Archive for March, 2010

The Entebbe Botanical Gardens MultiMedia Tour

Entebbe is a couple of hours drive south west of Kampala. It was the site of the original colonial capital, so it was an obvious location for the British to site a Botanical Gardens which they did in 1901. Today the Botanical Gardens are a huge forty acre park set on the shore of Lake Victoria – they make for a lovely day out.

In Uganda’s colonial past the Botanical Gardens provided the colonial botanists with somewhere to study classify and describe the local flora into species that can be commercially exploited and others. They also provided a handy test bed for trying out species that had proved profitable in other parts of the empire. So as well as being able to see lots of native Ugandan plants, birds, animals and insects we also found examples of the empires best exports: Rubber Trees, Cacao (chocolate), Sugar Cane, Oil Palms and the Cola Nut Tree (along with a rather conveniently discarded Coke can).

As well as species which are still commercially grown today we also came across many strange imports, like the Cannonball Tree from South America which has beautiful flowers and huge cannonball shaped fruit. The fruit are hard like nuts and stink when cracked. I don’t think it has ever had any commercial use other than an oddity, but it may have been used to settle stomachs. Our guide seemed to credit most of the plants and trees with this quality. Which makes sense; you can be fairly sure that the colonialists had a regular and urgent need for such plants.

As well as the trees we also saw amazing birds, terrifying insects, boisterous monkeys and some Canadians. We recorded the highlights on film – edited out the Canadians – and present it here for your viewing pleasure:

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Big Green Bananas

Ladies prepare Matoke - Namuwongo market, Kampala

Wow they eat a lot of bananas in Uganda. Not the sweet familiar bananas that we eat in the UK but big green ones which we call Plantain but Ugandans call Matoke (Ma-toke-ay).

Matoke is to a Ugandan what Potatoes are to the Irish, they are intertwined. (Any Irish person wanting to refute their country’s proximity to potatoes should know that Ugandans refer to potatoes as Irish). Today in parts of rural Uganda you can see a modern example of a population so reliant on one crop that if that crop were to fail it would lead to widespread starvation. It would make a great field trip for anyone studying Ireland’s potato famine. To give you an example of how heavily some Ugandan’s rely on Matoke I can tell you a story from a hospital we visited recently in Southern Uganda; here they often treat children suffering from malnutrition, not because they have nothing to eat, but because all they have been fed is Matoke and Matoke does not contain all the nutrients that a child needs.

You have to feel sorry for these fructivourous children. On top of the fact that their poor diet is a fairly good indicator that their family is impoverished, eating Matoke is horrible. I’ve never liked bananas so I may not be the best judge, but frankly it is barely edible. I think over time your body grows accustomed to whatever it is that provides the bulk of your carbohydrates and you start to crave it when hungry; by this process most Ugandan’s are life long Matoke addicts from early childhood, but sadly for me, I think it might be too late. I’m refusing to touch the stuff.

I understand that if you did want to cook Matoke you have to peel the hard white bananas with a potato peeler or knife and wrap them in leaves and steam this bundle in a pot, usually over a charcoal fire. I don’t know exactly how long you have to steam it for but I’d guessing it is at least a day. The result is usually mashed up into a tasteless, sticky, yellow, stoge.

Everywhere you go you see the bright green bunches of Matoke being transported. On market day the big roads in and out of Kampala are clogged with mud smeared, battered trucks belching black smoke and piled high with Matoke. (Even trucks that aren’t transporting Matoke have a few bunches poking out of somewhere presumably for the driver). If you look closely at the side of these trucks, through the mud smears, you notice that the majority of them have Japanese Kanji written on them. Most of the vehicles here are imported second hand from Japan (where they also drive on the left). Uganda is where Japanese trucks go to die.

As you get further out of the city you start to see people transporting Matoke on push bikes. The Matoke bunches are sold with the stalk still attached. The stalk hooks back on itself (as though the bunch tried to grow straight up, but then wilted back down with the weight of the fruit) the stalks are used to hook bunches onto bikes anywhere possible, if you can’t hook it on then tie it on. Usually you see two bunches attached on either side of the back wheel, like panniers, then as many bunches as you can manage on top of these above the back wheel and, if you’re happy to push the bike instead of ride, a bunch hooked onto the frame’s cross bar (picture).

You also regularly see people carrying Matoke on their heads, though not so much in the city. A bunch of bananas is a fairly irregular shape so the fact that people can carry them on their heads for any distance is quite an achievement. I saw two little barefoot boys, only six or seven years old, each with a bunch of Matoke half their size balanced on their head. They were walking along a dirt track on the top of a very high ridge in the mountains that separate Uganda from the Democratic Republic of Congo. The effort of trekking up there was almost enough to kill me. I don’t know where they were taking their Matoke, but if they were taking it all the way down to the little village in the valley, or even half way (and God knows how far they had come already), they’d have needed the strength of an ant, the agility of a mountain goat and the posture of a gymnast; there may be something in this Matoke after all.

Bataka Twetambire

Far in the deep south-western corner of Uganda on the border with the Congo, in an area of dense rainforest and steep-sided mountains, lies the remote region of Kayonza.

Although it’s remote, it is an area frequented by many a visitor to the country, a fact that is immediately noticeable by the kids shouting ‘Mzungu give me money’ with their hands stretched out. This is markedly different from the kids you find in Kampala and most other places we’ve been to, for whom an ‘Mzungu’ is seen as a curiosity not a cash machine. We were told that there are stories of misguided tourists throwing dollar bills out of the windows of their four by fours as they drive through villages, hence the demanding shouts.

The reason for the influx of Mzungus to this corner of Uganda is the presence of the world famous Mountain Gorilla. The Bwindi Impenetrable Forest is home to more than half the world’s Mountain Gorilla population. The Impenetrable Forest is a truly descriptive name in that this is rainforest at its prime. The forest has an average annual rainfall of 1,500mm…and it felt as if a large proportion of this fell on us whilst we were there!  The steep slopes are layered with trees and twisting climbers of different greens. One of the nurses at the health centre we visited said it sometimes felt like the forest was taking over, inching in and suffocating the inhabitants.

The reason we were whisked to this romantic area within our first week of landing in the country is that one of the first tasks I have been assigned is finding funds for an innovative community health scheme being set up by Bwindi Community Hospital. Now this isn’t your average Ugandan Community Hospital. Started as a missionary hospital in 2003, it pottered along as a small health centre until a couple doing a 2-year VSO placement took over management. They’re still there after 4 years and in this time the facility has advanced to become one of Uganda’s most efficiently run and innovative community hospitals.

On the back of a child health initiative providing free healthcare for the under 5 year olds in the area, a team of motivated community workers have compiled a database of demographic, socio-economic and health indicators for every household member in the region. For any researcher or public health graduate this database signifies a goldmine of information – it even includes GIS coordinates for every household and uses fingerprint scanning to identify individuals, thereby notifying the healthcare provider if the individual is registered on any of the free healthcare schemes and providing immediate details of their medical history. Now this may seem run of the mill for those of us who are used to detailed data being held on us covering every  element of our lives from the kind of washing powder we prefer to whether we pay our credit card bills on time, but I can tell you that for this part of the world it’s pretty impressive and goes a long way towards designing more effective outreach services targeted to those most in need.

In addition to this, there is a great maternal health scheme funded by Marie Stopes whereby expecting mothers can buy a voucher for 3,000 shillings (£1) which allows them 4 antenatal visits, a hospital based delivery (including c-section if required) and one post-natal visit. Without this scheme the cost for the mother for this would be 170,000 (£56) shillings for a normal delivery package and 320,000 shillings (£140) if a c-section is required. Understandable then why usually most choose to deliver at home and maybe only afford one antenatal visit. Large numbers (550 in 100,000) mothers die in childbirth in Uganda, largely due to the fact that they are giving birth far from the emergency obstetric services they might need.

In addition to removing the financial barriers to these services through the vouchers scheme, Bwindi Hospital offers the option for mothers to use their waiting mothers hostel. This is a service whereby accommodation is provided free of charge for mothers for up to 2 weeks prior to their delivery. By getting the expecting mothers in prior to going into labour, a number of important interventions come into play:

  • A reduction in time spent travelling along the treacherous roads in Kayonza whilst in labour
  • The time that the mothers are at the hostel is used to provide education on care of the newborn, basic hygiene, nutrition and family planning.
  • The hospital can monitor those showing potential signs of complications

It is our intention to try to replicate similar community level interventions in two health centres the northern parts of Uganda (more on this at a later date!).

Now, although we were keen on learning about the maternal and child health work going on in Bwindi, we were really there to learn about eQuality Health. This is essentially a community health insurance scheme, yet there are a few important differentiating elements to it.

The basis of it is that every individual above the age of 5 years pays 6,000 shillings (£2) for a year’s healthcare at Bwindi Community Hospital. A further 6,000 shillings per person is then paid to the Hospital by IMF (who I work for), financed externally by donors (where I fit in…), and assuming a minimum of 80% of the community (45,000 people) join the scheme, this should cover hospital running costs for the year. A minimal fee of 1,000 shillings is charged to patients per visit to avoid time-wasting visits.

Built into this is a quality monitoring aspect (hence the title) which means that an external assessor carries out regular checks on the standards of services provided. If the Hospital fails on any of these standards, we (IMF) don’t pay the hospital the 6,000 per person…essentially protecting the community from the common problem of poor inadequate standards of healthcare that seem to be endemic here.

Now to a good few people the idea of paying only £2 per year for good quality healthcare seems more than reasonable (particularly if you’re used to American style fees). However, we attended a meeting of community leaders who will be charged with the task of persuading their batakas to join the scheme. Batakas are ‘funeral groups’. The local population are organised into these groups to help share the costs of funerals and weddings etc, and this is the social framework we’re using to collect payments/registrations for the scheme, hopefully encouraging the batakas to work together to cover the 6,000 shillings for those who can’t afford as they do with other social payments.

It was fascinating listening to the bataka leaders voicing the challenges they had been coming across to the scheme managers. eQuality Health is only in its infancy (running since late Jan) and there are inevitable worries being thrown up from the community. A lot of them are just teething problems which will I am sure evaporate once momentum grows, however some of them highlighted to me stark differences in the mentality of these people in comparison to a western way of thinking. For instance, it came up many times that community members were requesting the choice of just register

ing household heads and not children / other dependents (one of the requirements for the scheme to finance itself is for all members of the household to join or else adverse selection occurs as we end up with only the sick people on the scheme and it is not sustainable).

Now I can understand the thinking behind this – Uganda is a society were family size is large; on average a Ugandan woman gives birth to 7 children during her lifetime, and these leaders were talking about some families with 15 dependents. However, what struck me was the importance that this society places on household heads over their children. In the west we are right at the other end of spectrum where children are wrapped in cotton wool and treated like fine porcelain.

In addition to this, we heard many protestations that they use traditional medicine (cue the witch doctor) over medical care and that if they are ill they do not go to the hospital, they pray to God instead. All of these points are valid and need to be listened to as they are key to whether this scheme gets off the ground. If it works many people are keen to see it rolled out elsewhere as it takes us away from a purely aid-dependent model of healthcare and encourages the communities to start paying into a system based on quality standards that they have ownership of and can trust.

Below is a picture of the bataka leaders proudly wearing their new eQuality Health t-shirts. Bataka Twetambire means ‘Bataka let’s heal ourselves’.


Butterfly Wings

Last weekend we drove 11 hours across Uganda to visit a community hospital in the South West of the country in a place called Bwindi. On the way there we drove along a rutted dirt road through Queen Elizabeth Nature Reserve. We saw all sorts of amazing animals along the way including an Elephant, which was really cool, but my favourite sight was huge clouds of butterflies. The butterflies were gathered in their thousands along the sides of one particular stretch of this road. I think they were there to drink from the puddles in the pot holes. When the cars and trucks passed they would all take to the air at once creating massive swarms of colourful living confetti. It was quite a sight, but one that we just couldn’t capture on camera. I tried filming as the car went along, taking pictures and even stopping and getting out, but the effect just doesn’t translate on film. They just look like so may bits of dirt, or falling leaves, so I was pleased when I got this picture by accident. Not of thousands of butterflies, but of one, in just the right place to give Clea her angels wings.

Clea's Wings

That's how she gets those great aerial shots.