Tuesday, November 12, 2013

The [Uganda] Motorcycle Diaries

On the road. The problem…the solution?

In a packed room of students and professors, Dr. Charles Muchunguzi spoke on his work with motorcycle ambulances in Uganda. The project, funded by UNICEF, aimed to decrease high maternal and child mortality by facilitating access to local health centers. Motorcycle ambulances would be a sustainable and efficient solution to target transportation issues in hilly, poorly kept roads. They would transport pregnant women to the closest health care center, mostly for the actual birth, as well as others in case of medical emergency.

Traditional ambulance maintenance costs, breakdowns and incompatibility with poor road networks had led to misuse or nonuse in poor communities. In addition, the motorcycle intervention had proved very successful in other countries like India, as well as in eastern Uganda.

Despite promising prospects on paper, development expansion is not simple. In the two districts of western Uganda (Mbarara and Bushenyi), the pilot project largely failed: the pregnant women did not use the ambulance. In the better-off Mbarara district, only two women used it during a nine month period. In Bushenyi, the communities showed mixed feelings about the ambulances; yet, without access to alternative transportation, they did use it more.

Riding in the “ambulance” felt anything but safe or reassuring to the women. If they had used it, they would have lain in the back on a thin mattress across a hard surface. The carriage of the ambulance would shuffle from side to side across the turns, giving the sense that they would soon topple over. Indeed, the very community health workerswho were asked to promote the intervention had experienced an accident in the vehicle.

The women, instead, chose to walk, ride a boda boda  (normal motorcycle) or give birth at home just as they had done before the project.

Encounter with the ubiquitous roadblocks (not just metaphorically)

Dr. Muchunguzi´s presentation gave the viewers a touching, if brief, encounter with doing interventions on the ground. I cannot say how refreshing it was to hear such a thoughtful, critical and honest presentation. It has not been often that I have met someone so willing to expose the difficulties with a project that meant so much to them. I felt truly honored to hear him speak.

For me, his presentation had meaning far beyond the individual project. It showed how projects set up by well-meaning organizations often do not work: he mentioned latrines (built by the work bank but not used because of community taboos against mixing feces of the young and the old) and bed nets (used for wedding dresses and fishing nets)

Many of my friends and colleagues who have done international work have come back with the same sense of frustration: many interventions are done for communities with little real impact in the long term.

Witnessing this frustration over and over can burn out the very people who wish to affect change.  How could such an elegant idea as a motorcycle ambulance, which worked in so many other places, fail?

Rather than being frustrated, Dr.Muchunguzi provided insight into how modifications might be made in order to make the solution work. UNICEF is currently working on redesigning the motorcycle ambulance; other ideas were provided by the community focus groups post-intervention, such as making four wheel ambulances (“does that then become a car?”) or subsidizing local cars. Also, communities that had already organized and funded the infrastructure for the project (a shed to put the motorcycle in, compensation for the driver), had much higher acceptability.


Motorcycles can be an elegant solution to an important problem, but only if people will use them. Asking them if they want what you have is not good enough. As Dr. Muchungunzi said, people are not stupid; they know what the developer wants and, with money riding in the balance, they will give it to you. Even flimsy motorcycle ambulances for free are better than nothing. Just as we might take a free pen because it is there, it does not mean we will continue to write with it if the ink is constantly drying up. Community buy-in to the purpose of the intervention and real contribution to the design of projects cannot be seen as ancillary to their success.

In the villages where desire for motorcycle ambulances existed prior to the project, the intervention worked much better. Community buy-in can be sought through active consultation in focus groups throughout a project, as well as incorporating appropriate and respectful care. For example, It is possible to incorporate cultural practices like vertical birth in clinical settings.

Moreover, a single intervention cannot stand alone. It is only a solution if the health care encountered in the health post is of high quality and will really improve maternal mortality. It is only a solution if the roads are good enough for the motorcycle ambulances to get to people’s houses.

His talk, to me, highlighted the importance of quality in planning interventions, quality in community buy-in and engagement in the project and quality in the services that are provided to people. While asking pregnant women to lie on thin, hard mattresses in precarious vehicles might be deemed cost efficient and sustainable, such a service may fail to respect their human dignity.. Rather than accept this loss of dignity, many continueto give birth in solitude or solidarity.

We would like to thank Dr. Muchunguzi for his presentation to the UVA CGH and IMS, as well as Dr. Kabachenga for his support of the motorcycle ambulance intervention research.

Monday, October 21, 2013

Opening Reception of "GUZIKA (to heal):The Art of Rwandan Children" Exhibit

Everyone had gathered around to watch the pair of young women dancers. As they hooked and whirled like spinning tops on the art gallery-turned-dancefloor, their bright geometric dresses seemed to take on a life on their own. Periodically wiping sweat from their brows, several drummers seemed determined to compete with the dancers’ liveliness. The young women began dragging reluctant audience members onto the floor with them, and soon several dozen children and adults were bouncing to the drumbeat.
The band, CHIHAMBA, was there to kick off the opening of GUZIKA (to heal):The Art of Rwandan Children Exhibit at the McGuffey Art Center in downtown Charlottesville. It was one several exhibits of artwork made by Rwandan children and art workshops for Charlottesville children hosted by the Rwanda Arts Collaborative throughout the month of October 2013.
UNICEF estimates that some 100,000 orphans live in youth-headed households in Rwanda. Recognizing the need to support the mental and emotional health of vulnerable children in Rwanda and the general prosperity of children everywhere, including Charlottesville, the Rwanda Arts Collaborative was created earlier this year. Renee Balfour, director and founder of Art With A Mission Charlottesville and Emmanual Nkurazanga, director of Art with a Mission Rwanda, worked together this year to facilitate art workshops for over 125 Rwandan children. The children’s artwork is on display in the McGuffey Art Center, Nau Hall, and OpenGrounds. 

The artwork will be available for sale, with all proceeds returning to the youth-headed households that produced them.
As I walked around the exhibit after the crowds were gone, I found myself lingering at almost every painting. It was hard not to be taken in by the vibrant colors and thick brush strokes that were common denominator of all the artwork on display. There was a rawness to each picture that seemed to be best captured by a quote from a Rwandan child that had been framed alongside one of the paintings: “Art raises me.”
I think that as promoters of public health, it can be hard at times to remember that we are first and foremost advocates of complete well-being. When we say that we support the flourishing of children, we are saying that we want much more for them than simply safe housing, adequate nutrition and access to clean water. We want to provide children with a means for narrating the spirit of their lives. By allowing young people to creatively reinterpret their day-to-day experience, we can foster a greater understanding of what it means to be an active member of a community. When we talk about art raising our hearts and minds, we are really saying that art broadens our perspective. We can nourish children's imaginations--and our own--when we offer them an opportunity to express themselves.

Tuesday, October 8, 2013

Report and Reflection: Dean’s Talk- Patrick Kyamanywa (Oct. 2nd, 2013)

Dean Patrick Kyamanywa strode to the front of the room, sat down on a stool, and peered out at his audience through his spectacles. Forty of us had collected at Open Grounds, a study and meeting space in the Corner building at the University of Virginia. The décor, heavy on granite, metal, and flat screens, was contemporary, perhaps even futurist. Images from Rwanda, land of a thousand hills, were projected all over the room. I felt like I was at a TED talk.

Dean Patrick is the Dean of Medicine at the National University of Rwanda. Over the past few years, there has been significant cross-talk between UVA and the National University of Rwanda. Several of my colleagues in the School of Medicine have had the opportunity to travel to Rwanda and learn about challenges in surgery and medical education outside America. All of them have come back raving about their time in Rwanda and most of them began seeking ways to return almost as soon as they came back!

Given the sci-fi feel of Open Grounds, I had expected a cool powerpoint presentation. Instead, Dean Patrick dazzled us all by speaking extemporaneously, only consulting his notes occasionally to ensure accuracy in his figures and quotations. His talk touched on several important issues. Most notably, he discussed the need for countries providing aid (whom he dubbed “The global North”) to seek input from the countries receiving aid (the “The global South”) regarding issues that need to be addressed in their country instead of being overtly prescriptive. Dean Patrick discussed several other aspects of international partnerships in the world of global health, noting how much Northern and Southern partners had to offer each other. He also made a compelling case for horizontal transfers of information: they allow for organizational independence in joint ventures as well as an efficient horizontal transfer of insight, and technology between southern partners.

I believe one marker of good speakers is that they leave you with more questions than answers. Dean Patrick did so by explicitly stating several questions for us to mull over during the discussion. One of his questions set me thinking: students who visit Rwanda gain immensely from the experience, but what do they give back?  

Several of the students in the audience had been recipients of scholarships that enabled us to travel abroad for research or mission trips. Personally, I had received three thousand dollars to conduct a small study in India. While there, I also had the opportunity to meet hundreds of my countrymen through weekly community health screenings. No book, no documentary, no public health class could have communicated to me the severity of health disparities in rural India or the enormity of the task before us like that summer’s work in India .

But was that really the best use of that money? What had I given back to India?

One of my most enduring memories from India is of an emaciated young boy who came up to me during a community health screening. He was thirteen years old, but looked like he was nine; his mother informed me that he had a weak heart. Slightly incredulous, I placed my shiny new stethoscope on his chest . “Lub-swoosh-dup….Lub-swoosh-dup….Lub-swoosh-dup...” went his ticker. There was no mistaking it: he had severe mitral regurgitation. I felt quite clever about my physical exam skills, but became quickly disenchanted when I realized that all I had done was label the child as a heart patient. After all, a valve replacement surgery costs at least half of his family’s earnings for an entire year! In all likelihood, the family would have to look on helplessly as his heart struggled with its leaky valve.

What good was my label to him?

Three thousand dollars could have paid for the surgeries of at least six children like him. Three thousand dollars may even have bought an ultrasound machine that cardiologists could use to monitor his condition. Three thousand dollars would easily pay for vaccination, vitamin supplementation, and deworming programs for him and all his classmates.

I blurted out a brief description of my time in India and asked the following question: “Transformative as the trip was for me, would the money have been better spent in more direct ways?”

Dean Patrick thought for a few seconds as he mulled over my question. To my relief, he smiled and then offered several arguments for why it was important to spend those three thousand dollars to provide me that experience. He argued that I had returned to UVA with a more sophisticated understanding of global health and with a fortified commitment to working on global health issues. Thus, he felt it was important to invest in a future generation of intellectuals from different fields who would grow to care about issues in the developing world based on their experiences during international research or mission trips. Hearing Dean Patrick’s answer made me feel grateful for the opportunities I had been given and reinforced what what is expected of me in the future. I am sure the other CGH scholars in the room felt the same way. I think everyone leaving the talk did so with their brain buzzing a touch more than usual.

Personally, I left thinking about how I would make those three thousand dollars count.

If you would also like to experience the challenges, joys, disappointments, and triumphs of research or service projects relevant to global health, do consider applying for a Center for Global Health scholarship. You can find out more at http://globalhealth.virginia.edu/. Information for the 2014 CGH Scholars Application Process will be available in the fall 2013.   In the meantime, please contact the Center with questions at 434.243.6383 or ctrglobalhealth@virginia.edu.