Tough Surroundings

Early last week, we said our goodbyes in Gulu town and made our way about 100 miles southeast to the district of Lira. We were invited by HEPS-Uganda (The Coalition for Health Promotion and Social Development) to film their work in the field. As I described in a previous posting, HEPS has for the past few years conducted rural right to health training programs in villages throughout Lira as well as piloted anonymous complaint and compliment boxes in several local health facilities. Unlike formal, legal complaint systems, such as the Uganda Human Rights Commission, these tiny wooden boxes are providing a user friendly and time efficient tool for patients to voice their struggles.
Our first appointment in Lira was a visit to the District Health Officer (DHO). We showed our letters of support and were quickly granted permission to do our filming in the district's health centers. Before we could leave his office, however, we still had one question. "Have you seen any of the mysterious disease here?" John asked. Though we had relocated further away from the most affected areas, Lira still shared its northern border with one of the districts hit by the illness. Most of the media was echoing our friend Luca's contention that the disease, with symptoms similar to a viral hemorrhagic fever, was pneumonic plague. With increasing news reports that early tests were coming back positive for Yersinia Pestis, the CDC, WHO, and Uganda Ministry of Health finally came out with a statement that evidence was actually inconclusive, meaning they still didn't know what was killing people. The number had reached 38, but no new cases were being reported. During this time, I began receiving a long thread of emails from Yale physicians and faculty concerned for our team's safety. Between them and our friends in Gulu, we were constantly being updated by those involved on the ground and those in-charge back in the US. While some European and American institutions decided to have their students retreat to the capital, it was determined that no evacuation was necessary for us, especially since the mysterious malady was very responsive to antibiotics and the most feared diseases had been ruled out. The deputy DHO of Lira also informed us that no cases had been seen in his district, and that we should simply proceed with the normal precautions (i.e. avoid close contact with sick patients and use the Purell often). With that in mind, we proceeded with our tour of the district.

Our first stop was a health center in an area called Otuke, located 3 hours east by 4x4 from Lira's capital. Because of the region's great distance from the district's governing city, Otuke was recently granted permission to form its own district. Despite facing the challenges of establishing a new body of local government leaders, the budding district borders one of the most lawless territories in East Africa, Karamoja. The Karamajong people are probably most known for their armed cattle raids throughout North Eastern Uganda. The basis for this communal practice of thievery has been given several anthropological explanations. One is that the Karamajong believe they are the true owners of all cattle by divine right, and another is that the raids serve as a right of passage for young males who also acquire greater status by having a greater number of livestock. Since the fall of the Soviet Union, a large number of AK47s have also poured into Karamoja increasing the violent nature of the cattle raids.

When we asked the DHO of Otuke about the major challenges to health service delivery in his district, he responded, "The number one problem is insecurity, especially from the cattle raiders." 3 days before our visit, the raiders had passed close to the health center and stolen 80 cattle. A few weeks before that, they had passed through a nearby village and left one man dead. After that event, the district's polio vaccination program was shut down until the central government brought in armed guards to accompany medical staff. After hearing the DHO's plight, it felt a bit strange to ask him how well the complaint boxes were being implemented in his his health center. He was happy, however, to tell us that the staff were still frequently consulting the boxes even while HEPS was no longer able to send one of their team members to oversee them. Despite living in tough surroundings, it seems from the HEPS complaint boxes that patients in Otuke are concerned most about the same problem as everywhere else in the country, no drugs in the health center.