The forgotten elderly

In many societies the elderly often get "forgotten' or ignored, this can be true in developing countries in Africa also. My friend Reverend Samuel Mahulu who I have been working closely with at the HIV clinic pointed this out to me Many organizations are getting funding for HIV, TB and malaria and children and orphans get lots of attention- as they need to, but when it comes to the elderly, they are often neglected, by their own society and the world as a whole.In Uganda there is no social security system, and most people have struggled just to make ends meet so they do not have any money saved for old age. Many of the elderly's grown children have left the village to find work in the city and are struggling themselves with caring for their own families, there is often no money left over to send home to the aging parents. Or worse, the children have died from HIV or some other disease and have abandoned the grandchildren in the village with the grandparents. As these grandparents age, there is often no one to look after their needs. As they age some of these people are really having difficulty just maintaining their daily basic needs such as food and water. As their physical health fails they are no longer able to go to the well to get water, or gather firewood ,or plant a garden. These are basic survival needs in rural villages in Africa,
They may have no one to help them or to visit them . They are unable to maintain their physical homes and their health.Reverend Muhulu and his church have started an wonderful organization in their church and want to expand the program to the whole community, then all of Uganda and even beyond.
It is called the African Development Association for the Elderly, their goal is to link youth and neighbors to the elderly that are unable to care for themselves. They have already begun visits to the elderly within their community and are assisting 30 people that are unable to provide for themselves. The organization has linked some generous neighbors with some of the elderly who will provide meals and firewood and water. They also have built some small dwellings for elderly who have had no where to live. They want to be able to build the organization to buy rain water catchment tanks, repair homes, (many homes have leaking roofs, holes in walls, no bedding and are infested with rats ,mice and bedbugs). They want to provide basic health care for these people, and transport to the clinic as needed. There goals are to improve the living conditions, health and sociailization of these people. These goals are lofty for a poor church organization, whose members may only be able to donate 20 cents a month towards the project, but they are committed, organized and caring towards these elders, where governments and even the elders own families lack compassion. I was very impressed with these folks and the love they showed towards these old people who are truly suffering. It is another area in which many people are having a difficult time.

Some more random entries from my journal

July 8th-Outreach clinic in Makindye suburb. The outreach team goes to several different suburbs once a month and distributes ARV medications to patients near that area. Out reach is done so that patients who are healthy and adhering to their ARV treatment do not have to travel into the main clinic to pick up their medications. Patients are only given a 2 or 3 month supply of medications to monitor their adherence to the medicine regimen and also assess patients for side effects. Patients may have to travel and then wait several hours to pick up their medications at the main clinic. Outreach was started in an effort to provide shorter wait times and less travel times for those patients who are staying healthy and adhering to their medicine regimen. It is a great service to the patients. A doctor, nurse, counselor and volunteer travel to each outpatient clinic. (7.5 hrs)

July 11th- Worked in TB tent with Dora. TB tent provides treatment for all patients with TB at Mengo hospital, even the patients that do not have HIV. Many patients who do have TB also have HIV, TB is an opportunistic infection of those with HIV. The TB treatment is an 8 month course of medication. Patients must come in each month to pick up their meds, adherence to themedication regimen is monitored. If patients are not responding to the initial treatment after 2 months the medications are changed. Response to the meds is monitored by a sputum test and/ or a chest x-ray. The clinic has volunteers in the community (usually another HIV patient from the clinic) who check in with the new TB patients and help them to make sure they are taking their medications. (5 hrs)

July 16th – Attended children’s support group for HIV+ children and their caregivers. Approximately 60 children attended. This group gives caregivers a chance to get together to discuss issues and problems they may be facing caring for an HIV+ child. The children separate from the adults and it gives the children an opportunity to play, laugh, sing and dance. The adolescents break off from the younger children and meet with counselors and share about difficulties they me be facing. Mengo nursing staff and counselors are there to offer support. (4 hrs)
July 13th - Worked at PMTCT prevention of mother to child transmission clinic. This clinic provides prenatal HIV testing of all pregnant women All of the women are required to attend an education class on HIV prior to testing. Each woman coming in for prenatal care will be tested for HIV, if a woman tests positive she is then followed by the PMTCT clinic. PMTCT will continue to educate the woman and place her and the infant on ARV’s during antenatal labor and delivery and if the woman is breastfeeding. When the woman starts her ARV’s will depend on the CD4 count. The clinic will continue to follow up and test the infant every 3 months for 1 and ½ years to monitor if the child converts to a positive HIV status. Infants may initially test positive due to the mothers antibodies that are passed through the placenta, but the child may end up being negative, which is why they are monitored for 1 and ½ years. Infants may also acquire the virus through breastfeeding, so the mother and infant may both be taking ARV’s when she is breastfeeding. It is recommended that the women only breastfeed for the first 6 months and then wean the child quickly. (7.5 hrs)

Some fun photos from Uganda

Diary from experiences at Mengo and Malaika

July 20th- Occupational Health clinic- This clinic is an outpatient clinic that cares for and provides schooling for mentally challenged children in Uganda. There are approximately 40 children that come daily for classes. The children learn basic education such as alphabet, counting , days of the week and crafts. They also learn practical skills such as cooking, cleaning, washing clothes and gardening. These children are often severely neglected in Uganda and there is little political , financial or family support for them .This project is funded by an organization from the UK. (7 hrs)

July 25th – Malaika’s Babies home- Worked in a UK funded orphanage that cares for 25 babies from the ages of 1 day- 3 yrs. It is funded and partially staffed by the childifoundation from the UK. The orphanage is very well staffed, with 4 babies to one Ugandan nanny and they also have 2 full-time nurses and 8 social workers. Many of the children have been abandoned by their mothers, one baby had been thrown down a pit latrine, and many left in churches, on the street or in the hospital where they were born. This is usually because of financial reasons or because the mother is HIV+. Some of the children are quite sick and have HIV, TB or malaria when they arrive. Malaika provides care for these children and attempts to find homes for them. The social workers work hard on finding adoptive families that are suitable and also search for a family member, such as an aunt or grandmother that would be willing to take the child. Of a child is adopted out, the social workers continue to follow the child to ensure the child and family are assimilating well and that the family is able to manage the child, especially if the child has medical problems such as HIV.- Assisted the nurse at the orphanage to care for 4 of the children that required Dr’s visits. The orphanage has a nurse that is on shift each day, and if a child is sick the child is quarantined to the nurses room in order to provide better care and to prevent infection of the other children. 2 of the children were going for routine follow up on ARV treatment and 1 had a respiratory infection and another diarrhea. The clinic can provide diagnosis, and the nurse can provide treatment such as IV’s and nasogastric tubes if needed.( 7 hrs)

July 26th- Malaika’s babies home – Went with a social worker to do a home visit on a child that was placed with the grandmother. The mother had abandoned the child at the hospital and refused to see the baby after Malaika’s home tried to contact her. The mother was HIV+ and had not told her husband she was positive, the baby was also positive. Malaika’s attempted to find a family member that would be willing to take the baby. The grandmother said she would provide care for the child, even though she was very poor and was already caring for 3 other abandoned children. Malaika’s went to the homesite to assess conditions, and they were very poor… The family lives completely off the vegetables they can grow and the few goats and chickens they have. The homesite was very dirty, cooking was done over wood fire, water is gathered from the well, the house has no doors or windows, and the people sleep on straw on the floor… this is actually a common site in the villages. Yet the grandmother was willing to take in another mouth and provide love to the child. Malaika’s worked with the grandmother on cleaning up the homesite and educating about the importance of washing dishes, food, clothes and children. They also are giving her education about nutrition and teaching her how to provide food with the limited resources they have. The other problem they face is keeping this child on ARV’s. The grandmother has been educated on the importance of adherence. She brings the baby into a nearby clinic for monthly check-ups and to get the medications for the child. Malaika’s social workers check on this grandmother every one or two weeks to ensure that she can continue to provide care for this baby, so far the grandmother has been doing well with the extreme lack of resources she has and the child is healthy, loved and happy. The grandmother is still quite upset with her daughter who refuses to assist financially or any other way with the baby. (7 hrs)

July 27th- Malaika’s Babies home- Care and socialization with the children, then assisted the nurse with taking 5 of the children to the clinic. Two children very sick, one had to have an nasogastric tube placed because he was not eating-he has parasites/worms. Another had a temp of 105 – and not eating- This ones father brought her to Malaika’s and said the mother had left him with the baby one month ago, but he did not know how to care for it. All attempts will be made to educate the father in care of the child if he is willing to care for it. (7 hrs)

July 28th- Meeting with the US Ambassador for Uganda, and the USAID missions director. They wanted to have a meeting with us to understand our work with the GHFP. We as a group and our supervisors gave a brief presentation about our experiences here in Uganda thus far. (3 hrs)

Mengo Hospital

Hi all as most of you know I have been working at Mengo Hospital HIV clinic in Kampala, Uganda for the summer. The more time I spend her the more I am impressed with the work that Mengo is doing in their work with addressing the HIV epidemic within their country. Mengo tests and treats patient for HIV, but their job is not so simple as that. 1st to find patients, they test patients (with the patients consent) on all of the wards of the hospital for HIV- this is where they find many of they patients. Once a patient is confirmed as having positive HIV test they are given counseling and education about HIV and referrals to the HIV clinic, or a clinic that can assist them near their homes. Once a patient is confirmed HIV + the staff makes sure to follow up with the patient and have them come to the clinic. If patients have a high CD4 count, (the white blood cells that fight opportunistic diseases) they are monitored and placed on a medication called Septran ( an antibiotic that fights the opportunistic infection). HIV attacks a person's immune system so this is very important in maintaining the health of an HIV+ person. Patients are monitored until their CD4 count drops below 350 for women and 250 for men. This actually is quite low, in the U. S. treatment would start immediately if a person was detected to have HIV. This is because of the expense of ARV treatment (it is a very expensive treatment) and due to all kinds of drug patents etc... it remains expensive,even for those most needing it.

Mengo monitors these patients every month for complications and also monitors the CD4 count. Once the CD4 count drops to the low enough level they start the ARV treatment. They give patients a lot of education and counseling before they start the ARV treatment, and continue to monitor and educate once treatment has been started. Patients are to come in initially every month and monitored for their adherence to taking the ARV's, then every 2 months... If a patient stops taking their meds and then restarts they can become resistant to the medication, so this monitoring of adherence is very important.

Patients are also monitored for side effects, and opportunistic infections, nutrition and willingness to disclose their status to friends and family. If people disclose their status they are much more likely to maintain adherence to their drug regimen.

Mengo also tests pregnant women and makes sure the women will take ARV treatment if they are HIV positive (and also give the newborn ARV's) to prevent mother to child transmission of HIV. Much education is given in this area. Many children I have seen are on ARV's and are becoming healthy kids that can go to school and have a good life. Many of the children may have lost their parents and are living with older siblings or relatives or even neighbors and having HIV gives the child difficulty because of the stigma attached with having HIV. Mengo works with the caregivers in helping these children stay on their ARV's and deal with the stigma. Nutrition is also an issue with these families because it is important for HIV+ people to have good nutrition, but because of the poverty level, it is difficult for them to have enough food.

The clinic also does outreach testing, which means it goes out into the communities and tests people, so people dont have to make the trip to the clinic,which they often wont do because of stigma, money and time to travel to the clinic. Counseling is done right onsite.

They also do home based care and care for patients at home that are too sick to travel to the clinic. The doctor and a nurse and a counselor travel to the pateints home and may administer IV fluids and meds and give counseling to family and assistance as needed. A spiritual counselor will travel with the team also.

Education is given to the community in many ways also, several of the physicians travel to schools and give sexual and lifeskills training and inform the adolescents about prevention. I recently attended a workshop in which Mengo was teaching the police officers in Kampala about HIV and post exposure prophyaxis. This is a very important population to educate because they may be the first responders to a rape victim who needs PEP treatment or they themselves may need the treatment because they have been helping people in an accident that involves a lot of blood exposure.

What I have seen here at Mengo has been quite impressive, given the lack of resources. The staff is committed, caring and very knowledgable, I feel quite grateful to have this opportunity to learn from the real experts in this field.

Pictures are of HIV+ children that are recieving treatment at the support club, and HIV+ patient recieving home care, and Childrens ward at Mengo hospital

Rwanda

One of my co-workers and I had a 4 day week end and made the 8hr buss ride to Kigali, Rwanda for the week-end. On first impression Kigali is a beautiful city, - one of the most beautiful in Africa,it is clean,friendly and well organized. We decided we wanted to visit some of the memorials that were made in remembrance of the genocide that happened in 1994 between the Hutus and the Tutusis. Prior to visiting these memorials, I had not had much exposure to the genocide beyond watching "Hotel Rwanda."


We visited 2 catholic church memorial sites outside of Kigali and the Kigali memorial. I remember the movie being quite horrific, but actually visiting the memorial sites was truly sobering. Hutu's and Tutusi's used to live together, marry each other and were friends for a very long time... then in the late '50's with the help of Catholic missionaries and French, a separation of the two tribes became prevalent and people were required to Carry ID cards differentiating the two tribes. Tutsi's were generally more wealthy and more favored by the missionaries and governments. The Hutu's stirred by propaganda began small genocides on the Tutsi's in the late '50's,this continued until the largest one, which killed over 1 million of the * million people in Rwanda in 1994. People fled to the catholic churches for sanctuary, believing that they would not be killed if they were in a holy place. The Hutu's carried out brutal murders when they were killing the Tutsi's,torturing ,dismembering and raping victims before they killed them. In one small church that we visited over 1,000 people were killed inside the church and another larger church over 10,000 people were killed. Hand grenades were thrown into the church to break in and soldiers would get on the roof and shoot down into the crowd of people below. Once they broke into the church people were bludgeoned with clubs and machetes. Women were brutally raped over and over from men and with objects. Small children were slammed against brick walls. People, clubbed, but still alive were thrown down pit toilets on top of each other until they were smothered.


Our driver shared that he was a Tutsi and had escaped his village and hid in the swamp for 2 months. He had no idea what had happened to his family. He had nothing to eat for 2 months. When he learned that the killing had subsided he returned to his village, finding dead bodies covered with flies and dogs eating them everywhere. He found his mother and sister thrown into their pit latrine with their breast cut off.


The tail of genocide is horrific and the stories go on.. I could not help but cry in sadness and wonder why... ? The U.N. deserted Rwanda at this time stating that this was a tribal war and not wanting to get involved. It is estimated that it would have taken 500 troops to stop this slaughter. Paul Kegale-a Rwandan, led troops from Uganda to stop this madness, and was able to -3 months this went on. He has since become the president of Rwanda and has taken a strong stand in stopping the tribal tension. All of the ID cards were destroyed and it is now illegal to differentiate between Hutus and Tutsis- You can be thrown in jail for even suggesting this. The government is mixed and al efforts are made to integrate the two tribes for peace. On the outside Rwanda looks like it is moving forward and beyond the horrific past. Many suggest not enough greiving has been done or was allowed...


The other part of Rwanda that we saw was the 5 volcanoes Park, which is home to Dianne Fossey the woman who studied and lived with the gorillas. We went past where she was buried and her favorite silver back gorilla Digit,buried near her. It turns out we were about 500 meters from a family of gorillas but they would not let us see them, as it costs $500 USD t see them and they try to limit the numbers of people to 48 per day who see the gorilla's for 1 hr! Oh well, very interesting to be in that area. It is truly a very beautiful place and my friend Anand and I climbed to the top of a volcano instead and looked into the crate lake it had formed.

in Kampala

Hi all, Well I have arrived safely in Kampala and now have been here over 1 week. We spent a couple days orienting t the Global Health Fellowship Program in Washington D.C. before we left to Kampala (this was my first time to D.C.,so I was impressed. As I have stated before - I am thrilled for the opportunity with GHFP and am looking forward to learnig tons.

I have now worked 5 days at Mengo Clinic- in Kampala. I am truly impressed with the work they are doing. The clinic serves over 5,000 HIV positive patients and sees approximately 200 patients a day. They do counseling.testing and ARV administration and management of symptoms of people on treatment. They do an excellent job with counseling HIV positive patients and working with the patients to make sure they adhere to treatment. There is much ongoing education and support groups for the patients, so they can maintain thier treatment. Many patients still suffer from stigma, poverty and lack of support. The people who work at the clinic are outgoing, positive and very supportive of their patients and welcoming to me- a newcomer.... am sure I will learn tons from them.

In Uganda, people must wait until their CD4 count is below 250 (which is quite low) before they can go on treatment- this is because of funding... There simply is not enough funding to treat all of the HIV + patients, so they let the CD4 count drop quite low before putting patients on treatment. Much of the funding comes from Pepfar grants supplied by the U.S.

I am learning to navigate the taxi system here in Kampala... It is difficult,crowded and dirty- traffic is as bad as in India- with 6 rows of cars jammed up -trying to drive in 2 lanes of road and every one beeping their horns, yelling and running over pedestrians,with motorcycles and bicycles trying to pass between vehicles that are too close together. To find your combi (the 16 paseenger vehicle in which they pack 18-20) you must risk your life dodging between cars and trying to squeeze between combis that are backing up or moving forward-with no regards to people walking between at all. On top of trying to navigate in an area in which you dont speak Lugandan, and people are yelling "muzungu!!!"-which means white person..and trying to overcharge you for the fare..... Ahhhh welcome back to Africa- This taxi rank is much more difficult,conjested and dirty than any have been in in South Africa or Lesotho!!!

Getting ready

As most of you know, I am preparing to leave for Kampala, Uganda for the summer. I have an internship with the Global health Fellowship which is sponsored by USAID. I will be working at the Mengo Hospital in Kampala in the HIV clinic. I will be working HIV orphans and vulnerable children. These children have lost one or both parents to HIV and may be HIV positive themselves. There are 8 of us interns that are going, most are current or recently graduated MPH students from different schools in the US, with strong interests in HIV prevention and treatment. We will have a brief orientation in Washington DC and then take the lllonnnggg flight to Kampala. I will post some more once I have more to tell!