On the evening before the final academic presentations at the Makerere University School of Public Health, we led a discussion on Ugandan and American perceptions of fertility, relationships, love and maternal health. We also sought to engage a broader culminating discussion to provide a sense of closure on the last Sunday at Ndere Center in Kampala. We sensed a slightly more somber mood: the days of independent fieldwork had come to a close and groups were mentally gearing up to articulate in fifteen brief minutes the very complex experiences and issues they had encountered over three weeks in Kampala and Rakai.
Our first goal was to rekindle some of the energy and dynamism that has characterized so much of this trip. We held two simple physical games, both requiring closeness and non-verbal communication. We wanted to harness some of the palpable restless energy, and the games did restore a sense of spirit, even after we had gorged ourselves on soup, Luwambo and all the classics — matoke, rice, yams, Irish potatoes, beans, etc. The competitive element allowed people to refocus after a minimally structured day in Kampala, first challenging three bodies to fit on a two-foot square leaf of newspaper, and then rearranging groups along a line without speaking.
Rather than structure a didactic conversation on the nature and scope of maternal health issues in Uganda, we opted to sensitize the group to the diversity of our own experiences (i.e. number of siblings, aunts/uncles, one's birth location, and anticipated number of children). Interestingly, we did not find a stark delineation between Hopkins and Makerere students. For instance, of the two people who reported having been born in a maternity center, one was American and the other Ugandan. The only universal perception was that of a uniquely rewarding MU-JHU collaboration, which students described as successful due to the group's cohesion, dynamism, openness, and diversity. Many cited preexisting anxieties that the group might gradually fragment into numerous cliques, but such a scenario never materialized in Uganda. Instead, the group was notable for its absence of "weird group dynamics", as well as its acceptance and receptiveness to individuals' needs.
The Social Context for Maternal Health in Africa
Social dynamics and relationship norms provide a contextual landscape for maternal health, both in terms of a woman's access to care and her health outcomes. We wanted to gauge whether the American and Ugandan students had encountered any surprising dynamics or behaviors, at the rural home-stay or in urban Kampala, that had informed their understanding of relationship norms (either American or Ugandan). Patience (MU) noted the seemingly inseparable nature of romantic relationships between Americans. She described love as pervasive and passionate, specifically noting the long distances over which relationships played out. She also noted, however, that divergences in academic or career paths were often enough sever ties between young couples. Both of her observations provide insight into how Ugandans might perceive American relationships.
The Americans were struck by the affection, generosity and intensity of platonic relationships between Ugandans. Jacques described contrasts between Ugandan and American social norms, noting that Americans are rhetorically "progressive," but in fact "very guarded about our space." In contrast, Ugandans more openly hug, hold hands and tolerate temporarily close quarters, on public taxis or Kampala's streets. Paradoxically, public displays of romantic love are rare and widely construed as inappropriate. As one MU student put it, "We don't have a kissing culture." The American students appreciated Ugandans' heightened sensitivity to physical well being and aberrations of the body. A bandaged knee, unnoticed in the U.S., had elicited Ugandans' concern (Joyce). Similarly, a conductor on a taxi had repeatedly asked Henry whether he was comfortable in the cramped space. The general mood of empathetic concern is perhaps best encapsulated by the typical Ugandan opening question in conversation: "How is your life?"
American and Ugandan Experiences: Birth and Fertility
Both MU and JHU students documented lower fertility rates among their generations, relative to their parents'. Of course, our results are not necessarily applicable to Uganda as a whole, for we were working with a highly educated group of students attending Makerere University. Nonetheless, these data do give a rough portrait of changes in contemporary reproductive norms across the life course and generations. Most students had 3-5 maternal aunts/uncles (45%), and roughly equal numbers had 1-2 (26%) and >6 maternal aunts/uncles (30%). The proportions of students reporting 1-2, 3-5 and >6 paternal aunts/uncles were roughly equal (~33%). The majority of students had 1-2 siblings (65%), with five students reporting 3-5 siblings. With respect to future fertility, most envisioned having 1-2 (48%) or 3-5 (39%) children. Of the three students who desired >6 children, all were Ugandan.
Adelina observed a qualitative correlation between a student's number of siblings and desirable future fertility rates. Henry noticed less of a contrast between Ugandans and Americans than the literature might lead us to anticipate. Indeed, we found some flexibility and variability in perceptions of the appropriate family size, and never encountered unrelenting perceptions of "normality" in fertility.
We also posed questions related to anticipated choice of delivery site for expectant American and Ugandan mothers. Americans generally believed that Ugandans gave birth at home, citing barriers such as transportation and cost of hospitalization, as well as cultural norms, perceptions of safety, and limited education as determinants of home birth. Brynn recollected a lecture by Gilbert Burnham, in which he mentioned that the majority of Ugandans live in secluded rural areas. Frank proposed that more Ugandan women might give birth in the presence of a traditional birthing attendant (TBA), due to lower cost and proximity to the village. In contrast, Ugandan students assumed that Americans gave birth in hospital settings, as access to health care was perceived to be high. Interestingly, Patience expected technology to be "so high" in the U.S. that some women might give birth in their own kitchens.
In fact, 83% of all (Ugandan and American) students had been born in a hospital, potentially reflective of the prominence of health facilities in the course of pregnancy and delivery in both countries. Only one Ugandan student had been born at home. This finding might offer an interesting starting point for further discussion related to the medicalization of childbirth, both in the U.S. and Uganda.
In Kampala with No Agenda
During reflections on the free day spent in Kampala, students echoed earlier positive impressions of the group dynamic as whole. The MU students relished in seeing JHU students respond to taxis, crowds and vendors on the streets. MU students also felt directly responsible for the experience of their American counterparts. JHU students sensed and appreciated the generosity and patience of their MU counterparts, and benefited from their guidance and the opportunity to independently explore the city. There was a general consensus that MU students would benefit from a future program in Baltimore, and that it would enable the Americans to reciprocate in some small way. Marie alluded to potential parallels between Baltimore and Uganda in terms of health and education. Adelina emphasized the necessity of experiential learning to good global health practice, and reasserted the need for travel and direct interactions between students in developing countries and the developed world. The desire to integrate Ugandan hospitality, work ethic and resilience into our lives in the U.S. was reiterated. For many, this program has revealed or reconfirmed academic and career paths, and that process has continually drawn from the invaluable aid (linguistic, cultural and social) of our Makerere collaborators.
The true extent of the program's impact on our spiritual, service and professional lives will reveal itself only gradually. But individual growth is also already evident. The candid nature of our discussions has enabled us to break through superficial impressions of place and people to tease out motivations, interests, and structural factors that influence health outcomes. I am hopeful that the group dynamics we cultivated were not the result of some arbitrary collection of complementary personalites, but rather the result of purposeful conversation, openness and engagement, qualities that can be replicated with future groups in Uganda, Africa, and throughout the world.
Sunday, January 29, 2012
Saturday, January 28, 2012
Friday, January 27, 2012
The group added some further thoughts to their post from Jan. 10:
During our reflection session, we decided to present open-ended questions to the group and probe deeper into their responses. We discussed the first night in the rural homestay, both positives and negatives. We also conversed about ethical or proper behavior issues such as responding to "too much food." We ended the open-ended response session with statements from many students about their goals and expectations during their homestay. We tied up "loose ends" by discussing fears to overcome as part of the experience.
"Too much food" was a common statement brought up during the session. The homestay families showered their generosity among the students by providing them with large meals, abundant with all kinds of foods. Numerous students in the discussion exclaimed that they felt bad for refusing food and that "it was so much." THe students from Makerere University chimed in, claiming that a cultural rule in Uganda in terms of being a guest was to never refuse food. They claimed that refusing food was considered downright rude.
Some students in the discussion session expressed fears about surviving the homestay as well as fitting in with the family. There was a general vibe that the students were still getting used to living in a rural homestay. A few students from Makerere University shared comments about how hilarious it was for them to watch when JHU students adjust or behave. The method of "basin showering" was a common cited new experience for many of the JHU students during the rural homestay.
Sunday, January 22, 2012
On Wednesday, our group split into two sections for the day's site visits and activities. One half of the students visited the Naguru remand home in the morning and the Sanyu Babies Home (SBH) in the afternoon, while the other half did the opposite. When the group came back together for the reflection session in the evening, it quickly became apparent that each group had very different experiences. The dialogue that resulted from evaluating the different experiences yielded some of the most emotional, profound, and meaningful reflections thus far.
In the first part of the reflection session, we asked the students to describe the day's experiences in one word. While students from group 1 used words such as "touching, interesting, and interactive," students from group 2 said, "deceit, misery, reality, and sad."
Next, we asked one person in each group to summarize their group's activities as objectively as possible. A member of group 1 described how his group participated in a debate with youth at the remand home. At SBH, group 1 held, fed, and played with nearly all 50 babies. In contrast, a member of group 2 described that her group was told not to hold children at SBH and instead made beds and washed windows. At the remand home group 2 held a question-and-answer session with all 180 youth. Upon leaving, they witnessed a boy being caned as punishment.
As we moved into the final part of the reflection session we asked students to compare and contrast experiences. The caning incident became a starting point for discussion, and students were visibly shaken by the occurrence. As facilitators, it was interesting to hear comments of guilt voiced by group 1 members who seemed to have a more positive experience overall.
In the end, the group engaged in a group discussion and came to two conclusions. First, we concluded that for as hellish as the circumstances may have appeared at the remand home and at SBH, very similar circumstances exist in US orphanages and juvenile detention centers. This realization made us consider why Americans feel that they must visit these sites abroad but often do not bother to explore similar places in their own communities.
Second, some students raised concerns about the orphanage "marketing" its babies to international visitors. Some expressed that they felt uncomfortable playing with the babies because they did not think it was fair to favor their own pleasure over the attachment the babies so often feel when visitors only briefly pass through their doors. This led to a larger discussion about our motives and the purpose of our site visits. When someone mentioned "selfishness" as a motive, another student asked us to consider how much international aid workers' might really be motivated by self-interest. As she said, someone once argued, "the third world is the playground for the first world."
We ultimately concluded that trying to discern the purity of our motives and those underlying all international aid efforts is a very complex task. However torn or confused we felt after this reflection session, we appreciated the opportunity to step back and really examine our experiences.
Our day consisted of visiting Baylor AIDS Initiative, MU-JHU, and Mulago Hospital. We gained more information on how these institutions are assisting the needs of mothers and children affected and infected by HIV/AIDS. As the Children and HIV group, while we were greatly benefited from this day, we also wanted to see in the reflection session how the other groups applied what they saw. Furthermore, we had been back in Kampala from Rakai for no more than a few days, so we were curious about how the students felt at this point.
We began our session with a light game called "Do Unto Others What They Would Do Unto You," in which we saw many interesting things, including a student pretending to peel matoke while doing the "robot." Then, we had an interesting discussion about our expectations and also how they have been met. Many of the students agreed that this trip has met or even exceeded their expectations. We also discussed about how it felt to be back in Kampala, a big and crowded city with many aspects that contrast with our rural experiences, such as toilets and a faster pace of life. We then asked students to reflect on the trip to the institutions and what they found to be surprising or interesting. We discussed the privacy of the patients and information confidentiality. Some felt that there was a lack of privacy in the wards, while others believed it is because Mulago is a teaching hospital, so students regularly observe. One student noticed that there were separate public and VIP sections within the hospital, according to how much patients can afford. As a response, a student felt that regardless of where they are, all patients should be treated with respect and dignity. Another student was surprised by the sheer number of mothers visiting for the first time at a late stage in their pregnancy, raising the question of why they would not come sooner. Also, many students noticed a stark contrast between the internationally funded institution (Baylor) and locally funded hospital (Mulago).
We went on to ask about how the students could relate their experiences to their own themes. The water and sanitation group realized the significance of clean water all throughout the hospital and institutions. They were also surprised at how children who survived HIV ended up dying from diarrhea. The OVC (orphans and vulnerable children) group had learned about a special program that Baylor offered to these particular children. Something that stuck out to the education group was how children of educated mothers were more likely to survive than those with uneducated mothers. Finally, the maternal health group realized that as much as mothers had access to transportation, once they arrive, access to services seemed to be insufficient.
Personally, our group came to realize just how many are affected by HIV, and we gained so much information on our topic, from PMTCT programs to the counseling of adolescents and caretakers. Also, we learned more about the process, in terms of where patients are referred to, depending on their situation. For example, children are treated at Baylor, while pregnant mothers go to MU-JHU. We look forward to learning and reflecting more from our stay in Kampala, as well as gaining more insight on how children with HIV are affected.
Conducted Tuesday, January 17, 2012
Saturday, January 21, 2012
We came back to Kampala via one of the Ssese Islands, taking two ferries and spending the day and night between in Kalangala on Bugala Island. While the accommodations were not everything we had hoped for, we did have a relaxing day before plunging into our week of investigating youth health and education in Kampala.
Before leaving the Rakai area we had a goodbye party with the host families in Masaka. There were many speeches and lots of dancing, including the seeming requirement that you dance on your way to the front to make your speech!
Special thanks go out to Fred, Agnes, Stephen and Eric at Rakai ... this never would have been such a success without all of your help!
Special thanks go out to Fred, Agnes, Stephen and Eric at Rakai ... this never would have been such a success without all of your help!
Tuesday, January 17, 2012
The end of our home stay and the day at Ssese Island marked the halfway point of our trip. This happened to also be the time when we ran our reflection session. Instead of focussing entirely on our theme topic of OVC, we decided that this was a great opportunity to reflect upon the experiences we had in the first half of the journey and those that are coming up in second half. For example, we discussed the lessons we learned throughout the home stay that changed our perspectives on topics that we easily take for granted. In particular, after the home stay many realized how important it is to conserve water in the rural areas, and how we greatly abuse the amount of water we use due to luxuries such as indoor plumbing and showers.
While we were working at the Rakai Project, the group started to delve into the controversial topic of research and medical ethics. Since it spurred such a heated but interesting debate, we decided to mention the topic again in our reflection session. Therefore, we asked questions such as, "would you rather donate your labor for a volunteer project, or just your money?" and "would you rather work on treatment for HIV/AIDS patients or work on preventing HIV/AIDS with behavior change?" After the discussion of these questions, we concluded that there is no right or wrong answer to these questions. It's a matter of what you personally value and the intentions that you have.
For the second half of our stay in Uganda, we are giving a lot of attention to our theme group topic and presentation. After having a very eye opening experience in the rural village of Rakai where the prevalence of orphans (especially from parents who were victims of AIDS) is very obvious, we are looking forward to finding comparisons of the treatments of orphans in a more urban setting. Tomorrow we are visiting a very popular orphanage called Sanyu Babies Home and then we plan on visiting smaller, more typical orphanages during our free day in the city on Thursday.
Conducted Sunday, January 15, 2012
Conducted Sunday, January 15, 2012
Sunday, January 15, 2012
Our reflection session occurred the day after each group got to spend the entire day shadowing their home stay families, an event that we were all both anxious about and looking forward to. Prior to the reflection session, we had a quick debrief in the morning about our experiences and we already noticed a difference in gender roles. The boys in the group clearly had entirely different experiences than the girls in the group. The boys were not invited by their families to participate in chores, cooking, and housework, whereas the girls were taught how to peel matooke, crack groundnuts, sweep the compound, wash clothes, clean dishes, etc. The extent of participation the boys experienced was limited to observing processes such as making barkcloth, which is a cloth made from the bark of a tree that is used for arts and crafts, and as a sign of respect during a burial. For the most part, the girls in the group were able to interact with the women in the household whereas the boys were only able to interact with the men. Observations were also made about gender roles within the household; aligned with their cultural standards, women and girls in the family would kneel when greeting people and would eat on the floor apart from the men and guests.
During the reflection session, we opened by asking each group to briefly describe their day with their families and something new they learned. For the most part, people picked up new Ugandan words and phrases, different types of agricultural products, and household skills. We were happy to learn that everyone's initial impressions of their families had changed for the better and over the course of just a few days, people had developed strong relationships with their families. A fun question we asked was about the most interesting members of the families. Many people told stories about rambunctous and mischievous children who were always at the center of attention. When asked about the goals they had in the beginning of the home stay and whether or not they achieved them, people had very positive responses, whether their goals were to form bonds with members in the families or to successfully bathe with a basin of water. Some goals that were not achieved were usually due to the gender divide because the interactions the boys in the group had with women in their families were very limited.
Since we are one of the Water and Sanitation groups, we asked some questions focusing on water usage in the households. Most groups were taken by their families to visit water sources that the households used and some were even able to participate in the collection of water with jerrycans, which proved to be quite a laborious process. Everybody gained a new appreciation of water and awareness of their own habits with water compared to the households. One person spoke about how they realized in their American home, they would leave the faucet running while brushing their teeth, but in Uganda they learned how to conserve water and use it more efficiently.
Everybody had a very successful experience with their home stay families and formed lasting bonds with them. Not only did we all discover new things about Ugandan culture, we also discovered aspects of ourselves that proved to be resilient and adaptable.
Conducted Friday, January 13, 2012.
Conducted Friday, January 13, 2012.
We led the group in an open-ended discussion consisting of questions related to our first day in the rural home stay. Stories, shared by all the members (Makerere and JHU students), depicted images of too much food heaped on plates and anxiety over novel living quarters. Interestingly enough, many of the program participants admired the generosity of the host families and stated that they "felt bad for not eating all the food." Furthermore, the discussion sessions concluded with statements of goals that the students wanted to achieve during their village home stay. From establishing long-lasting relationships to surviving a rural home stay, all of the students seemed really determined in making the most out of this experience.
Conducted Tuesday, January 10, 2012
Conducted Tuesday, January 10, 2012