Field trip to Iganga. Part 3: the reflective return.

The country director invited us for a late lunch; a kind offer that was much appreciated by all. Arriving at a restaurant we agreed after some time to each order a plate of chicken stew with the standard collection of carbohydrates. We made polite conversation until the food came: plain boiled chicken, plain boiled rice, plain boiled sweet potato and matooke (a type of savoury banana/plantain that is steamed for hours in leaves). As I have discovered, Ugandan food is often a neutral palette of cream, beige, mustard yellow and off white, occasionally brightened by a splash of miscellaneous "greens", and tomato. Flavours are equally neutral, with Ugandans tending to eschew any use of spices and seasoning beyond salt, in favour of  unadulterated blandness. The waiter brought us each a small bowl of salty vegetable broth of the type my great grand mother used to prepare. "Is this chicken stew?" I asked, wanting to know so I could avoid ordering it again. The driver laughed, and said she was happy because she didn't like stew anyway-too spicy. The CD was back to business of one of his three mobile phones (It is not uncommon to have multiple phones here, with a sim for a different network in each phone to reduce call charges) . We finished up and travelled to the district health office to try and gather some more information on infection rates in the area.

I asked the CD if the information was collected centrally by a demographic health survey (DHS) and accessible from Kampala. He explained that invariably one would be passed from office to office on a wild goose chase and that the breakdown per district would not be available. He noted that the last DHS had been conducted in 2005, and at last I understood his eagerness to get at least an idea of what the current infection rate stood at. As the others disappeared into an office to hunt for numbers, I stayed outside, and introduced myself to the team from JSI who had just pulled up. JSI are NACWOLAs donors on the STAR EC project-strengthening HIV&AIDS and TB response in central/eastern Uganda. JSI themselves received funding from USAID and then subcontracted the actual implementation to local partners like NACWOLA. Ideally NACWOLA should be able to attract large grants directly, but they currently lack the M&E systems and management capacity to make this happen. I introduced the possibility of working with NACWOLA to develop an M&E strategy, and the specialist from JSI said he would be glad to offer technical assistance to the process.

I relaxed a few moments on the step, in the sun, before the others emerged and we set of back to Kampala at around 4.30pm. We tucked into the bananas given to us by the psychosocial support group leader. Irene made the (subconscious) connection between our visit and that of politicians, saying that when she travelled as a journalist on a political campaign, villagers would present far more than they could possibly afford to politicians in the hope of increased support. The politicians would return to Kampala with goats, chickens and great sacks of maize, only to deliver nothing. We all agreed that a bunch of bananas was probably acceptable, but that when people offered more, clever ways of turning the offer down without out rightly refusing needed to be exercised. Suggestions for such excuses included being unable to strap the goat to a bicycle that you intend to travel part of the way home on. 

We passed the time in the traffic home, discussing the universal challenge of encouraging men to access health care services in general, and not just for HIV&AIDS. Irene spoke of how you could treat woman for a sexually transmitted infected but that unless her male partner was treated too, she would repeatedly reinfect herself and return for services indefinitely.  We identified the need to reach out to more men, and to target men more with sensitisation. We discussed the big cultural ceremonies at which community sensitisation, for men in particular, could be conducted. Irene talked of the male circumsision season in western uganda, where almost everyday you could see small boys getting their foreskins "chopped"  in full view of the audience gathered. Sensitisation and HIV education activities had at least already increased the use of a fresh blade for each boys procedure. We spoke of the silent HIV epidemic in Iganga, and the practises among most at risk populations, including plantation workers, long distance drivers, sex workers, men who have sex with men.

We talked about the problems of polygamy for HIV prevention, and how the taboo nature of talking about sex that makes discussion of HIV&AIDS transmission& prevention and family planning an extra sensitive issue. We talked about the possibility of streamlining family planning into the information and support  provided by community support agents.  We talked of better partnerships between organisations working with community health workers and village health teams, and the serious need to identify opportunities for collaboration, to reduce overlap, and to fill in gaps. Irene and I discussed that I  (NACWOLA) and possiibly Marie Stopes could at least look at the other organisations and government involved in Iganga district. We saw a great need for these organisations to partner up, to try and streamline activities and resources, and to provide better, fully co-ordinated outreach services to the poor. A national strategy for the use of community health workers loomed as a gaping gap that we began discussing how best to fill. 

We dropped the CD at home with a big thankyou and a vigorous wave. It was brilliant that he had come, and that he was genuinely interested in engaging more with the realities of what was going on at the community level. His interest and genuine offer of support will no doubt be of great help to NACWOLA in the coming months. As we wound up and down and across the hills of Kampala, to the other side of  town, the dusk quickly tuurned to darkness. Each black mound was sporadically illuminated with the warm glow of houses and the snaking lights of heavy traffic. The driver dropped us at the hotel, Irene drove home, and I settled happily onto the veranda of the hotel with Brooke, the fellow anthropologist, and a beer.

Field trip to Iganga. Part 2: the joy of peer support

We left the hospital for our next engagement: a psychosocial support group meeting being held under the canopy shade of a wide flat tree. As we drove up, excitement ruffled through the group, and a crowd of school children in yellow and brown uniforms scampered around the car. We introduced ourselves, took a seat on a wooden bench that had been set out for us, and rather than sitting in and observing a psychosocial support group, the ceremonials began. We sat in a row as an audience to their full attention, and listened to a welcome and background story given by a male community support agent (CSA). Much of what was said was lost to lack of translation but some prize bits of information were relayed to me in English. The groups name translated as “People living with HIV take care of ourselves.” A truly voluntary group, unsupported by lunch provision and transport allowances, this group formed to offer one another psycho social support and to conduct income generating activities. As they have no land they pool their resources collectively to hire the land which they now farm on. They also do bricklaying to earn money for the group. International HIV/ Alliance presented the group with a cow last year to use for ploughing the land. That cow has since given birth and they are training the calf to plough too so that they can lease the wee beast to others.

The CSA explained that they provide nutrition advice, follow up those who have not been attending the services they referred them for, support anti retro viral therapy adherence and refer pregnant mothers to prevention of mother-to-child transmission services etc. He also mentioned that he teaches against witchcraft as a cause of illness. At that point however he also mentioned the importance of believing in God. As far as I know missionary services are, like reproductive health services, yet to be streamlined into the community support agent model. The latter is something I hope to work on over the next 6 months. The CSA repeated the phrase “a tug of war” in relation to getting men to join groups and access services. One of the reasons he attributed this hesitance to was the self stigma that men with HIV attach to themselves. This particular psychosocial support group tries to set an example to others by revealing their HIV status and showing others how to live positively. It was all very positive.

We asked how the group thought men could be encouraged to access services. An old woman suggested that women should not be treated unless their husbands come to the clinic with them. In response to this it was noted that this approach had been tried and that it failed miserably, resulting in far fewer women being treated, and no more men. No more suggestions were offered. I asked how the group was started and was told that it was thanks to a nurse who had put three HIV positive people in contact with one another, and supported them to begin a group in absence of formalized services.. She arranged for them to attend CSA training with NACWOLA. While NACWOLA aims to bridge the gap from the community to the health service provider by starting at the community, many persons at health service providers have begun bridging the gap from the opposite side, as the nurse did here.

On asking the group how being part of this group made them feel , some bold and confident women stood up to share their answers. Their answers attributed this new found confidence to psychosocial support which offered them feelings of unity, a new life, shared experience and knowledge, joy away from the stigma of HIV and empowerment through realising that the power to prevent the spread of infection begins with themselves. We thanked the group for their time, and turned to leave, but not before being presented with a fanned out hand of miniature bananas. The CD handed over UGX 20,000 (about £6). I wasn't sure which was worse; to reinforce the stereotype of "donors" arriving in white 4 by 4s,spending a pitiful amount of time before handing over cash and disappearing for ever more, OR to challenge those expectations and break the stereotype by not giving any much needed and well received petty cash. It had been a private donation borne of the generosity of the Country Director, but arriving in the branded vehicle that Irene had (fortunately) arranged to use through hr own agency, changes the context of everything you do. 

We piled back in the car and set off down a rough dirt track, flanked by lushly planted fields sprouting avocado, jack fruit, maize and cassava among other crops. The CD requested to be dropped en route so that he could pray in the mosque. We arrived at the site of a home visit that the CSA with us was due to make, and followed him into the house. We greeted the young girl (maybe 14), her tiny baby and her grandmother who lived there, accompanied by 5 other aids orphans. Once seated on the sofas, a rakishly elegant man stooped down and up into the house through the low entrance. Dressed in a long flowing white tunic and an islamic cap, he bent to shake the hands of all of us in the room, greeting people in the local language, before reaching me. At that point, he took a dramatic pause before exclaiming 'Good Morning!' in a comical voice that induced a long laugh from the room.

The CSA looked to us for guidance as to what to do next. I suggested that he continue to do as he would if we weren't there, if that was ok, and that we would just observe quietly and conspicuously.  We learnt that the CSA had been passing through the village when he saw that the girls baby had been looking ill. He had taken a measurement of her upper arm and referred her to the clinic. It was unknown whether the baby had been ill from HIV, poor nutrition, or more likely, a combination of the two. The girl had run away to "the island" and returned pregnant. It was therefore suspected that the father was a member of a fishing community who characteristically have very high HIV infection rates. After receiving treatment and services the baby was in visibly better health. As we sat talking, the driver rang Irene's mobile repeatedly. She was hungry and the CD had finished praying. That was our summons to leave. I avoided being completely rushed though, and dawdled a few extra precious mins to talk with the women and take photos.

Travelling back in the car we passed the absurd site of a man sitting on a low stool in the middle of a field in a smart suit and tie. It was the country director. We reversed, picked him up and all had a good laugh.