The Road to Development (Pun Intended)

Roads are an underestimated necessity of health and development. Getting from Point A to Point B in most of the developed world is rarely a matter of concern. Of course, we all know how annoying it is when a road is closed, when a pothole blows out a tire, or when general traffic tacks on another hour to our journey. Here in Atiak roads are far less reliable, blown tires are a common occurrence, and it takes 2-3 hours to travel 50km. Bad roads leave people stranded and on more than one occasion I have been touched by just how dangerous that is for rural communities.

Last week a woman had to be transferred from the clinic to the health center in Atiak. With low fetal heart tones and a labor that had stagnated,  greater intervention had been deemed necessary by the midwives. In an ideal situation the woman would have been transferred to a well-staffed, equipped hospital. I’m not sure one of those exists in Uganda, but Lacor Hospital in Gulu is fairly reliable and the best option in Northern Uganda. Unfortunately, the three roads that lead from Atiak to Gulu were washed out by heavy rains and closed. Hundreds of trucks lined the roads waiting for the rains to stop and the roads to be prepared. Gulu was not an option for this woman or anyone else that week. Fortunately, this woman was able to deliver her baby and Oliva and Racel successfully resuscitated the infant and repaired the woman’s episiotomy. But not every woman has been lucky in the end.

When the roads to Gulu are passable other issues remain. Atiak and Gulu are separated by a mere 56 kilometers, but the horrible road makes the trek anywhere from 2 hours to 8 hours during the rainy season. Transferring a laboring mama to the hopistal in Gulu can pose as many risks as not transferring her. On more than one occasion, women have given birth in the Earth Birth ambulance after hours on a bumpy road forced the baby out. With a birth attendant in the vehicle as well, most of these women and their newborns have been ok, but there is always the risk that they won’t be. There is always the risk that a 2-3 hour drive is nowhere near close enough for women and infants to be safe.

Last week, I went to Gulu with Rachel to get some supplies for one of the projects I have been working on. It took 4 hours to travel the 56km and there were several instances in which I thought I was going to crack my head on the ceiling of the car as the potholes and mud pits tossed our bodies around. 3 days later, the road was closed to cars and trucks after more torrential downpour washed out the roads. This presented a small problem as I needed to take a bus back to Atiak for a meeting while Rachel stayed a few more days in Gulu. With no other option, I hopped on the back of a moped with my duffle bag strapped to the back. It was actually an incredibly fun ride, late in the afternoon as the sun started to set across gorgeous green landscape. But my point is that the road was so awful only tiny mopeds could get by. It was so dusty and muddy that by the time I got home I was the filthiest I had ever been. My legs were caked in mud and I drew pictures in the dirt on my face. We had to walk around enormous holes and puddles that few vehicles could have navigated. Rachel remained stranded in Gulu for several more days and the ride home took her 7 hours and several bribes.

Bad roads quarantine communities and  jeopardize individuals. I happen to find my most personal encounter with these awful roads a bit amusing (see above paragraph), but there is nothing amusing about people being unable to reach a hospital, unable to transfer their goods so that they can sell them in the market and earn a living to pay for their families’ food and school fees. Roads are essential. They are life-altering and life-saving. They connect people to opportunity and in turn have a significant impact on levels of development and health.

Further Evidence of the Necessity of Safe Reproductive Health Services

Reproductive health, which includes access to safe abortions and contraception, is a controversial issue everywhere in the world. It is controversial in Uganda. It is controversial in the US. It is controversial in politics, made more contentious by religion, and I very much doubt that it will cease to be a controversial issue in my lifetime. It is therefore safe to assume that some of you reading this may find this post controversial.

A few weeks, ago a young woman came to the clinic miscarrying in her 4th month. After the fetus was delivered one of the midwives inspected him and noted that the skull was damaged, though she chalked it up to a fetal-development issue, perhaps related to the miscarriage.

Later in the afternoon, the woman was transferred to the local health unit in the center of Atiak where she died the following morning. An autopsy revealed that she had not miscarried, but that she had performed her own abortion – succeeding in terminating her pregnancy, but also in taking her own life.

This is an unfortunate and upsetting story no matter which side of the abortion debate one is on, but I will not keep quiet about my politics. Access to abortion is an essential resource for women across the globe. A young woman’s life would have been saved if she lived in country where abortions were legal and accessible across all economic classes and this is a large-scale reality. If a woman is desperate enough for an abortion, you damn well better believe she will find a way to get one in spite of the illegality. This was also the case in the US prior to the legalization of abortion in the 1970s and remains the case in areas of the US where woman simply cannot afford a legal abortion. It is estimated that an average of 1.2 million back-alley abortions were performed annually before the Supreme Court ruled on Roe v. Wade in 1973. Many of the women who received those abortions died as a result of complications or were otherwise gravely impacted by the procedure (http://www.prochoice.org/about_abortion/history_abortion.html).

This is the current case in places like Uganda. Criminalization is NOT a deterrent against abortion, particularly in communities entrenched in poverty and with a permeating history of war and rape. When a pregnant mother of multiple children has been abandoned by her husband who has been deeply traumatized by war; when a woman cannot get work because in rural Uganda the only work is to farm her own land; when a woman must fend for her children and herself on literally no income; when a woman has been repeatedly raped, forced to marry a rebel leader, and impregnated; when a woman can only afford to eat once every other day; when a woman is out of reasonable options; when a woman feels for whatever reason that she cannot give continue with a pregnancy- no government, no society, and no religion should blame or attempt to stop her from considering and seeking a termination to the pregnancy. She will find a way to end the pregnancy regardless and the likelihood that it will end without further incident is low.

The World Health Organization estimates that 21.6 million women seek illegal or unsafe abortions each year – 98% of them occurring in resource-limited settings. These women need options. They need access to and education about contraception. They need people to help them work towards developing a society that gives women more power over their sexuality and their relationships with men. In societies where men refuse to use condoms for cultural (or any) reasons and where women do not have the option to say no, these women need to find hope somewhere else. If that hope comes from knowing that she does not need to worry about feeding another child or reliving the pain of her rape or abandonment by delivering a child who is a product of that experience, that must be respected.

I understand that abortion is controversial, but abortion happens whether it is illegal or not. Please understand that societies that ban abortions take far more lives than they save. To consider oneself pro-life in the face of that fact is hypocritical.

Tropical Diseases That Knock You Off Your Feet

My friends from grad school and I have often joked that you aren’t a true development worker until you’ve survived a disease endemic to a developing area. I’m both pleased and devastated to announce that I have received that badge of honor as a survivor of malaria!

I was, of course, never in any danger of not surviving this particularly nasty parasite (take a breath, Mom and Dad), but it has still rendered me useless for the better part of 10 days. Furthermore, the truth remains that malaria does take millions of lives each year – particularly effecting young children, the elderly, and the poor.

Contracted through a female mosquito carrying the parasite, malaria enters the blood stream directly and may sit dormant for up to two weeks before the body gives rise to the symptoms.Symptoms range from a high fever, an excruciating head ache, extreme joint pain, vomiting and diarrhea. As long as one receives treatment in time and enjoys an otherwise healthy immune system, death from malaria is not as common as figures may lead people to believe. In fact, every person I have met in Atiak has had malaria at one point (or many points), yet has lived to tell me about it. That is not to say malaria doesn’t take far too many lives.

According to the World Health Organization, 90% of malaria deaths occur in sub-Saharan African – also the poorest region in the world – taking the life of a child every 30 seconds (http://rbm.who.int/cmc_upload/0/000/015/372/RBMInfosheet_1.htm). Children are most impacted because they typically lack the strength of an immune system that can fight off the malaria parasite. Add this to the fact that very few families in poor communities can afford to feed their children more than once a day and fewer still can afford malaria medication where governments or NGOs are not providing it for free and, while tragic, it’s not all that surprising that malaria takes the many young lives that it does.  Malaria is also a problem for pregnant women and newborns, as malaria is one of the leading causes of severe maternal anemia cases, which presents a high risk for miscarriages and still births, in addition to low birth weight and neonatal death (UNICEF).

Malaria and other tropical diseases (yellow fever, typhoid, guinea worm, etc.) also play a profound role in economic development – or perhaps we should say economic underdevelopment. The fact of the matter is that disease and poverty are inextricably connected. Malaria can knock a full-grown adult on their backs for weeks, rendering them incapable of work or providing for their families to the extent that they need to. When entire communities are impacted by the disease it can become incredibly difficult to move forward as an individual, family, or village. Diseases pull children from school, either because they are ill themselves or because they need to fulfill the roles left empty by an ailing mother or father. Not tending to the crops is not an option – it is typically the only means of livelihood. Someone has to fetch water or there will be none. There is no “calling out sick” in rural Africa and when malaria takes its toll and one must stay in bed, you better believe a number of people will also be impacted.

There are a few methods of prevention that have been deemed largely effective. Foreigners traveling to malaria-endemic areas can take anti-malarial pills to prevent infection, though they aren’t necessarily 100% effective. Sleeping under insecticide-treated mosquito nets has largely been deemed the most effective way to prevent malaria, but people working in development have found ways to argue about that. Should the nets be provided for free or should they be sold inexpensively, say for a dollar? Studies have shown that when the nets are provided for free people sometimes use them inappropriately, often as fishing nets. The response was to put a small price on the nets, thinking that if people invested their own hard-earned money that they would have a sense of ownership over their health and use the nets correctly. But this marginalizes the very poor, who are left to decide between a net for each bed in the hut or food for that week. Nets also need to be retreated with insecticide and replaced every so often, adding to the cost for families. So what do we do? Provide a hand-out or put a cost on the nets? A hybrid solution in which those who can pay do and those who cannot receive nets for free  would exacerbate class divides by pointing out the very poor – many of whom wouldn’t come forward for their nets in order to avoid shame.

In my opinion the nets should be provided free of cost, but incorporated with the net should be a brief educational pamphlet in the local language as well as in images that instructs on the proper use and the necessity of the net. Some governments and NGOs have taken similar approaches and while there is not going to be a fool-proof solution to malaria, there are ways to start bringing the incident rates down. This will, in turn, have a positive impact on education rates and local community development.

Joy Where We Least Expect It

My past few blog entries have been less than uplifting. The experiences I described were difficult things to be even the smallest part of and difficult things to put into appropriate words. While I want to describe and examine the circumstances and consequences of underdevelopment in Atiak, I do not want to forget the other side of life. I spend a lot of time trying to battle against the stereotypes of the African continent (disease, poverty, death, uncivilized war, etc.) and I do not want this blog to contribute further to the stereotypes without also covering the good. After all, it is the good rather than the bad that brought me back to this region of the world.

I work with incredible people who have literally lived through hell on earth. Experiencing war and tragedy in the way that the people of Atiak have can break people – turn them cold or numb. The same can be said of other tragedies that happen both in Atiak and everywhere else in the world – losing a child, contracting HIV, being abused or killed based on race or ethnicity, being too poor to eat, the list goes on. Yet, while the people I have met here have every reason to resent the circumstances of their history, to be angry or vengeful, they are anything but. There is a resiliency among the people of Atiak that both humbles me and restores my faith in humanity when I’m being cynical. I see the resiliency and the vibrance each day.

I have mentioned in a previous post that I share a room with a woman my age named Nighty. The Lord’s Resistance Army abducted her when she was about 12 years old and kept her for at least a year as a rebel leader’s wife. Since Nighty’s escape she has mothered four children and been left by her husband who decided he didn’t want the responsibility of fatherhood. If you met Nighty on the streets of the US you would never guess that she has been through such hardship. She fills so many roles as a young woman – mother, daughter, sister, cook, seamstress, translator, friend. One role she has never caved to is the role of the victim. Nighty works hard. She sends money home for her children’s school fees. We stay up late at night and laugh about stupid things the way I do with my friends everywhere else in the world. She patiently attempts to teach me Acholi (I’m truly terrible at this language!). She hugs my when I’m homesick or just because. We dance in the kitchen when Pasca, the other cook, breaks out in Acholi song. We run errands in town and occasionally drink too much wine with the other members of staff once everyone’s children have gone to sleep. Nighty appears to have moved past her personal history to such an extent that it actually shocks me. Sure, she worries about things – when she’ll see her other children next (they live with Nighty’s mother in a different village a few hours from here)  and money – but Nighty is a beautiful and grateful individual when life has given her every reason not to be.

Pasca lives in the center of town about 2 miles from Earth Birth and rides her bike to work every morning. She is a widowed mother of two children . Her husband died due to issues related to being HIV+ after first passing the virus to Pasca. She also lived in Atiak through the worst of the war. Much like Nighty, you would never guess that those are the circumstances of Pasca’s past and present. She speaks maybe 30 words of English, which also happens to be the level of my vocabulary in Acholi, and yet we have been able to become good friends while disregarding a language barrier. She sings traditional Acholi songs and makes me dance around the kitchen with her. She showed me her children’s report cards with a proud smile on her face. Actually, Pasca always seems to be smiling. This weekend Pasca invited Nighty, Christine (another amazing woman who used to work for Earth Birth, but has since moved back to Gulu), and me to her home in the center of town and prepared lunch for us. She slaughtered one of her chickens for us, prepared rice and beans, passion fruit juice, showed us her garden, her hut, her family photos, and welcomed all of us with the same level of happiness that she does each day at work. Pasca is part of a local cooperative of women who make beads and jewelry and we’re working as partners to expand the project and sell the product. When the cooking is done for the afternoon, we’ll often sit outside the kitchen and make beads from recycled paper with Nighty and Esther, one of the local birth attendants who is currently a student at Earth Birth. It’s a simple activity, but it’s one of my favorite things to do here thanks to the company of these women and the friendships I’ve been able to form with them.

When it comes to spirit, Nighty and Pasca are not out of the ordinary. I have befriended several of the local birth attendants who have the same liveliness seeping from their pours. They share with me stories of their children, they sing and dance, teach me about their culture and their traditions, and they do so with pride. The history of this area, the high mortality rates, the poverty – these circumstances all attempt to turn these people into statistics, into people to pity. In reality, these are people with spirit and with hope. Be inspired by their resiliency before pitying the circumstances in which they live. I believe it will make working together to change those circumstances far easier.

Bad Things Come in Threes

There’s a saying that bad things come in three and the past 2 weeks have taken this saying to heart. Since the infant death I wrote about earlier this month the midwives at Earth Birth have lost another baby and had to resuscitate another – whether or not that child will make it has yet to be determined, but if he does he will almost certainly have suffered from brain damage.

The second death happened earlier this week. An 18-year-old girl, pregnant with her first child, suffered through more than 36 hours of painful labor. She was so tiny in stature that it took her five hours to deliver the child. I left at this point when it became clear that the heart tones of the baby were dangerously low. When I woke up the next morning Rachel informed me that the baby boy had never breathed on his own. She and Olivia spent over two hours trying to resuscitate the baby, but nothing worked. The baby was not going to breathe on his own. The mother, referred to affectionately as Little Mama, is grief stricken and staying at the clinic for a few more days to handle the grief with more support than she will get from her husband at home – who, by the way, has been nowhere to be seen throughout the entire ordeal. While I’m glad I was spared the sight of the resuscitation, I still felt very much liked I had been punched in the stomach when Rachel told me what had happened. I went to bed fully expecting that the baby’s heart tones would regulate once the difficult labor was over – which I have seen happen in previous births here. I went to bed expecting to go see Little Mama in the clinic the next day, breastfeeding a baby.

Yesterday was the third, and hopefully the last, bad birth experience here. Another first time mother had been in labor for hours. I finished up whatever I had been working on in the kitchen and went down to the clinic to check the progress. When I pulled back the curtain to the delivery room I hadn’t known that the baby had already been born and that, like Little Mama’s baby, could not breathe on his own. A small, silent baby boy lay on his mother’s chest while Olivia went through the resuscitation process. It took me a minute to fully process what was happening, but left as soon as I figured it out. Olivia came to check on me later and told me that the baby had started breathing on his own, but it was touch and go from here. He had been deprived of oxygen for so long during delivery that if he does make it there is a distinct probability that he will have brain damage. Rachel transported the mother and baby to the hospital in Gulu yesterday afternoon, but I haven’t gotten the sense that there is much hope for him.

In the midst of all of these difficulties and losses, there has been one birth that has kept me marginally sane out here. On Saturday, a mother gave birth to her 4th baby – a girl, born breech and six weeks early. She weighs just 2kg! She was born feet first and experienced a lot of difficulty breathing in her first few hours, but she’s made such unbelievable strides as a premature baby born in a difficult setting. She needs to stay at the clinic until she puts on more weight, but she seems to be in the clear. After the past couple weeks here, we need success stories like this.

A 1993 Land Cruiser is the Only Way Out

In a community as remote as Atiak, the few resources accessible here are often a laboring woman’s only lifeline. I have ridden along on labor calls that have taken an hour or more down dirt roads, around potholes that could swallow a person whole, and through ditches that have taken down massive trucks with one poorly planned maneuver on the part of the driver.

Earth Birth is fortunate enough to have a car (the only one in the community) that operates as an ambulance, which enables the organization to reach marginalized women and families who would otherwise be left to decide between walking to the clinic or delivering alone. The car, a 1993 Land Cruiser complete with a Boyz II Men cassette tape, may actually be some sort of time travel machine back to the end of the 20th Century, but here in rural Atiak it is a modern luxury for laboring women and has already saved numerous lives. In fact, the vehicle may have saved a life just this morning. We received a call that a woman was in labor in one of the surrounding villages. When our driver and Nighty arrived, the woman was hemorrhaging on the roadside. The baby had not been delivered, but the placenta had detached and was blocking the cervix. Our driver and Nighty were able to rush her to the clinic where the midwives determined that there were no fetal heart tones and that the woman needed to be transferred to the nearest hospital – 2 hours away in Gulu – in order to stop the excessive bleeding and deliver the baby in a way that could at least save the mother’s life. A midwife helped the woman into the Land Cruiser and will work towards managing the bleeding while on the drive to the hospital. Hemorrhaging is one of the leading preventable causes of maternal mortality in the developing world and without the Earth Birth vehicle it is likely that a young woman would have contributed to that statistic this morning. Now there is at least hope. Hopefully, I’ll be ale to update the blog with her condition later this evening.

The car, while necessary, is expensive. Between fuel and maintenance it costs Earth Birth approximately $10,000 per year to upkeep the vehicle. The co-founders are currently looking for a funder and I promised to get the word out through this blog. If you or anyone you know can contribute towards this essential resource please send Rachel an email at rachel@earth-birth.com or visit the website:

http://www.earth-birth.com/get-involved/give

Thanks again to all of you for your emotional support this past week!

A Difficult Personal Narrative (warning: somewhat disturbing)

Last night around sundown a woman in labor arrived at the clinic. She had been in for a prenatal appointment two days prior and everything had seemed fine. Heartbeat was strong. The baby was moving. It was the 23-year-old woman’s 3rd pregnancy and all signs pointed to a healthy, uncomplicated labor. All that considered, I was surprised when Rachel pulled me aside and said she couldn’t find the heartbeat.

After several hours in labor progress was minimal. Rachel and the TBAs on duty still could not locate a heartbeat and the young woman was struggling to push. I couldn’t blame her. I was sitting in the delivery room, helping to hold the woman up in a squatting position to make pushing easier and I just kept thinking to myself that I couldn’t believe this woman was knowingly and calmly going through hell to deliver what she knew would be a dead baby.

A few hours into this whole ordeal Rachel would still periodically check for a fetal heartbeat. At one point, it sounded like she had found one. Rachel was doing everything in her power to help the mother get the baby out, but he was presenting shoulder first – impossible to deliver without a c-section. Earth Birth is fortunate enough to have a car that can operate as an ambulance, so Rachel had our driver and one of the TBAs take the woman to the hospital (two hours away) for the procedure and continued with a new sense of hope for mama and baby.

Not ten minutes later the car pulled back up to the clinic. As the woman exited the car with the help of the midwives I saw her dress covered in blood and balled up, clearly carrying the baby. The horrible roads and maybe the stress of such a traumatic labor had forced the baby out. His skull bones had not developed, but he had probably been alive until the point at which heavy labor began, explaining the clear heartbeat at the prenatal appointment earlier this week. Once labor began the contracting uterus likely crushed the baby’s head. When they unwrapped the baby I didn’t even know what I was looking at, but I did know that I felt like passing out.

A few moments later the woman birthed the placenta – it was about 1/4 of the size it should have been. Much like the birth last week with respiratory distress, but far more extreme, this woman was likely unable to eat as much as any person needs in order to properly sustain themselves, let alone a pregnant woman. The small placenta and the resulting lack of nutrients caused issues in fetal development. Tests weren’t run, but it’s too easy for me to assume that the baby may have developed skull bones if the mother could have eaten properly.

It was a difficult experience for me to go through – the first time I had seen anything like it and in a part of the world far removed from my support systems in the US and London. I’m sad, of course, and I hope I never see anything like that again, but I’m also angry and struggling to process the entire ordeal. It’s easy to blame the circumstances – a poor woman in a poor community without adequate food resources gives birth to a dead child with a crushed head? I mean, really, how do I not blame the circumstances? It was also so hard to watch the mother. Her husband was nowhere in sight – he had sent his younger brother instead. Throughout the entire delivery this woman, my age, was so strong. We walked the room together to speed up labor, she pushed without complaint, she was so strong throughout the entire thing. It was when we unwrapped the baby that I almost had to leave, just to avoid bearing witness to the mother’s reaction. My heart completely melted for her and there is nothing anyone can do to make this easy for her.

I’m trying to turn the experience into a way to motivate me. Some moments it works and other moments I can’t think, but it’s been less than 24 hours so I suppose I need to give it time, experience some good, happy births and move forward.

Thanks for reading such a personal and unfortunate post and thanks to those of you who were able to support me via the crappy internet connection yesterday and today.