facilities) salaries; and substandard working conditions (lack of supervision and training, no potable water, non-functioning toilets). It’s no wonder why health workers in Uganda get a really bad rap for being unfriendly, disrespectful, and even abusive to patients.
I want more moms in Uganda to survive childbirth. And I want them to be well cared for in hospitals, so that they’ll want to deliver there. Which is exactly why I want well-trained, fully-equipped, and fairly-paid health workers to become a top priority in this country. This excellent report highlights more about the Ugandan health worker perspective on these issues.
Improvements in infrastructure ≠ improvements in maternal and child health outcomes.
Mubende Regional Referral Hospital’s sparkly five-year-old maternity ward, financed by the Japanese government, looms over its crumbling predecessor on the hospital grounds about four hours from Mukono. But its clean, bright industrial architecture masks some disturbing realities. In 2014, Mubende hospital had the highest institutional maternal mortality ratio of any regional referral hospital in the country – at 1 death per every 116 deliveries. And in 2015, the hospital still has the highest risk for fresh still birth, at 1 death per every 22 deliveries.
To be totally honest, it’s not 100% clear to me why this is the case. Yes, the hospital struggles with high rates of sepsis, a lack of adequate resources (no big surprise there), and a shortage of health workers (only 3 of the 39 government health workers posted to Mubende are actually working there). But these are the issues faced by each hospital we’ve visited.
Ultimately, this paradox brings to mind one of the key questions I believe the international development community is grappling with: is investing in infrastructure worthwhile when the systems remain broken at their very foundation? Would these bilateral resources be better spent building the capacity of the hospital to provide emergency obstetric and neonatal care through health worker training? Or perhaps providing technical assistance to hospital administrators and the National Medical Supply to boost the effectiveness of the supply chain? Or just paying these health workers a living wage?!
But of course, those projects wouldn’t result in a really stellar before/after photo op.
Sorry for the cynicism. I’m not saying this is all bad, and in fact, the Japanese development agency is also working with the hospital on various quality improvement projects – which is a good thing! But seriously, mothers are dying of preventable causes, and systemic solutions to these issues exist.
Uganda’s government might actually have to answer to the people when it comes to maternal health.
Maternal health in Uganda has been all over the news, thanks to a recent Supreme Court ruling. Basically, it determined that a lower court had wrongfully dismissed a 2012 petition arguing for government accountability in the failure to provide sound maternity services.
Though it’s really nothing more than lip service at this point, it’s certainly encouraging to see this issue pushed at the national level in a country where, from what I’ve seen, a lack of political will to provide adequate health sector resources is quietly killing off mothers.
Speaking of which, there’s a presidential election coming up here in February, and recent polls show that health service delivery is the highest priority for Ugandans. Though it’s unlikely that Museveni – who has held the seat of power for nearly 30 years – will be deposed, the results of this case and hopefully voters’ pressure could potentially spur national action on maternal health.
Beyond being thankful for what we have.
Gratitude – appreciation, giving thanks – is a really powerful practice. I am filled with so much gratitude for so many things in my life. In this particular moment, I’m feeling really grateful to be having this experience, with all of its challenges and adventures. I’m grateful for all of the amazing people in my life, who love, encourage, support, and challenge me. I’m really thankful that you all read my blog posts – and post comments – and send me sweet, loving, and encouraging messages. Thank you!
There’s just something else that I want to put out there for contemplation about gratitude. Let us not look at the tragedies, suffering, and sadnesses in the world only as an opportunity to be thankful for our blessings, AND as the only opportunity to express gratitude. Do you catch my drift?
Having worked both in the US health care world and now in the global health arena, I see that there are issues endemic to both of these ecosystems that desperately need to be addressed in order to achieve health equity. There are vulnerable populations – individuals living in poverty, experiencing trauma, struggling with mental illness, experiencing high-risk pregnancies – who need additional support to be healthy and well. There are systemic challenges – inadequate or poorly allocated resources, political stagnation, and generally a lack of respect for and desire to control women’s bodies – in both of these worlds that need our attention. And they are not well-served simply by our gratitude, unless it’s coupled with action.
I believe it should be our collective cause as humans and stewards of this planet to work toward ending all human suffering (internal and external). I think gratitude, if harnessed productively, can be a gateway to action in this regard. OR, it can be a reason to say, “Well at least I don’t have it that bad,” and ignore the ‘less-bad’ issues in the ‘less-messed-up’ parts of this world. Let’s not do that!
And now for some quick life updates and lessons.
Mary’s birthday was on October 24 and we had a week full of surprises (for her, for a GHC fellow who is getting married this weekend, and for another GHC fellow celebrating her golden birthday). It went something like this: surprise birthday cake on Thursday, surprise birthday brunch on Saturday afternoon, surprise bachelorette party on Saturday evening, surprise birthday party on Saturday night, surprise birthday apple pie on Sunday morning. Whew!
Getting chased by little kids can really improve your mood on a grumpy Sunday morning. I’ve been working out like crazy. (Have I told you I’m climbing Kilimanjaro for New Year’s? Yup, it’s a lifelong dream and it’s officially happening, December 28-January 3. I’m PUMPED. And super nervous! Luckily there’s a track on campus where I can run relatively undisturbed in the early mornings/late evenings.) It’s become my new ritual, my alone time to reflect, and one of my favorite things to do here in Mukono. Last Sunday morning I was STRUGGLING, earphones in, music blasting, dragging myself through my run. About 10 laps in, I glanced behind me and realized I had a parade of about 8-9 little kids chasing me, screaming, laughing, and giggling. Even in my sweaty, curmudgeonly state, I couldn’t help but crack a big smile as they jogged alongside me, barefoot and carefree. They stuck with me for the remainder of the run, and even joined me for some yoga afterwards. Honestly, sometimes all you need is some pure childish joy to shake off the Sunday morning cranks.
Mary and I repped Save the Mothers at Uganda’s national celebration of the International Day of the Girl—and the First Lady of Uganda was there. Two brave young women (both Somali refugees) shared their experiences as victims of female genital mutilation in front of the audience of hundreds of government leaders, UN reps, civil society organizations, and other stakeholders. It was intense.
Yoga and meditation are integral to my ability to do this work. As I’ve normalized and gotten settled into my life here, I’ve finally gotten back into my yoga and meditation practice. And WOW, what a difference it makes in my resilience and groundedness in this experience. In other yoga-related news, I’ve recruited two new students (Quraish and Tony), who already want to earn their teacher certifications after one session. Yay for yoga!
And finally…I stood on the equator!