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I’m the sort of traveler that books the ticket but doesn’t really think about the upcoming trip until I set foot on the foreign soil. I realized, fairly early on, that my usual game plan wasn’t going to work in Uganda.

I had to morph into a boy scout on steroids with my preparation or maybe more like a boy scout on vaccines. Before stepping foot in Uganda my vaccinations included:
Hepatitis A, Hepatitis B, Typhoid, Tetanus-Diptheria.
Yellow fever, you have to have the certificate to enter the country, here’s mine……

And last, but definitely not least, a hefty pack of Malarone to guard against malaria.

Oh poor me. Or really, more like, lucky me, at least I thought so after meeting with Dr. Sam Zaramba.

Dr. Zaramba is the Director of Health Services for Uganda in the Health Ministry, he introduced me to the phrase “God’s Petri Dish” to describe Uganda, a place that is lush and fertile for crops but also a fertile breeding ground for disease.

Mosquitoes here are more than a pesky annoyance. Malaria, a life-threatening parasitic disease, contracted from infected mosquitoes, kills 320 people every day. It kills mainly children and pregnant women. And if that’s not enough, there’s also a HIV/AIDS component to malaria. Those with weakened immune systems, are more suspectible to malaria and those with HIV, who contract malaria, are more likely to have their HIV evolve into full blown AIDS. Talk about a vicious circle.

Two thirds of the country has an endemic malaria infected mosquito crisis. One of the worst affected areas is the Apac region.

In the Apac region, most of the mosquitoes are infected with malaria and its inhabitants, on average, are bitten 4 times a night by an infected mosquito. If a New Yorker was hanging out in the region we’d probably contract malaria immediately but Ugandans have built up some immunity so not everyone gets infected. Ugandans, for example, have no problem with the West Nile virus but for New Yorkers it was a real problem that resulted in street spraying and public health initiatives.

So what’s the Ugandan government doing to combat malaria? Well they have 3 pronged approach.

1) ITNs - that fancy acronym is the simple solution of Insecticide Treated Nets.
So it’s a mosquito net for over your bed but treated with insecticide. A few figures…the nets cost $8 each and last 3 years but as 32% of the population live on below $1 a day and 82% live in rural areas, cost and distribution are real problems. Through the Global Fund and the President’s Malaria Initiative, Uganda has 4.6 million nets in use. Remember this is a population of 30 million. Over the coming year, 900,000 will be rendered useless as the nets last for only 3 years. To cover 85% of the population they need 17 million nets.
Now here’s a shocker, so we’re at the Ministry of Health in Uganda and we’re having this high level discussion on combating malaria and just how fantastic the nets are how they could help eradicate malaria if used correctly when Dr. Sam Zaramba drops the bombshell that he won’t use a bed net!
It makes him too hot and he feels like he’s suffocating under it…..hang on a minute, if it’s a problem for the Ugandan director of health services to use, a few other people are also going to have a problem using it correctly.

Uganda usually receives nets that are rectangular that would fit over a bed but most of the population live on mattresses on the floor and require conical shaped nets so that production needs adjustment. If they could provide and train 85% of the population to use nets, it would eradicate malaria as the insecticide on the nets would protect the other 15% of the population. Dr. Zaramba concentrates on indoor spraying for his needs which brings me to our second prong of attack.

2) Spraying – also called IRS – Indoor Residual Spraying.
Have you noticed that Ugandans LOVE acronyms.Uganda started spraying DDT this year in northern Uganda around Gulu and Lira. They use it only indoors. DDT has a checkered history in the US but not so with the health officials we spoke with. There is one major downside though, if Uganda manages to reduce malaria but find they can’t sustain the momentum of spraying, malaria could come back with a vengeance, mutated into a more potent form and Ugandans would have reduced immunity after its reduced presence. Dr. Zaramba told us he has been paying out of his own pocket for spraying in the village that he comes from and nobody has been admitted to hospital for malaria for the last 6 years. That’s pretty amazing.

3) Drug therapy
There are a number of drug therapies that are in use, Artemisinin-Based Combination Therapy (ACT), chloroquine/Sulfadoxine-Pyrimethamine (CQ/SP) and Quinine. Yes I know it from tonic water too but here’s how it works for malaria.
So the first line ACTs are produced by Novartis, the biggest problem, no surprise here, is the cost. Dr. Zaramba was frank, the pharmaceutical companies want to make too much money and the price is prohibitive. It’s difficult for sub-saharan countries to maintain.
Uganda took the initative against international drug prices last year. They opened a new pharmaceutical factory with the Indian company Cipla that will provide malaria and HIV/AIDS drugs at 40% less and accessibility should be much better.

Accessibility is a real issue as most people live 5-10kms away from a public health facility so they go to the local store that sells malaria medicine privately. Malaria, to Ugandans, is like the common cold to Americans, except the common cold usually isn’t life threatening. There have been a number of corruption scandals where doctors employed by the government were selling government supplies of malaria medicine privately for profit. As Ugandans didn’t have a public health facility nearby they would pay and a secondary factor is that doctors are paid so poorly by the government that there are no stipulations on working publicly and privately at the same time.

How come some people get bitten and others don’t? Well again size matters. Bigger the body mass more likely, if you create more CO2 also more likely to be bitten.Some have less immunity as I mentioned those who have HIV have higher infection rates.

There doesn’t seem to be any practical way to stop the breeding of mosquitoes, as there is water everywhere so that approach is not pursued. There is no effective vaccine available or really even in the works.

Our hosts came back a number of times to global warming as the reason for the increase in malaria infections with a nod also to the growth of rice farming and urbanization of areas that leads to a lot of stagnant water, a breeding ground for mozzies.

(Photo Anthony Cornel)
Mosquitoes pass the infection by biting a person who has the parasite that causes malaria and then bites another person. Basically you need to eradicate the parasite in people and then you can eradicate malaria. But…..some people have the parasite but are asymptomatic. So the health ministry would like to have a “population cleansing” that is provide drug treatment to everyone whether they have symptoms or not but that’s not going to happen for a while as drugs are too expensive and production has not begun yet in their new factory.

The bottom line according to our hosts, give them 17 million nets within a one or two year period, allow them to continue spraying DDT, and in 5 years there will be no more malaria in Uganda. They stressed that the message they want us to bring is that malaria is possible to eradicate. But, to quote “as we are speaking the nets are not here”.

In Kampala with a population of 2 million there is no government operated bus system. The city is trying to introduce buses but, at the moment, only possesses 7 of them. Think about that for a moment. – 7 buses for 2 million people.

I did not see one of the magnificent seven but I did see the creativity and resourcefulness of Kampala’s residents in getting around.

You need to go somewhere. Here are your tickets to ride:
Ticket #1
Bicycle

It’s amazing what people manage to transport on them. In New York I feel laden down on my bike with my lunch, newspapers and gym gear. A Kampalan would snort with laughter. What about a bed frame, live goat or 40 kgs of charcoal? Some bikes I’ve seen have not been far from all of the above, at the same time.

Ticket #2
Taxi
Although what Ugandans call a taxi we would call a 14-seater mini bus nightmare.

They are plentiful, with passengers packed like sardines, and very slow. All the buses are private sector, there is no determined route or price, the primary factor influencing cost is the mood of the driver. Check out the first 10 seconds of this video of taxi traffic to get the idea…yes I am reprimanded in the first scene.

Ticket #3
Boda Boda

This is by far the easiest and most dangerous way to get around town. You go by motorbike, there are gangs of young lads on every street corner, ready and waiting to take you wherever you’d like to go for the princely sum of 50 cents. It’s supposed to be one rider, one passenger on a 100cc bike but rules, especially for the boda boda, are made to be broken. I myself am guilty of one rider, one passenger (me) and…my suitcase. I know, I know, but I really was in a hurry.

Sidenote: The term “boda boda” comes from “border border” where the business originated, carrying people across the border between Tanzania and Uganda.

Ticket #4
For the long distance trip there are 67- seater buses. I’ve seen a number of them. I tried to photograph but they zoomed by me, leaving me with little more than red dust on the lens. They kinda look like two of New York’s infamous Chinatown buses perched on top of one another….with their alarming center of gravity and terrifying speed on unpaved roads it doesn’t need any futher explanation on why they are locally known as “Flying Coffins”. Nuff said.

Now get down on your knees and give thanks for your metrocard.

Victoria in Kampala tries on Brian Lehrer Show T-shirt

I love radio, you know, really love it. You just don’t get the stories across quite as effectively in any other medium. I’m from Ireland, a place with an oral tradition where radio is part of life. I came to the US and found a career with a passionate bunch of public radio heads that love story-telling just as much as I do.

So what’s the story with Uganda? Well today, folks, I can confirm that Uganda is indeed Radio Country. There are about 120 radio stations in Uganda. This happened suddenly due to the liberalization of the media markets under President Museveni in 1989.

Now there are still fairly strict media rules which I’d like to get into more in another post. Suffice it to say, there are some things that when printed or broadcast are not appreciated by the government. When we met with President Museveni - do you like how I just threw that in as if I meet with a head of state every Sunday evening? - he said there needs to be media rules, as Uganda is a young democracy. Museveni referred to Rwandan radio broadcasts that incited hate and divisiveness and, according to him, helped enable a genocide. The President believes it’s imperative for Uganda to remain united and the media should not have the power to divide the already tribal population. That comment could be chewed on for a while… hopefully we will have President Museveni on to chat directly with with Brian about it. I will post on our Museveni meeting in detail soon too.

OK, here’s lay of the media landscape. Uganda has only 3 major dailies: New Vision, the government-run newspaper, The Monitor, its main rival, and Bukedde, a local language (Lugandan) daily. Their combined circulation is less than 100,000 copies per day. That’s 100,000 to a population of about 30 million!

Those figures really say something about the capacity and power of print media. According to my extraordinary guide Sam, the printed word reaches decision makers, the politicians and big business; radio, on the other hand, with 120 stations, will reach the ordinary person, the banana grower, the cattle keeper and so on.

So, radio is the real medium of the masses, while print is the media of influence. It’s been like that “since eternity,” to quote Sam on how the media share and divide their roles.

He told me it’s been very difficult to have 3rd and 4th daily newspaper – attempts don’t last more than a year and there are only a couple of surviving weekly publications.

Traveling around the country, I’ve seen plenty of radios.

Here are a few of the radio “outposts”

In a humble thatched hut in a traditional village,

Yes, I too noticed the Businessweek tucked into our village headmaster’s hand. I can only guess that my fellow fellowshipper, David Rocks provided a copy, there weren’t too many newsagents in that part of the world.

On the edge of the Budongo rainforest

(bottom right hand corner)

and maybe most surprisingly in Kasubi tombs where the former Kings of Buganda are buried,

Here’s our beloved radio perched over the kingdom’s beloved stuffed pet cheetah!

So you’re in your New York apartment and although it’s 2am, the pipes are banging, the car alarm and fire truck insist on demonstrating their blaring acoustic capabilities on regular intervals, and maybe even a police helicopter, insistently hovering, in the wee hours for who knows what reason……

Things are different here. Take a listen to the soundtrack of my Kampala nights.

Click on the link and see if you can spot a certain producer, looking mighty determined to get President Museveni on The Brian Lehrer Show.

When you visit a country that is new to you, or in this case, a continent that is new to me, there are often a few aspects that stand out. For me it was signs. Jere are a few of Uganda’s signs of the times.

Exhibit A

We’ve all read those snippy postings, in the ladies’ bathrooms’ anyway, that attempt to reprimand users into more appropriate bathroom cubicle manners - you know, “do you think I want to clean up after you?” type of thing.
But I think really for bathroom scoldings this sign at Mukono University wins hands down, wherever your feet may be.

Despised, wrong and shameful! Thank you.

Exhibit B
There is now universal free primary education in Uganda which has been lauded by many. It’s not without some critics, though. They cite hidden costs that very poor parents find difficult to bear, e.g. books, uniforms, etc. Education is held in high regard no matter how poverty stricken the environs may be. I saw this notice in Kamwokya, a slum area of Kampala.

Always come early to school

Exhibit C
Bicycles and wheelbarrows are the preferred method of transporting large materials (actually, “preferred” is the wrong word, substitute “only”).

Wheelbarrow for hire 1500 (about a dollar)

And my personal favorite…..

Exhibit D


In case it’s difficult to read - on giant billboards across Uganda - it says
“Would you let this man be with your teenage daughter? So why are you with his?”
It’s a massive campaign to try and stop “cross-generational sex” between young women and “sugardaddies” as part of the HIV/AIDS prevention strategy.
I really noticed it, but one Ugandan said, “if you want Ugandans to ignore something, put it on a billboard” — so go figure!

It’s the sort of stuff you read about in the news and see photos of on TV, so I’m not sure that I can reverse any desensitization that many of us feel when we see stories about HIV/AIDS, but this particular day changed it for me.

We pulled into a grassy compound with a number of small cottages filled with villagers awaiting treatment for HIV. The patients ranged in age from babies to about 50, what we would call middle-aged, but what Ugandans would call old. I have only seen two elderly women and one elderly man in my time here; life expectancy hovers around 59. The patients had undergone their various treatments, including the relatively recent addition of anti-retro viral (AVR) drugs, and they were waiting to speak to us to help us learn about their lives.

I spent most of my time with a group of teenagers. They were solemnly seated on a bench and appeared deep in thought, their minds, most definitely were somewhere else. These kids, ranging in age from 13-18, are all HIV positive and all had lost their parents to AIDS; some of them could not remember when.
Meet John Bosco, Alphanti Kigemuzi and Abdul Kareem

15 year old Alphanti Kigemuzi, a 2nd grader, told me in his soft-spoken way that he would like to be an engineer in the future, but he then stopped and amended gently, “if life allows me to”.

Both of his parents are dead. His father died in 1998 and his mother died in 1999. He doesn’t have any brothers or sisters, so he lives with an uncle. Alphanti told me that he doesn’t remember when he became ill or when his parents died, and his case is typical. John and Abdul have similar stories.

John, a shy young man, is 18 and only in 2nd grade due to his illness.

Abdul Kareem is 16, lives with a grandfather, and doesn’t remember when he became sick, although it was quite a long time ago.

These kids at least have one adult caring for them. This area became famous for child-headed families where a child as young as 9 would be raising the children that were orphaned due to AIDS.

It really hit home that these teenagers know that their fate is uncertain, and even the doctors are unsure about how their illness will progress or how long they will live. Although they feel less sick now with the medication and say they have no problem taking the drugs, the depression that surrounds the kids is striking. That’s when it changed for me. It’s not often that you have a group of teenagers hanging out together but don’t interact with one another and don’t exude any of the usual energy that teens are supposed to have.

It’s obvious, even to a non-medical outside observer like me, that these kids are sick - some of them very sick. I should mention that the doctors that treat these kids are not only hopeful but really proud to share what they have accomplished for these kids, primarily with funds from PEPFAR. I asked whether they had many journalists visiting, and the doctors found my question really amusing and laughed out loud. A group of journalists hearing their stories was an unexpected though much appreciated novelty.

Quick video interlude on how to use the resources you’ve got, rather than the resources you wished you had, to paraphrase Donald Rumsfeld inappropriately.

I’m traveling with a group of editors and producers as part of the International Reporting Project and we have a rather ambitious schedule that, might I add, we have been able for the most part to complete.

There’s one place we didn’t get to though, but not for lack of trying… We wanted to go to Kasensero, it’s a small fishing village on Lake Victoria, that has been integral to the history of HIV/AIDS. We traveled for a couple of hours from the clinic at Rakai down a dirt road with quite a few bumps, and even a few baboons, and were only 20 kilometers away when we encountered a road block of sorts.

I used the perseverance I observed among the villagers when uploading the following videos. Using the term “glacial pace” to describe the Ugandan Internet connection is being magnanimous.

Part 1 - Mud Wrestling

Part 2 - It Takes a Village

And don’t be discouraged, there’s even a…

Part 3 - Try, Try and Try Again

These clips are short, but by the time the car was cleared, night was falling and rain was likely, so we had to abandon our expedition. I’ll just have to come back.

So if you read the previous post, you heard about the Rakai Health Sciences Program, a leader in HIV/ AIDS research that I visited yesterday. And you’ve probably heard about the ABC of HIV prevention: Abstinence, Be Faithful, and Consistently and Correctly use Condoms.

Condoms have been controversial of late, as in order to receive funding from href=”http://www.pepfar.gov/”>PEPFAR (the President’s Emergency Plan for AIDS relief), the ABC program must comply with the regulations of promoting abstinence over condom education.

Well there’s a new C in town, or to be accurate, there is now ABCC…

What’s the new C? Men, cross your legs, it’s male circumcision.

In 2005, a trial at the Rakai clinic saw a decrease of 51% in HIV infection in circumcised men. This was so significant a number that they stopped the trial 6 months earlier than planned and began rolling out a comprehensive circumcision program, which is now underway.

OK, the skinny on foreskins… Here’s a box of them at the clinic about to be sent off for testing… eek.

Globally, 30% of the men are circumcised. Usually it’s done for religious or cultural reasons. It’s probably the oldest and most common form of surgery. So why does cutting off the foreskin better protect a person from HIV? Scientists suggest it’s effective because cells inside the foreskin are an ideal breeding ground for the virus and allow it be passed on during sexual intercourse. Cut them out, and the breeding ground is gone. And, apparently size does matter; they have figured out that the larger the foreskin, the easier it is to be infected with HIV.

Next, I went to the circumcision surgery waiting room. A group of men from aged 15 to 61 were waiting in line to get circumcised. I tried talking to some of them about what led to their decision, but the uncontrollable giggling that erupted from the group led me to believe they were never going to talk about that decision with me (yes, I’m female). They didn’t mind my taking their picture, though.

Here are the issues:

Currently men from age 15 on are getting circumcised. What’s the right age for circumcision to be performed? Babies, teens, adults? All of the above?

Who should consent for the children? There are a heartbreaking number of families without adults in this district due to parents who died from AIDS. More about those children later.

The doctor-to-patient ratio is overwhelming: 1 doctor to every 18,000 patients. Currently doctors perform the surgery, but that’s probably not sustainable. Who, then, should perform the surgeries?

Should antibiotics be used, or could they create antibiotic resistance within the community?

How do you do appropriate follow up with a remote rural population?

Rakai is trying to answer those questions. And while we are on questions, here’s a rhetorical one: Did you know, on average, it takes 1,000 unprotected sex acts with an infected partner to contract the HIV virus?

Would you like to read more on this circumcision study?

It’s kind of difficult to describe the past 24 hours that included crossing the equator, visiting a unique AIDS research and patient facility, hearing some hair-raising stories about witch doctors and attempting to dance to Ugandan and Congolese reggae (no pictures please), but here goes. I’ve managed to score an Ethernet cable, which makes the job much easier.

We left our hotel in Kampala really early yesterday morning. I must remember to tell you a little about our hotel at some point, it’s got a tale or two. But not now. So, yesterday we got up early and hit the road toward the rural district of Rakai in southwestern Uganda.
Dr. James Ntambi sat beside me on the bus ride and recounted the following story. In the early 80s a number of people started getting very slim (in a culture that adores curves – they even add a few pounds to the store mannequins). These very thin people died after a relatively short time, but nobody could figure out what was ailing them. The disease became known as Slim Disease in Uganda and really baffled everyone as to the cause. There was a number of rumors including witchcraft, but none could be substantiated. Here’s where Rakai comes in. Two Ugandan researchers, Drs. Nelson Sewankambo and David Serwadda from Makere University in Kampala, noticed the particular severity of the epidemic in the rural Rakai district in southwestern Uganda. They began extensive research on the people of Rakai, and through their work discovered the first case of HIV in the country by making the connection between Slim Disease and HIV. Drs. Sewankambo and Serwadda then planned an investigation into the baffling disease and set up shop in 1987 in a rented room at the Milano South-View Inn in Kyotera.

That tiny clinic, lit (when there was electricity) by a 40 watt bulb and home to blood samples spun by a hand centrifuge, grew to be a leader in HIV/AIDS research and prevention. The clinic is now in direct partnership with the NIH and CDC. The area became the epicenter of HIV and AIDS in Uganda, both in cases and research, and even slipped in Ugandan vernacular. If you wanted to insult someone, calling them “Rakai” or “Slim” was an effective way.

We were fortunate to visit the Milano South View Inn yesterday in the middle of a health mobilization meeting. The meeting brought together health mobilizers from the neighboring regions who were chosen through local elections in their districts.

The health mobilizers then come to Rakai to get the latest information on prevention of HIV/AIDS and bring that information back to their villages.

I also got to interview one energetic young man, Siraje Ssenyonga.

Siraje took his role as a mobilizer as a prestigious honor, and was delighted to share how his thoughts on his village’s reaction to HIV prevention information. What were those thoughts? All will be revealed in the next post!