the bureaucratic headache

i'd allowed myself to be lulled into complacency, ignorance, acceptance. i was spoiled. for over a month i have not had to deal with any government agency (other than the ministry of health) directly for any kind of service. then, today i was thrown back into the deep end. today i had to apply for my work permit - without one i cannot legally stay in uganda, so i knew i had to bite the bullet. my accountant/field administrator/go-to-guy (michael) has been working on my work permit for over a month now. finally, after 10 trips to immigration by him, multiple application forms completed and documents gathered by me, we thought we had everything we needed. little did we know. what was missing? my criminal record. that's right, my criminal record.

my day then became the following: immigration office to NGO board to u.s. embassy to office to u.s. embassy to NGO board to photocopier to NGO board to immigration office. a 30-minute process turned into a 5+ hour wild goose chase all over kampala.

an application for a work permit requires any number of things, including: 2 passport-sized photos (of course!), CV, academic qualifications, appointment letter, income tax clearance, annual report, audits, proof of failure to employ a ugandan...oh yeah, and a criminal record. but, the most mundane requirement is a file folder. yep, you have to supply your own file folder so the immigration office can file your application. not surprisingly a little cottage industry has developed right outside the immigration offices selling file folders. women sitting on mats on the ground selling stacks and stacks of file folders.

we get our file folder, but still no criminal record. how do you get a criminal record in uganda? simple. you write up a statement on company letterhead that says "i, (insert your name), swear under oath that i have no criminal record." then the consul at the u.s. embassy puts you under oath (contrary to the movies there is no bible), watches you sign the document, and attaches a cover sheet notarizing the statement with the seal of the u.s. embassy. no looking up of a record, no nothing, they just take you on your good word. of course it has to be stamped...uganda is really big on stamps.

criminal record in hand, we naively return thinking we've done it all when we're blindsided by the assistant secretary to the NGO board, who had randomly sent us off to get the criminal record in the first place.

her: i need photocopies of all these documents for my files.
me: why didn't you tell us that when we were here before?
her: i am telling you now.
me: but, if you'd told us before, we could've come with the photocopies already.
her: hmm...well... how did you know you'd have the right documents? i couldn't tell you before.
me: but, you saw all the documents we had and you said they were all fine except the one we were missing. so you could've told us before.
her: well, i am telling you now.

ooohhh, i was irked. but what could we do but go photocopy? lucky for us there was a photocopy machine close by that had paper and power. the power is key 'cos (1) photocopiers need power (duh), and (2) there's hardly ever power. so, we got uber lucky. granted the photocopier only copied one page at a time (and we had something like 50 pages of documents), but at least it copied.

finally, we have it all. they accept the documents, they will work on my permit, they'll get back to and then...the real kicker...the immigration office keeps my passport. blech.

a dutch friend commiserated with me tonight, saying "opening a bank account, buying a car, getting a TIN (personal tax ID), getting a work permit, paying taxes." my list exactly. multiple hoops to jump through, lots of waiting, and overkill on the documentation. beware of doing government business in uganda.

i don't mean to whine or to sound bitter, but i really did start to question people's motivations today. what is the point if when we finally get and do everything we're told, you simply toss the file aside without looking at it while saying "fine, come back in a week." michael decided that it was worker dissatisfaction. i might agree with him. where is the motivation, where is the supervision to keep these workers going enthusiastically when they're holed up in cement offices with cracking paint, broken wooden desks, missing filing cabinets, no electricity? all they do all day is stamp, stamp, stamp and deal with disgruntled customers. the government top to bottom is plagued by lack of funds, corruption, and nepotism. what is this one worker going to do to change that?
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the bright spot of the day is that michael got to go to america. yep, he stepped on u.s. soil at the embassy. i said "welcome to america," and he asked "is this what america looks like?"

favorite, least favorite

a friend asked me today what my favorite and least favorite things were about living in uganda. my response...
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favorite: working in a position that actually matters both within the organization and within the community.

least favorite: the culture of dependence created by the international aid community.

africa is different: FP in uganda

i attended an all-day workshop today hosted by the ministry of health and family health international (FHI) re: community reproductive health worker (CReHW) provision of family planning methods in uganda. in 2004, FHI partnered with the ministry and save the children to conduct research on a pilot program in nakasongola district that trained CReHWs in community-based distribution (CBD) of depo-provera. what does this mean? it means that women and men who lived in the community and who didn't necessarily have any medical background were recruited by save the children to work as CReHWs, and as such underwent a 21-day training on STDs, HIV/AIDS, reproductive health, and family planning. once trained the CReHWs worked within the community educating men and women on the above topics, providing basic family planning methods (pills, condoms), and referring clients to local health facilities for reproductive health services. (sound familiar? yes, it is very similar to MIHV's family planning community health worker program described in this post.)

the idea of CReHWs isn't novel (community health workers are used all over in public health, both stateside and overseas). what is novel is the addition of another, separate 21-day training exclusively on community-based distribution of depo-provera. if you don't know what depo-provera (aka DMPA or NET-EN) is, it's an injectable contraceptive containing progestin, which is one of the hormones found in combined oral contraceptives (the pill), and prevents pregnancy using pretty much the same mechanism as the pill. in a nutshell, a CBD program for depo means that we are training non-medical providers to provide an injection. i highly doubt that would fly in the U.S. as far as i know, there is a very strict regiment in the U.S. that regulates who in the medical hierarchy can give injections. but, here it's different. there has been CBD of depo in bangladesh since the 1970s, it's been available in parts of latin america since the 1990s, and it's been in africa (specifically uganda) since 2004.

why is africa different?

at first glance, one might question the medical wherewithal of allowing a non-medically trained individual to give injections. but, as research shows, these paraprofessionals actually achieve comparable outcomes to the medical professionals in numbers of satisfied clients, percentages of clients who experience side effects associated with the DMPA, and percentages of clients who suffer from injection site problems (e.g. abscess, infection). to be honest, when it comes down to it, you have to be creative in the delivery of care and services when you live in a country whose health infrastructure is at times non-existant. no, i cannot imagine my neighbor walking into my house in the U.S. and giving me an injection, but i also cannot imagine having to walk 25 km to get to the nearest clinic or doctor or nurse.

in my earlier post i talked about "why family planning," but i didn't put family planning specifically into the context of uganda. so, what's the picture in uganda?

- the infant mortality rate (IMR) in uganda is 97. IMR is conventionally defined as the number of deaths <1 year of age in a defined time period per 1,000 live-births during the same time period. as reference, the IMR in the U.S. is about 6 (i say "about" because the IMR fluctuates based on region, race, ethnicity, socioeconomic status, etc).

- the maternal mortality rate (MMR) is 506, which means that 506 women die due to complications of pregnancy and/or delivery for every 100,000 live-births. again, as reference, the MMR in the U.S. is 9.8 (it drops to 7.5 for white women and spikes to 22 for black women...but, that's a topic for another time).
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- the total fertility rate (TFR) in uganda is 6.9. in other words, the average ugandan woman gives birth to 7 children in her lifetime. at today's workshop a man from nakasongola district shared that he and his wife opted for family planning because they'd had trouble spacing their children...they had 5 children in 6 years.

a treatise on family planning

(i haven't been writing nearly as much as i'd like about my job here. this is my effort to change that. if you're not interested in public health, no need to read further. if you are interested in public health, sorry i haven't been more descriptive about what it is i actually do here.)

the organization i work for - minnesota international health volunteers (MIHV) - is a U.S.-based NGO/PVO (non-governmental organization/private voluntary organization) that works in community-based maternal and child health, both in the U.S. and in Uganda. our expertise is in community health education, mobilization, training, participatory research, and monitoring and evaluation. everything we do involves partnering with the communities in which we work to positively influence behavior change.

health is influenced by 4 factors: access (to health services/medical care), genetics, environment, behavior; but the factors don't enjoy equal influence. their proportional influence on health status more-or-less breaks down as follows: access 10%, genetics 10%, environment 20%, behavior 50%. when it comes to dollars spent, the proportions reverse. most of the healthcare dollars in the U.S. are targeted toward improving access to care (think public health insurance programs, universal healthcare, "free" emergency care), and very little is targeted toward modifying behavior to achieve desired health results or to prevent poor health outcomes.*

take the following health outcome: maternal mortality (public health lexicon: # of women who die due to complications during pregnancy or in the immediate post-delivery period). causes of maternal mortality can either be direct or indirect. in the developing world, direct causes of maternal mortality primarly include hemorrhage, sepsis, eclampsia (hypertensive disorder of pregnancy), complications of unsafe abortion, obstructed or prolonged labor. many illnesses are aggravated by pregnancy, such as anemia, hepatitis, tuberculosis, malaria, STIs; maternal deaths attributed to complications of these pre-existing illnesses are qualified as indirect.**

if you approach the problem of high maternal mortality from the "access" perspective, you might consider building a maternal health hospital that has highly-qualified and -trained health professionals, well-stocked supplies, and modern technology so that when a pregnant woman is in trouble, she can get to the hospital and get the necessary care she needs to both save herself and her baby. on the other hand, if you try to reduce high maternal mortality from the "behavior" angle, you might examine what behavior puts the pregnant woman at risk in the first place. then, you ask: is this "risky" behavior something that can be changed positively in order to prevent the complication from ever occuring?

most poor health outcomes can be prevented, that's the basic premise of public health. but, what about pregnancy can be prevented in order to minimize the risk for the mother? certain types of pregnancy qualify as "high-risk." if you're from the developed world, you're probably thinking ectopic pregnancy, multiple birth, prematurity. but, if you live in the developing world high-risk pregnancy is a whole different bag o' tricks. young mothers, women with inadequate nutrition status (e.g. stunted growth, poor pre-pregnancy weight, anemia), high parity (public health lexicon: number of births) mothers, very old mothers, women with closely spaced or unwanted pregnancies. each of these scenarios increases a woman's risk of dying due to pregnancy and/or delivery. but, each of these scenarios is also preventable.

thanks to modern contraception, all women can make the choice when, how many, how often, and when to stop having children. when: a teenager decides she wants to wait to have children until she is old enough to be a mom. how many: a mother who already has 3 children decides 3 is all she wants. how often: a mother with a 1-year old decides she wants to wait another 2 years before her next child. when to stop: an older woman wants to be sexually active but decides she does not want any more children. each of these women's choices reduces their chance of a high-risk pregnancy and increases their chance of being healthy throughout pregnancy/delivery and their baby's chance of surviving to 5 years old.

but, what if you live hours from modern development? what if you are illiterate? what if your religion prevents you from using modern contraception? what if your culture values loads of offspring because it proves the man's virility and strength, upholds the woman's role as caretaker, and assures there will be someone to take care of you in your old age? what if infant mortality is so high in your community that you feel you must have many children to compensate for all your children that will die before their 5th birthday? what if your culture prizes boys over girls, and a woman is not worthy unless she bares a boy? what if you don't know that the decision to have children is yours alone?

enter public health organizations like MIHV.

almost 50% of my salary in uganda is funded through a grant MIHV received from the FlexFund, which is a funding arm of USAID specifically directed at community-based family planning and reproductive health projects. our FlexFund family planning project aims to increase contraceptive use among women of reproductive age, but as you can see from the list of barriers noted above, increased contraceptive use isn't exactly straightforward. to increase contraceptive prevalence rates (public health lexicon: number of women using contraception), we are...
(1) educating community members (both women and men***) on the benefits of family planning for women, families, children, and communities to stimulate demand for family planning
(2) expanding service delivery by training community health workers to visit women and families in their homes to educate on family planning, provide selected family planning methods (condoms, pills), and refer women to local health facilities to receive other modern family planning methods (injectables, IUDs, implants)
(3) training health facility workes and private practitioners in proper counseling techniques to assure that women choose the family planning method appropriate for them
(4) assisting health facilities in managing their family planning logistics (public health lexicon: supplies) to enable them to meet generated demand for family planning.

our strategy is that by increasing awareness and demand, improving the supply chain, and sensitizing (public health lexicon: educate, dispel myth, calm fears, introduce new ideas) the community, we help to create a supportive environment for family planning, thus increasing the liklihood that a woman and her partner will choose to plan their family.

as you can imagine, family planning is a sensitive topic. we could not possibly be successful if we simply walked into the community and said "this is what we think, this is what you're going to do, and this is why you're going to do it." i started this blog by saying that MIHV partners with the communities in which we work on every project we undertake. public health-ers are not in it for personal benefit, profit gain, or to climb the corporate ladder. what good does it do me to help someone live longer and healthier (except make me feel good about what i do)? but, it makes all the difference in the world to that woman or that child or that family, that she lives longer and lives healthier. MIHV partners with communities because they are the ones who will make the change, who know what change they are willing to make, who will benefit from the change made. they're the experts. we just support them in exercising their expertise.

my first term in grad school, i wrote a brief paper on margaret sanger for beth virnig's class. margaret sanger is known as the mother of modern family planning. she was the first one to bring family planning to the global table as she advocated for a woman's right to choose when, how many, how often, when to stop. of course, as a daughter of a very liberal, independent woman who has been inculcated with women's rights since i was born, i looked at margaret sanger as the harbinger of women's lib and the fore-mother of roe v. wade. beth called me out quickly saying, "yes, all true, but this is a course in public health. what is the public health significance of margaret sanger and her work?" of course! margaret sanger in the 1920s, the pill in the 60s...the beginning of the decrease in maternal mortality through the increase of family planning. in the 1st world, family planning translated to more women in the workforce, a stimulated economy. in the 3rd world it translates to less poverty.
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*credit to lynn blewett's health systems course, u of mn school of public health

**credit to ian greaves' working in global health course, u of mn school of public health

***almost everything i have written re: family planning is about the woman. however, family planning is not just about the woman. public health-ers working in family planning are very, very specific about that. successful family planning involves both partners in a relationship. in the case of this blog, however, it's just been easier to write about the woman (i.e. easier to say "she" instead of "s/he" or some other PC version of saying "she and he"). i apologize for my blatant bias.

disclaimer: all views expressed are mine and mine alone. in no way do i speak for or on behalf of MIHV in this forum.

drama in the field

i was in the field the last 2 days (left 6:30am monday, back at 10pm tuesday, worked 29 hours in 2 days...exhausting) doing my regular supervisory visits of the field staff and program activities. MIHV works with a local drama troupe to stage drama shows educating community members on particular health messages. the jury (in my opinion) is still out on whether these drama shows produce results, but people do come en masse. sister and i went to a show yesterday staged in an extremely remote section of ssembabule district and 150-200 people showed up. even if i question the chosen method of message delivery, i have to admit all is not lost if we're talking to that many people.

me, sister, and the actors sat in the middle of a dusty field (ostensibly a soccer pitch with it's rickety goal posts) as the troupe drummed & danced calling in the village members. people streamed onto the field from all corners...out of the banana fields, from the roads, from their homes...and they just kept coming. maybe the mzungu was an additional attraction to the drumming? to my dismay, i was the guest of honor, so i was placed right in the middle of the crowd next to the village chairman. no blending into the background there.

ever been in a place where you knew with 100% confidence that there was no one within 50km that looked like you? that was me yesterday. the sole white person sitting among a sea of black. no wonder the little kids on the side of the road jump up & down, point, and yell with excitement "mzungu! how are you?" when we drive by.

ps. i just checked out the wikipedia definition of mzungu. uncannily similar to my statement above. huh. 101paige 101africa 101iph

who's who in global health

supposedly grad school is the place to network, find a job. i networked pretty well, yet somehow i made it through grad school without any idea of the big players on the international public health scene. sure, there was a guest lecturer in my "working in global health" course who had a lot of suggestions on how to find a job internationally, but he never actually said who there was to work for.

so, if you want to work in global health, here's some of the organizations to check out (beware, this is a community of acronyms). i guarantee you this list isn't exhaustive and i admit it reflects my current bias by being heavily weighted toward NGO/non-profit, but it is a place to start.

• MIHV
  
• family health international (FHI)
• ORCmacro/CSTS+
• save the children
• engenderhealth
• the ACQUIRE project
• JHU/CCP
• health communication partnership (HCP)
• elizabeth glaser pediatric aids foundation (EGPAF)
• CDC
  
• african medical & research foundation (AMREF)
• the international rescue committee (the IRC)
• american refugee committee (ARC)
• marie stopes international
• the malaria consortium
• africare
• USAID
  
• pathfinder international
• PSI
  
• world learning
• CARE
• helen keller international
• program for appropriate technology in health (PATH)
  
• john snow inc (JSI)
• the DELIVER project
• actionaid international
  

if you don't mind religious affiliations, there's also

• catholic relief services (CRS)
  
• ADRA
• lutheran world federation (LWF)
  
• worldvision
• christian children's fund
  

sorry, but i didn't take the time to list them by areas of interest (e.g. family planning/reproductive health (FP/RH), malaria, integrated management of childhood illness (IMCI), HIV/AIDS, nutrition, maternal & child health, environmental health), but you'll figure it out pretty quickly once you look at their websites.

fyi: if you want to do international health work without living overseas, it'll be challenging to find a job outside of new york or DC. i got lucky by finding MIHV in minneapolis. there's also a few in seattle and san francisco. 101paige 101iph

conservation through public health

earlier this week, i met the founder and ceo of a very cool uganda-based NGO: conservation through public health. they work in bwindi impenetrable forest national park promoting conservation and public health by improving primary health care to people and animals in and around protected areas in africa (their mission). (and, their vision) to control disease transmission where wildlife, people and their animals meet while cultivating a winning attitude to wildlife conservation and public health in local communities. how cool is that? their programming is targeted toward the mountain gorilla population, as it intersects with the local community in bwindi. they welcome volunteers, so if anyone's interested... 101paige 101iph 101africa

career advice from npr

if you look at the "career path" of my 20s, you might say that it's zig-zagged somewhat. people tend to look at me quizzically when i give them the run-down: history undergrad to litigation/communication consulting to law to pre-vet to public health grad school to hospital admin to global public health/development work. and, how exactly did you get from point a to point b? valid question. that's a story for another time, but for now i can say undoubtedly (and with some pride) that i have embraced the opportunity to explore my career options.

i listened to an npr podcast of all things considered today. it was an interview with robert sapolsky, a neuroscientist at stanford (and the author of a primate's memoir). he was talking about how it's human nature to fall into routine as you age, and how the older you get the less likely you are to try something new. for example, your life-long musical tastes are determined between ages 14-21; by the time you're 35 the music library of your life is for all intents and purposes set. more to topic, he said that those who stay in one profession for a long time and gain eminence in that profession are the least likely to explore new things. of course, it's not a bad thing to be eminent in your field - you're well respected, you're extremely knowledgeable about a particular subject however narrow or broad - but, you are less likely to get your belly button pierced after age 23 or try sushi for the first time after age 40ish. his suggestion: to stay open-minded and open to adventure, keep your professional life dynamic. i guess (unknowingly), i've taken his advice to heart.

i recently received an email from an old colleague who talked about viewing jobs as projects. some last for a year, some for 2, some for more. then, you find another project. i like that approach - it makes us all project managers, and validates my career trajectory thus far. i always considered her a valuable mentor when we worked together, so i was lucky to hear from her again after 5 years and receive some more straightforward advice.

my dad, another of my favorite professional mentors, always tells me to build on what i know. if there's a common link connecting your "projects," you'll create a collection of experiences and skills to draw on in any new environment. no question that's been true with me. i know it's not so obvious, but trust me - there's a common link. 101paige 101iph

my first flavor of African bureaucracy

For my first 2 weeks in Kampala I have spent almost all of my working-time figuring out the logistics associated with starting a HQ office in Uganda’s capital. MIHV has been working in the field in Uganda for about 15 years, yet we’ve never had a formal HQ office in Kampala. One of my main tasks is to be MIHV’s official representative in the capital. I’m talking about establishing an office from the ground up – buying the office furniture & supplies, installing a reliable source of electricity, buying a car, buying a cell phone, renting a postal box so mail can be delivered, opening a bank account. All of this seems mundane and straightforward, but throw these tasks into the context of Africa and suddenly everything changes. 2 ½ weeks of solid work later and I’m still trying to accomplish some of these tasks. The reasons? Multiple.

First, there’s Africa time. Everything takes just a little bit longer – okay, sometimes even hours or days longer. Maybe it’s the lack of computers, electricity, money. Maybe it’s the slower pace of life and laid back attitude toward time. Whatever it is, always bring a book. That’s my first lesson learned. I already knew it, but now I know it even better.

Second, there’s the bureaucracy. No one ever telling you everything you need the first time you ask. Too many handwritten ledgers. Money paid here, there, who knows for what. Sit and wait. Talk to another man that’s on a power-kick because he’s in a government position stamping some random document that somehow lends credibility and validity to a meaningless piece of paper. Sit and wait. Repeat process. Again.

Case in point #1: it took 4 trips to the bank before I finally had a list of all necessary documents needed to open a bank account.

Case in point #2: my adventures navigating the government system. Last Friday, I spent the afternoon at Uganda’s Company Registrar’s Office trying to “certify” some MIHV business documents. I had already been there the day before and was crossing my fingers that this time I had everything I needed. I got to the registrar, he directed me to a bank downtown where I paid 45,000/= (about $25) to the Uganda Revenue Authority, got a receipt, returned to the registrar, he told me to come back in 3 ½ hours and maybe he’d be able to finish up the process. So far, I have spent the day before plus 3 hours trying to get a man to stamp some pieces of paper. I told him I was fine just sitting and waiting until he felt he had the time to address my concerns. Our conversation…

What do you have to do to certify these documents? You just stamp them and sign your name, correct?

(grunts) Yes.

Are you sure you can’t do that now while I sit here and wait?

Do you see all of these papers that I have to deal with? (points to a haphazardly stacked, disorganized pile of papers, reports, files)

That’s fine…I’ll wait. (I continue sitting directly in front of his desk watching him work)

(Gruffly removes reports from the top of the stack and randomly opens pages to stamp. Stamp, stamp, stamp. Sign, sign, sign. No rhyme or reason. Every once in a while shouts someone’s name to retrieve more reports for him to stamp.)

30 minutes later...after some conversation about his home village, his family, and MIHV’s field sites…

I can take care of your documents now. (Flips through the pages of the documents, stamps wherever he feels necessary, scribbles a signature, hands me the “certified” papers.)

Thank you.

Case in point #3: Phil & I went to Entebbe airport to get our lost luggage, spent 4 hours in an empty airport trying to jump through all the necessary hoops to get to the other side of security (go over here, go over there, stand in line, patiently wait while an “official” man meticulously catalogs names in a handwritten ledger, receive a random laminated visitors pass, then go through security the wrong way anyway to get to baggage claim), and still walked away with 1 less bag than we checked at MSP.

The most amazing thing about it all, though, is I’m learning to be patient. Anyone who knows me well knows that “patient” is definitely not part of my demeanor. I don’t know…they say that Africa can change a person…maybe it’s already working on me. 101africa 101paige

reflections, first impressions

I’ve got 5 hours to kill in Schiphol, the Amsterdam airport...on my way home from 1 month in Africa (2 weeks in Dar, 2 weeks in Uganda).

Reflections, first impressions, lessons learned:

(1) My name’s hard to pronounce.

For a native English speaker, my name’s about as easy as it gets…Paige. Simple, straightforward, albeit unique. But, for non-native English speakers, my name poses some significant pronunciation problems. I suppose the ‘i’ throws people, so in Uganda I’m Peggy. I’m somewhat used to that (although I’m not terribly fond of the name), since I was also called Peggy when I lived in Chile. But, thankfully, I eventually acquired a nice nickname from all my travels in Latin America…Lucero. Given to me by an orphan in the Dominican Republic. It means “morning star” and my Dominican friends would often call me Lucero de la madrugada. I think it was the blonde hair. Anyway, now in Africa, I’m back to Peggy. Sometimes, they shorten it to Peg, but the worst is when it becomes Pig. Sorry, but that’s just not going to work.

I try to explain that it’s pronounced just like a page in a book, but then they spell my name without the ‘i.’ I dislike the inaccurate spelling even more than I dislike the inaccurate pronunciation, so I guess I’ll choose the lesser of the two evils.

It’ll be easier once Phil’s with me in Uganda because then I’ll always have someone around who pronounces (and writes) my name correctly. Hopefully by virtue of repetition and constantly hearing Phil call me Paige instead of Peggy, Peg, or Pig, people will catch on.

(2) My trip was an interesting combination of the “real Africa rarely visited by muzungus” and the “privileged Africa rarely visited by Africans.”

Muzungu means ‘white person’ and is a fairly universal term across all of Eastern Africa. Driving down the street little kids and adults alike will simply point straight at me and simply say “muzungu.” Sometimes it’s said in an accusatory tone, but more often it’s simply made as an observation.

Both when I visited Kibeha District (3 hour drive from Dar es Salaam) and Ssembabule District (3 hour drive from Kampala), I entered a world rarely visited by white outsiders. This isn’t to say that white people are non-existent here because that would be misleading. There are lots of ex-pats all over Africa working for NGOs, relief agencies, international development organizations, but Kibeha, Tanzania and Ssembabule, Uganda are not tourist attractions and do not fall on the map of most people visiting Eastern Africa for 3-4 weeks. Each is extremely isolated. Ssembabule does not have a single paved road, has no running water, and the town just received electricity this past year. However, the majority of the district remains without electricity. Two significant developments of the industrial, modern age (electricity, running water) have yet to reach this corner of Africa 100 years later. (Interestingly, although industrialization skipped over Ssembabule, the cell phone industry did not. It’s a modern marvel – thanks to satellite – that people who live in the remote bush of Africa and who have never had a telephone can now talk to anyone, anywhere.)

Combine these isolated environments with the high-end lifestyle we led while in Kampala. We stayed at a modest, but comparatively upscale hotel (Hotel Africana) and did the rounds at the classy restaurants each night, of which there are plenty. Kampala is definitely not lacking in tasty ethnic restaurants: Khaza Khazana (Indian), Krua Thai (Thai), Kyoto (Japanese), Arirang (Korean), Feng Feng (Chinese). Plus there’s the Pavement Tandoori, which isn’t quite as high-end, but has equally if not better Indian food than Khaza Khazana. Anyway, back to the point. These restaurants are moderate according to Western standards ($25-30 for 2 people), but when you consider that the average annual income in Uganda is only $325 they immediately become extravagant. I felt uncomfortable and sheepish going to these fancy restaurants night after night, restaurants completely separated from the reality of Africa.

We spent our days moving around town going from one NGO to another, moving within these circles of ex-pats working for the greater good of Uganda yet completely removed from the reality of Uganda. Kampala is an interesting juxtaposition of poverty and development – the streets on which Ugandans live are unpaved, obstacle courses of potholes, gullies, and dust…the streets on which NGOs have their offices are paved, lined with trees, clean, and quiet. The separation is astonishing. I understand the need for quality office space (high-speed internet, working toilet, clean working environment) and will most likely have something very similar. And I understand that these NGOs who are trying to change the status quo in Uganda will do so more successfully if they are able to get things done on a daily basis. Yet, the separation between the people they serve and themselves is distinct.

I’ve never traveled like this before. Typically, I get by on a minimal amount of money a day, often eating food from street vendors and usually living with a family in their home. I suppose that’s the difference between traveling on your own dime and traveling for work. Even so, I still felt uncomfortable knowing that our driver Kizito earns about $100-150/month and each night he dropped us off at a restaurant where we spent $30 for 1 meal. I asked him what he thought of that on our drive to the airport…

“For the muzungus that come here, they need different food than us. For us, we’re accustomed to the local food – we like it. I can get a good meal for 5,000 shillings (approx $3). I like to eat fish and eggplants…that’s what I make for myself when I cook dinner.”

(3) Africa is an NGO world.

Drive around Kampala and everywhere you turn there is another NGO – Save Africa, Save the Children, Save the World. You name the problem and there’s an NGO there to solve it. Entire Kampala streets and neighborhoods are consumed by signposts announcing the numerous offices of the numerous NGOs.

50% of the national Ugandan budget comes from foreign investment. Uganda, like the rest of Africa, relies heavily on the private sector (i.e. NGOs). I’m torn on my opinion of foreign aid and its role in development. On one hand, there is great need in Africa for poverty reduction, education, health promotion, emergency relief and NGOs get stuff done. On the other hand, NGOs remove the responsibility for social, economic development from the government and create a dependence structure between the NGO and the local government. On top of that, the objectives and political motives of the powerful few who control the donor money (USAID, DFID, CIDA, etc) dictate the development goals adopted by the African nations. (A good example of this is the Mexico City Agreement that must be signed by all grantees receiving money from USAID to carry out family planning/reproductive health programming. The Mexico City Agreement bans any grantee from promoting, providing, or educating on abortion.) As a public healther working in international aid/development, I obviously believe in the ability of NGOs to make the world a better place and to give people a chance for a better life. Yet, I struggle with the dependence on foreign aid, and the ambiguous delineation of authority and responsibility among NGOs, foreign donors, and local governments that the current structure of international development creates. 101paige 101africa 101iph

poor Americans

Conversation with Kizito on my drive to the EBB airport tonight...

There are no poor people in America.
But, there are!
If there are poor people in America, then why do the American people give so much money to us?
It is not the American people that give you so much money, it is the American government.
But, if there are poor people in America, then why does the American government give so much money to Uganda? Why doesn’t it give the money to its own poor people in its own country? Why does it come to countries like Uganda and why does it spend so much in places like Iraq, if there are poor people in America?

(Kizito makes a good point. The role of the US government in the development of the 3^rd world is unbelievable. Because our president opposes abortion, USAID is obligated to.)

Do you like all the NGOs in Uganda?
Me? I like the NGOs. They’ve done a lot of good for a lot of people in Uganda.

When asked about the Uganda government…

People in government have money. The rest of us have no money. There’s so much unemployment here, but if you know someone then you can get a job. There are a lot of people here who have a lot of education, a diploma, but they can’t get a job because they don’t know the right people. But, if you know someone, then you can get a job. The people in government know people and have all the money.