By Sherry Blumenthal, MD
As a retired obstetrician/gynecologist and founder of the PAMED Women Physicians Caucus, I cannot help writing about a recent trip to Uganda to trek gorillas and chimpanzees, where I learned so much more than ape behavior.
PAMED members can join the Women Physicians Caucus by clicking here.
Many of us remember Idi Amin and the hostage crisis at Entebbe International Airport, but Uganda today evokes none of the publicized drama of the 70’s and 80’s.
The drama now lies in the abject poverty of a large segment of the population and the position of women in the traditional society. Health care is spotty for the entire population.
While about 10 “medical schools” are listed, only one reports offering an MD – Makerere University Medical School in Kampala, the capital city.
Some offer a three-year “Master’s Degree” in specialties such as OB/GYN, anesthesiology, and pediatrics, a prerequisite for admission to the medical school. Some villages have clinics and dispensaries, but they are poorly staffed and equipped.
According to locals, and also the director of communications at Bwindi Community Hospital in the village of Buhoma, it is the best facility outside of Kampala. The hospital was established by an American physician, Scott Kellerman, and he and his wife Carol are the major supporters.
There is a well-established volunteer program at the hospital, and I had the opportunity to speak to the director of volunteers and a general practice volunteer physician from the UK. I also toured the facility.
Buhoma is the “gateway” village to Bwindi Impenetrable Forest, the gorilla trekking destination in Uganda and the country’s major tourist draw. There are only 810 mountain gorillas remaining in the world, and 400 are in Bwindi; the rest are in Virunga National Park in Rwanda and in the Democratic Republic of Congo in the same mountain range.
The three countries border each other in that area. Dian Fossey, of “Gorillas in the Mist” fame, did her groundbreaking research in Rwanda, and the first formalized tourist program started in the 90’s to try to protect the gorillas from poachers and encroachment of villages on the forest.
The gorilla families are “habituated” to human apes, which takes at least one year. This means that they are calm when observed fairly closely for short periods and by small groups of us. Most families include about 10-15 individuals of various ages, with the leader being the dominant male “silverback.”
Each family has its own territory, and trackers can locate where in that territory the family has slept the previous night to aid in finding where to go on a trek through the forest to find them. Since Bwindi is mountainous, the trek can be very rigorous and long, sometimes covering 7-8 miles of machete-cleared areas through the dense forest, and requires a lot of stamina.
The reward is to sit and observe a family in its natural habitat at close range, or to follow the family for an hour crashing through the forest in search of food (they are primarily vegetarians but occasionally consume insects).
While many villages were displaced when the National Park was established, about 20 percent of the revenue from the Park goes to the villagers. The most severely affected are the Batwa Pigmies, who now live in the area of Buhoma, and are extremely poor. The Park creates jobs and brings more revenue to the area in tourist accommodations and staff, guides, trackers, and sales of souvenirs.
It is logical that Bwindi would be the focus of donations and philanthropy due to its prominent status. But certainly the hospital resembles nothing with which we are familiar.
It is composed of multiple one-story buildings connected by dirt roads. The floors are concrete as is most of the construction. The medical care, however, is surprisingly consistent with western standards when possible. Staff go out on motorcycles to the villages to vaccinate and educate the population.
The AIDS epidemic devastated Uganda, along with most of sub-Saharan Africa. Part of the spread to women was the result of the “double-standard” of sexual behavior – men had extra-marital relationships but that was not customary or permissible for women.
The custom is for women to marry at a fairly young age, and an unmarried woman or widow is likely to be an outcast and/or unable to support herself. Most women and men with whom we had contact were married. Women have not been educated nearly to the level of men, since their primary role is to bear and raise children, keep the home, cook, and do laundry (by hand).
Husbands brought HIV and other STIs home and pregnant women passed it on to their fetuses in-utero. Many parents pre-deceased their children, creating a large population of orphans, some cared for by surviving relatives with many of their own children.
AIDS education is prominent in Uganda. Anti-retrovirals are available in most health clinics. Bwindi Community Hospital prides itself on delivering only one HIV-positive neonate in the past year (to a woman who was non-compliant with regular pre-natal visits).
A problem with getting education and anti-retrovirals resides in the difficulty of getting to a community clinic. Roads are almost entirely unpaved outside of the capital, and few inhabitants have transportation. There are some public buses in larger towns and many mini-vans that provide transport, but many inhabitants do not necessarily have money to pay for them.
A common sight is women (with babies on their backs) and children walking along the side of the road, sometimes barefoot, carrying three-gallon plastic jugs of water, bales of sticks for firewood, or large bunches of bananas on their heads.
There are some bicycles, often used to transport bananas or other goods while the owner walks beside them, pushing. Motorbikes, more common in larger villages, are ridden almost exclusively by men, often with a woman or several family members sitting behind them. And so much of the population lives far from the clinics. For example, Bwindi is the only facility within 70 kilometers.
Many villages also have free family planning clinics. The family planning area at Bwindi is particularly robust, with diagrams of all accepted methods and a poster stating “Small families are richer families.”
Families previously consisted of six or more children, but most younger couples are having three, and possibly less if one is a boy. As in many cultures, boys are favored over girls, and there have been cases where the husband has abandoned his wife and children if she gave birth to girls only. In one village there was a woman who delivered 16 children, but only six survived. Recently at Bwindi, a 12-year old married girl gave birth.
At Bwindi Community Hospital there is an OB/GYN, but he is available only two days per week. Cesarean sections are performed in an operating room, which purports to be sterile but the doors open to the outside.
He performs them on his work days, while a general surgeon who is available two days per week or a staff physician perform them at other times. Vaginal deliveries are done by a midwife in a “labor and delivery” area.
There is a dormitory-like building that houses women living far from the hospital, in the last few weeks of their pregnancies. Since all women do their own laundry, there were numerous colorful sarongs, laid out to dry on all of the hedges leading up to the building entrance! Women usually drape the sarongs around their waists when not pregnant, and above the fundus when pregnant-so much for maternity clothing.
In the pediatric in-patient building, mothers stay with their hospitalized children in their beds and families bring in food for them.
Orthopedic surgeries are done only two days per month. This is unfortunate because the major cause of hospitalization is now trauma (from motorcycle riding) whereas it used to be from infectious diseases. There is an X-ray facility housed in a metal shipping crate.
The outpatient clinic has an outdoor waiting area of long benches, where patients sit to be seen for prenatal, pediatric, or other visits. I noted a woman, obviously very ill, lying motionless on a blanket on the ground with her sniffling young child sitting next to her.
After seeing the nurse, prescriptions are filled in the dispensary free of charge, unless the patient is admitted. All in-patient facilities are wards. Bwindi is starting a health insurance program for the community, costing $4 per month to insure free care.
There are few women physicians in Uganda because the culture does not support medical education for women. The few rarely marry or have children. Nurses and midwives are in short supply.
While women in the U.S. are fighting for equality in the workplace, the women in Uganda are fighting for survival. I was encouraged to visit a project called “Ride 4 a Woman,” where women who are widowed or abandoned learn a skill such as sewing and have small vegetable gardens. There is also a facility that houses abused women on the grounds of the project.
If anyone is willing to volunteer some time to provide medical care in Uganda, please email me. I can give you contacts. The people are welcoming and appreciate all the help they get. Health Volunteers Overseas, a non-profit in the U.S. has a program to place OB/GYN volunteers in Uganda and Vietnam.