A week of goodbyes

My last week in Kampala is drawing to a close before I head off on safari, so it's been a succession of farewells.

Andrew, the Head of Research at the Infectious Diseases Institute (IDI) and my local client / manager is on a business trip in South Africa this week, and so he invited me to lunch at his home on Saturday meet his wife Joyce and son Jeremy.

Monday was my last rehearsal with the Kampala Symphony Orchestra, who are preparing for their next concert in late September.  It's traditional to take cake when you leave - the two carrot cakes I'd baked disappeared in about two minutes flat.

Tuesday I paid a last visit to Bridget, my tailor, who had made some tops from me from some African print fabrics that Andrew and Joyce had given me as a parting gift.  That night I said goodbye over dinner to Jeff and Nedra, the other Pfizer fellows still here in Kampala before we all go our separate ways on safaris or back to the US.

Wednesday was a flurry of activity; I performed in the IDI clinic waiting room for a second and last time, and then had a farewell lunch with Allen, the head of the Research office whom I've been mentoring, and her team.

In the evening I was invited over to Debbie's in Makindye for one last musical soiree - I'll be returning my rented cello to the Music School this afternoon before giving a last couple of cello lessons there.  I will be sad to see the cello go - I've schlepped it around Kampala and had a lot of enjoyment from playing with and for other people as well as keeping me gainfully occupied in the evenings.

Friday will be my last day at IDI - hard to believe it's almost over!

Public debate on HIV Prevention

To celebrate 90 years of Makerere University and 50 years of Ugandan independence, a public debate was held yesterday on "HIV Prevention in Uganda: are we moving in the right direction?"

Prof David Serwadda of Makerere University School of Public Health introduced the debate, proudly noting that all speakers were Makerere University graduates.  We'd rushed to get to the downtown venue since I was scheduled to give my final project presentation immediately beforehand, but happily the meeting was running on Ugandan time, i.e. about 30 minutes late so we caught his opening remarks.
Serwadda explained the rules of the debate - two proponents and two opponents would speak, with written questions taken from the audience.  There was some amusement about the coin toss to decide which side went first since Ugandan coins don't have heads or tails but a coat of arms on one side and an animal on the other.

Alex Coutinho, Head of the Infectious Diseases Institute where I've been working these last three months, won the toss and spoke first for the opposition.  Alex reviewed the most recent statistics, which no-one disputed are all moving in the wrong direction.  HIV prevalence in Uganda has increased from 6.4% in 2005 to 7.3% in 2011 and from 5.7% to 7.2% in rural areas, where fewer people receive antiretroviral therapy (ART), so the increase can't be due to more people living longer on ART.  In fact the number of new infections per year is 130,000, well above the national target of <100,000.  Uganda's neighbors are doing better with HIV prevalence in Kenya 5.2%, Tanzania 5.7% and Rwanda 3%.  Alex asked 'What on earth are we doing wrong?"

Alex had three recommendations for moving forward:

1) Engage leaders - not just President Museveni but the leaders of the opposition, religious leaders, district leaders - to be visible, vocal and sustained about the issue and to lead by example, coming forward to be tested or circumcized.

2) Scale up HIV prevention efforts to cover more of the general population; currently only 50% of eligible Ugandans receive ART (treatment of infected individuals as prevention), only 25% of pregnant women and their babies have access to prevention of mother to child transmission programs (PMTCT) and only 150,000 of the targeted 4 million men have been circumcised.

3) Strengthen the health system, which is not functioning well, per AIDS and other indicators like infant and maternal mortality.

Dr. Fred Wabwire-Mangen, Professor of Epidemiology spoke next for the Proposition.  Historically most efforts went into scale up of ART; 46% of US aid dollars went to treatment of infected individuals in 2005 and only 26% to HIV prevention.  The focus is now shifting to prevention. Fred described the new Ugandan National Prevention Strategy whose goal is to reduce the number of new infections by 30% from 2011 to 2015 and to eliminate MTCT through behavioral, biomedical and structural interventions that are tailored to high risk groups such as commercial sex workers (CSWs).  The challenge will be implementation - is Uganda's health system up to it?

Next up was firebrand AIDs activist Milly Katana speaking for the opposition. Milly was an instigator and founding director of the United Nations Global Fund for AIDS. "We are the embarrassment of Africa; We are ashamed to show our nametags at international meetings!" was her opener. Milly spoke passionately against current Ugandan AIDS policy which she claimed is based on ideology not science.  She exposed the ugly underbelly of the AIDS epidemic in Uganda - "things that some of us don't want to believe are happening in our communities."  Millie urged the audience to focus on addressing the drivers - poverty, gender based violence and substance abuse.  She asked who is helping or providing programs for the most vulnerable communities - fishing communities, commercial sex workers and men who have sex with men.  "We either ignore them or send law enforcement to round them up and bury them in prison."

The last speaker, for the Proposition was Dr. Stella Alamo-Talisuna, head of Reach Out in Mbuya, who recently hosted a visit by Hillary Clinton.  Stella argued that Uganda has led past successes against AIDS through openness and innovation, and urged the audience to keep the momentum in the fight and not cry defeat too soon.  Stella urged us to challenge stigma, encourage public debate and dispel fear and secrecy.  "We have been too silent, too long about too many things, and that includes HIV prevention." She listed some of Uganda's successes - leading innovation in pivotal studies of preventive therapy, circumcision and PMTCT, successes in coverage for HIV counseling and testing.  Ugandan First Lady Janet Museveni has recently agreed to champion the new goal to eliminate MTCT.

Stella's recommendations were to promote a combination of preventive approaches and to focus on translating scientific breakthroughs into real practice.

All four speakers agreed on the need to pursue combination prevention approaches since no approach alone is 100% effective - the shotgun approach since there is no magic bullet.  Moreover they agreed on the urgent need to fix the broken healthcare system, and to introduce some form of national health insurance system to reduce reliance on foreign aid, which currently pays for 85-90% of HIV health costs - the remainder is provided in kind via space and staff by the Ugandan Ministry of Health.

The audience submitted a large number of questions; most of these were focused around the question of what was being done to help the most at-risk groups.  10% of new infections are among commercial sex workers, but there is no legal framework governing either these workers or their male clients within which programs can be run.  HIV prevalence is 13% among men who have sex with men, but these people are being rounded up by the police.

The chair of Uganda's National AIDS Commission, Professor Vinand Nantulya took the podium to make some remarks.  He pointed ruefully to his receding hair as he told us of his sleepless nights since being appointed to the Commission.  "All is not well and it disturbs me."  Nantulya called for a return to the integrated 'ABC' (Abstain, Be faithful, use a Condom) approach that worked so well in Uganda in the past, claiming that separation of A, B and C was the reason for movement in the wrong direction.  He outlined his five point plan calling on all Ugandans to take responsibility to protect themselves - babies, youth, adults, leaders and finally a call to align local resources in the fight against AIDS.

Ugandan Cooking Lesson

A nice surprise was waiting for me when I got back to the apartment on Sunday evening - Jackson had called round when I was out with a big bag of matooke and onions to give me a cooking lesson.  A couple of weeks ago I'd taught him how to make apple pie and carrot cake; in return he wanted to show me how to cook Ugandan food.  We scheduled the rematch last night - Jackson cooked matooke, groundnut sauce and ginger tea and I showed him how to make banana bread.

Here are Jackson's recipes.
Boiled Matooke
Allow about 4 matooke (green plantains) per person.  Matooke will keep in the fridge for about four days; discard any that turn yellow as they are not good to eat.
1. Peel the matooke and rinse in water to remove excess starch and any juices from the skins.
2. Place in a pan with just enough water to cover, and boil vigorously for 20 minutes until bright yellow.
3. Drain and serve

Groundnut Sauce
1. Finely chop 1 tablespoon onion and a clove of garlic and fry in 2 tablespoons oil with a pinch of salt until browned. 
2. Add 1 tablespoon finely chopped green pepper and fry.
3. Add 1 peeled and chopped tomato and some chilli powder to taste.  Mash until smooth.
4. Add three heaped teaspoons of groundnut paste and blend over the heat.
5. Add 1 cup water and blend until smooth
6. Add about 1/2 cup more water to thin the sauce and simmer for 10 minutes over a gentle heat.

Ginger Tea
1. Bring 1 pint full cream milk to the boil in a pan with 1 cup water and 1 teaspoon black tealeaves
2. Scrub ginger roots in water to remove any dirt
3. Pound about 2 inches of root ginger with a mallet until finely crushed and add to the boiling milk
4. Simmer for 5-10 minutes then strain into a teapot or flask
5. Serve sweetened with sugar and banana bread!

Jackson stays in Kampala during the week but his home village is near Mbarara in western Uganda.  He comes from a family of cattle farmers and has 20 cows of his own.  While Mbarara is in the heart of the Ankole region, famous for its long horned Ankole cows, Jackson told me that Ankole cows aren't very good milk producers so his herd are crossbreeds.  He supports his two younger sisters, Fiona and Janet through school from the proceeds of selling milk and meat - their father died ten years ago and thir mother left, current location unknown.

Choral Festival

Church choirs across East Africa came together this weekend at Namirembe Cathedral, Kampala's Anglican (Church of Uganda) cathedral for the Onesong festival.

Everyone enjoyed getting into the spirit before the performances with music led by the Praise and Worship team.  The singers got to their feet and ended up in a giant colorful conga on the lawn!

Ladies of Namirembe Diocesan Choir, from churches across the diocese

The ladies in red dresses were from St. Andrew's Magomeni Choir in Dar es Salaam, Tanzania

Men from All Saints Nairobi Choir, Kenya

Audience members started joining in!

The ladies of All Saint's Cathedral Nakasero (the Catholic cathedral in Kampala) were dressed in gomesis as colorful as Ugandan butterflies - they could almost have been wearing Japanese kimonos.

The choirs varied from an all men and boys cathedral choir, through a choir of seniors, and a barbershop trio - Uganda's answer to the three tenors!  While most of the music was traditional church music with organ accompaniment, the choirs came alive when they sang in African style, with drums.  My favorite was this choir from Tanzania.

Followed by all Saints Nairobi with this song

The choirs massed for a couple of songs on the theme of East African and church unity; here's an extract from a song written for the occasion by the Kenyan choirmaster who is conducting.  Many of the songs were sung in Swahili or English, lingua franca in the region.

Mabamba Swamp

The sound of steadily falling rain as I woke at 5am on Sunday did not augur well for our planned birdwatching expedition to Mabamba Swamp.  Uganda is one of those places like San Diego where you don't usually have to factor the weather into your plans.  Still, Jeff, Beth and I are intrepid enough that a minor inconvenience like rain was not going to put us off our hunt for the elusive shoebill stork.

Mabamba Swamp lies on the shores of Lake Victoria, just one bay across from Entebbe, however it takes about an hour and a half to drive there from Kampala.  We picked up our guide, Richard Hannington, at the roundabout in Kasanje, about twenty minutes' drive from Mabamba Bay.  Richard has been guiding birdwatchers for 12 years and is very knowledgeable about the local species; when he's not guiding he drives a boda boda.

Local ferry boats ply their trade across the water to Entebbe and also to the islands in Lake Victoria.  By the time we returned, around 10am, the waterways were busy ferrying passengers (and their boda bodas!) back and forth.  There's even a car ferry, seen here with a hamerkop perched astern.

As well as Hannington, our boat had an oarsman; when we set out the only sound was the rippling of the water under the prow of the boat.  At first the skies were threatening and a little rain fell, but the sun later emerged from the clouds, making for some atmospheric photo opportunities. Papyrus is abundant in the swamp, and waterlilies that bloomed purple and pink as they were warmed by the sun.

Local fishermen catch tilapia with nets and lungfish (also a favorite of the shoebills) with calabashes in the swamp.  Technically it's poaching since this is a designated nature reserve.

It didn't take us long to spot not one but two shoebill storks.  We were lucky; Hannington estimated that only about half the visitors to the swamp see a shoebill and it's rare to see more than two; the total population at Mabamba is only nine birds, and this is the best place in Africa to see them.  The storks are actually in the pelican family and can weigh as much as 7kg and stand five feet tall.  They have the distinction of being called the ugliest of birds!

This one reminded me of the dodo, but it's definitely not flightless.  Hannington told us this was a female; it flew across the channel to land near the male stork, and then walked away.

One of the other species unique to the swamp is the winding cisticola, which gets its name from the way it spirals as it climbs the reeds.  Other sightings (not shown) include yellow billed duck, swamp flycatcher, blue headed coucal (a large brown bird), common waxbill, pied kingfisher, bunting, African marsh harrier, egrets and a sandpiper.

After the shoebill sightings, we paddled to a lagoon close to the lake.  African Jacanas ran lightly across the lily pads like stepping stones, flying across any gaps that were too large to straddle, while long tailed cormorants dived for fish.

 Long tailed lapwings also perched on the floating lily pads.

Brown squacco herons fished from the banks.

We got a close-up view of this purple heron before it flew away.

We enjoyed watching this family of white faced whistling ducks - the ones without white faces are juveniles.

We saw four or five malachite kingfishers - it was really a treat to be able to photograph them at such close quarters.

On the way back, this weaver bird put on quite a show, defending its nest in the papyrus.

Eid

Today was a day of celebration for Muslims - Eid al-Fitr, marking the end of Ramadan. Driving back from Mabamba Swamp, we saw several village congregations sitting on the grass, the men in front dressed in long white robes and cylindrical embroidered caps, the women at the back, saying the special Eid prayer.  When we reached the outskirts of Kampala people were leaving the mosques carrying their prayer mats rolled under their arms, the women having cast off their usual black and wearing veils of all colours - pink, peach, pale blue, deep blue and spangled gold that glittered in the sun.

Here are some pictures taken outside the Gaddafi Mosque today.

Cooking Oil

I enjoyed last night's performance of the thought-provoking play Cooking Oil by Ugandan playwright Deborah Asiimwe.  The play is about a teenage girl, Maria, (compellingly portrayed by Esther Lutaaya) who dreams of completing her education and graduation day as a lawyer, but whose family forces her to sell cooking oil misappropriated from a US Foreign Aid program where it is meant to be freely distributed, to support her brothers through school.  The corrupt local politician, Silver, who gave Maria's father the misappropriated oil to sell as a favor, tries to persuade Maria to sell it across the border since the village is his market, but Maria is afraid of being molested and robbed by the border guards and continues to illegally sell the oil in the village.

The performance took place in the round at In Movement, a beautiful studio venue with an open-sided platform covered by a reed-thatched roof; with the audience seated on woven banana fiber mats and pillows.  The play incorporated music played on guitar and a large inanga or Rwandan zither.  Maria's mother washes, peels and fries cassava during the performance, and she handed round freshly cooked cassava chips afterwards during the audience discussion. 

The discussion topics included "Does Uganda need foreign aid?", corruption and women's education.  The expats were the first to speak up; our view in general was that aid is needed but the problem is a lack of processes to get it to the people that need it.  It was very interesting to hear the perspective of the African audience members present; some argued that aid is not helpful - for example cooking oil and powdered milk are not useful in times of famine and drought when there is no food to cook and no water to reconstitute the milk.  Others said that aid was not necessary and that leaders should set an example by investing in development and should empower citizens to help themselves rather than rely on handouts.

On the topic of corruption, the view was less optimistic, that it is too dangerous to stand up against corruption, so if you can't beat corruption, you have to collude to survive.  On education, an audience member argued that the Ugandan system need to change to teach people to think for themselves rather than blindly follow what they are told.

For Beth and I, both working in development, it was a very stimulating discussion, which we continued over Ethiopian food at Fasika - spicy chicken, goat, beef and lentil stews or wats with chopped spinach and mixed root vegetables served on a huge slab of injera, a spongy sourdough flatbread.

In the car on the way home we agreed with the taxi driver's view that the kind of Ugandans that can afford to go to the theatre have probably not experienced the poverty and hunger that is all around the slums of Kampala and the rural areas of the country, and that foreigh aid is still very much needed as well as development.

Olympic Gold

I cheered as Uganda's Stephen Kiprotich crossed the line to win Olympic gold in the marathon.  Today pictures of his triumph are splashed all over the front pages of the Ugandan newspapers.

You may not realize what a big deal this is to Ugandans - it's the only medal the country has won in the 2012 London games, and only the third Olympic medal ever, after John Akii-Bua's gold in the 400m hurdles in 1972 and Davis Kamonga's 400m bronze in 1996.

Orphans and street children

According to Unicef and the Ugandan government there are about 10,000 street children in Uganda, about 5,000 of whom live on the streets of Kampala.  Many of these children, some as young as three or four years old, travel from Karamoja in the north, lured like Dick Whittington was to London by Kampala's streets "paved with gold".  Sadly when they arrive here they face a hard reality and a life of scavenging, begging, exploitation and danger.  Many use drugs and sniff solvents or petrol as an escape from their troubles.

In addition to these street children there are many more orphans - in Uganda the term is used to describe a child who has lost either one or both parents.  It's estimated that there are around 1.8 million such orphans in Uganda.  Sometimes one or both parents die of AIDS, sometimes mothers die in childbirth, or just abandon their families and leave.  A father may support his children financially but be unable to care for them, so the children often go and live with an "auntie", grandparent or neighbor.  These orphans are very vulnerable - they often go hungry, miss school since there is no-one to pay the fees, or are beaten and abused by "aunties" resentful of having another mouth to feed.

On Saturday I went to visit Kitenge Africa Foundation's project off Bombo Road.  Fancy weddings were in progress at Watoto Church and Emerald Hotel on the way to the project, quite a contrast to the poverty just a few steps away.  The church backs on to a drainage ditch where children from the adjacent slum go to wash and fetch water.  Kitenge organizes activities for the slum and street children on the church grounds on Wednesday and Saturday afternoons.  When I arrived the children were playing football with a makeshift ball - a bundle of plastic bags and rubber bands.  Justus, the founder explained that they were holding tryouts for a girls' soccer team.

As we approached the yard I was spotted by an enthusiastic little boy aged about five.  As soon as we entered the gates he took a flying leap into my arms, so I carried him around for the rest of the afternoon.  He was a bit grubby and smelly but clearly loved cuddles and it was clear that someone used to read to him because he had the idea of turning pages in a book.  I have since made an African ABC picture book to take and read to him next week.

There is a stand-pipe in the church grounds where the children can wash, and we set up a medical center where they could come and have minor scrapes cleaned and dressed.  Each child came and pointed to the wounds that wanted attention - quite a few grazed knees.  Several had nasty cuts on their feet, from treading on broken glass.  Some have plastic flip flops but others don't have shoes.  Some had been beaten, with cuts on their heads and arms.

Kitenge is a Christian organization so they have a devotional session with teaching and worship.  After that I was invited to speak to the children - about 50 of them, boys sat on one side and girls on the other.  I talked about the importance of education, of being healthy and of helping one another.  I'd brought several bunches of bananas with me so we did a quiz - maths, geography and Bible questions, with bananas given as prizes for the correct answers.  I'd also brought a big bag of sweets so handed those around afterwards.  Then the children were given food - warm rice and meat that they squeeze out of small plastic bags, and were divided into small groups for more activities.

Justus introduced me to one little girl of about eight.  She said her auntie beats her all the time and has accused her of stealing money to buy new clothes - in fact the clothes were given to her by Kitenge.  She is now living with a jjajja "grandmother" but the jjajja also beats her.  It's hard to know what to say.

The luckier children are taken in by orphanages; although some orphanages require that surviving parents and family renounce all future rights to reclaim the child, to enable adoption, and not all families agree to this.  On Sunday at brunch I met several young American women working at NGOs in Kampala while finishing PhDs that were in the process of privately adopting orphan baby girls.  One of the girls was placed in an orphanage when her mother died in childbirth; the father is alive and visits but can't take care of his daughter, and at least she is well fed and will be educated in the care of her US legal guardians-to-be.  The women told me that it costs $3-5,000 to hire a lawyer to privately adopt a Ugandan orphan; the cost of going through an adoption agency is $30,000.  Apparently the rules for adoption by US citizens only are far more lax than rules for adoption by any other nationality, on a pragmatic assumption that the children will probably be better cared for in the US than they could be elsewhere.

Post script - August 18 2012
I visited the street children again today.  Little David (the boy in the blue shirt in the photos) was so pleased to see me that he wriggled under the fence to greet me and be picked up.  I took my African ABC to read to the little ones and some crayons; David liked the boda boda and traffic jam pictures best and demanded that I draw lots more boda bodas!

I spent most of the afternoon doing "Medical" which mainly involves cleaning and dressing cuts and grazes.  It's concerning how many of the children have deep cuts and puncture wounds on their feet from stepping on broken glass and nails.  They line up and point at the place where it hurts - the little girl on the right wanted attention and kept coming back with new places (old scars) for me to fuss over.  I noticed that she was wearing odd shoes - one flip flop and one clog - taking odd socks to the next level.

Baking Lesson

I had a very relaxing Sunday afternoon; I met for coffee at 1000 Cups with Justus and Morgan, business partners in 1000 Shades of Green tour and safari company and also founders of Kitenge Africa Foundation to discuss plans to meet with and address the street children that they care for in Wandegeya slums.

Then it was back to my own kitchen to give a baking lesson to Nancy's friends David and Jackson.  We made apple pie and carrot cake.  My helpers must have good cooking karma since both pie and cake turned out absolutely delicious!