Interrupting her morning routine of tending to her family's cattle, maize, groundnuts and cowpeas, Maria Siampendi (pictured above) sits on a wooden stool in her cooking hut and talks with a visitor. A massive thatched roof protects the hut's interior from the rain, while space between the roof's bottom edge and the hut's brick walls allows for ventilation. Siampendi wears a red-orange shirt and a skirt printed in geometric patterns of yellow, green, red, orange and royal blue. She sits next to a couple of fire-blackened bricks and a pile of ash. Her dog, a brown and black short-hair with a splotch of white on his face, curls on the ground beside her. A bundle of firewood stands in the corner of the brick hut.
“Malaria has been a big problem here. From when I was young until now, I've experienced some type of malaria. In the past, it was not as easy for people to die. Nowadays, it's more deadly. I know many children have died of malaria. It really happens often. If it's not treated properly, the disease can claim a life.
Because malaria can attack the brain, [the sick] talk in an unfamiliar language. Some people say, "It's not malaria. It's witchcraft on my son or daughter." So they take them to a witch doctor for traditional medicine. And they do not take the child to the hospital. That's when many can die. Those who know take their child to the hospital.”
Associate professor, Molecular Microbiology and Immunology; principal investigator, JHMRI MIAM Project
Clive Shiff was born in Zimbabwe (then Southern Rhodesia) in 1930 and began his career working on a malaria control program as a medical entomologist in Zambia (called Northern Rhodesia at the time). By coming to Macha, Shiff says he's returned to his "old stamping grounds." There, on a Sunday morning in January, Shiff muses on the possibilities of controlling malaria across Africa.
“The sad thing about all this is that eradication failed. Eradication is a program that ends because once you have eradicated the disease you no longer have any more to do. That was the concept WHO had in the 1950s and '60s, but it didn't work. Eradication can't work on a continental basis like this because you may succeed in bringing malaria to the brink of eradication in a certain area, but the movement of people from other areas will ensure the parasite is reintroduced.
Each country needs to commit to a national malaria control strategy that can be sustained in perpetuity. You want to protect the centers of population and economic importance where you get the most bang for your buck. You want to focus there on transmission control. The distribution of drugs with proper diagnosis is the next tier. Then you can expand from there as funds become available. The key is developing a localized strategy that can be sustained by the government under their own resources. The difficulty is you have to sustain for the long term.
It has been done, and it can be done. It requires political stability, political and financial commitment and a good scientific support system.”
Obstetrician/gynecologist; Gates Scholar; and lecturer, University of Ghana Medical School and School of Public Health
While working at St. Dominic's Catholic Hospital in Ghana's rural Kwaebibrem district in 1999, Richard Adanu treated dozens of women for pelvic-floor dysfunction (PFD). The condition, which is frequently related to childbirth, can cause the uterus to protrude into the vagina and can lead to difficulty controlling urination and other problems. Adanu treated the women's symptoms, but he wanted to do more.
“The typical clinical response would be... "Let me fix the ones I see." My public health training says, "Let me go out and find out how much is there and what can we do to prevent this from happening because it doesn't have to happen."
There must be a number of women who have some residual damage but who are living out in the community and have probably been made to accept their situation as normal. [The attitude is], "It happens at childbirth. You're not leaking urine, you're not dead so you must be happy with what you are ending up with."
In the PFD study we're planning, we will go out there and find these women that nobody is really talking about and find out what we can do to make their reproductive health better. One of the most valuable things I learned in the Hopkins MPH program was the training in research methods. Before a person can begin to change the situation, one needs to go out and study it properly, come out with the right answers and then implement interventions.”
MPH student, Uganda
As part of a team from Makerere University's Institute of Public Health, Annamarie Kisalu evaluated Uganda's implementation of the Integrated Management of Childhood Illnesses (IMCI) initiative for improving children's health. She visited health centers and hospitals in 10 districts in Uganda and learned about the problems with her country's health system.
“When you're training to be a physician, the things that have your adrenaline running are the complicated cases. When you go to the rural areas, the predominant problems are uncomplicated malaria, pneumonia, diarrhea... For the most part, these can be managed by a clinical officer or a nurse. It gets to the point where some physicians are saying, "I could do it in my sleep," or "My brain's dying out here."
But unfortunately when complications come, you're not able to deal with them because the health system isn't really functioning. I once prescribed IV quinine for a child with severe malaria at a hospital, but there wasn't any available. So out of compassion, I paid for the drugs. It was 5,000 shillings (about US$3) at the time for the whole course. This is not a luxury many health workers can afford because they don't always get paid on time. Besides, you can't buy drugs for all of the patients.
Seeing some of the problems, I finally understood why a fair number of my colleagues leave Uganda or go to work in nearby private clinics where they can have some satisfaction in seeing improvements in patients they treat.
We have to make our health system work. I would like to go back and practice public health, mostly towards improving the efficiency and use of our health system.”
Manager, Century Gold Undertakers
A pearly white casket with gold-plated handles stands just a few feet from busy Queen Elizabeth Road in Ibadan, Nigeria. The coffin is a not so subtle advertisement for Century Gold Undertakers, a hundred yards or so from the main entrance to University College Hospital. Its tiny showroom houses coffin samples (classic lacquered wood, metallic brushed gold or dark blue). Outside, a worker builds a new casket set on truck tires. Preparing for the morning's funeral, six "Band Boyz" don navy blue shirts, grab their drums and trumpets, and warm up with "When the Saints Go Marching In." Manager Seun Abiodun says a proper funeral reflects a good life.
“Let me just say things are going fine. Business is good. We sell maybe three caskets per week, about 12 per month. This one [an ornate lead-lined casket] costs 100,000 naira [about US$780]. For those people who are not rich, we sell for maybe 50,000 or 30,000 naira [US$390 or $230]. Those who can't afford to buy one, we tell them, "You should use the stretcher they're using at the hospital."
It is not sad work. We are happy we are selling caskets. It's a celebration of life. We are doing the celebration of life for the old ones. If you are in old age, you just die. If they die now, [their families] come here to buy caskets. And we organize the Band Boyz for them and pallbearers to hold the casket.
Let me just say we are praying for those people who die.”
Rakai District, Uganda
Sitting beneath the banana trees outside her home, Divina Nakanyike weaves together the bright purple, pink and yellow strands for a mat she is making. As her grandchildren cavort barefoot around her, a pig roots in the dirt nearby. Nakanyike grows beans, ground nuts and green bananas called matooke. In good years, she sells some of the harvest to buy clothes. Her face creased with age and her hair thinning, she looks much older than her 60 years.
“Five of my children died, and I'm taking care of nine orphans, my grandchildren. One of my sons was a tailor, another a carpenter, and the third a trader taking matooke to Kampala. And the two girls were housewives. There was really nothing to do. They fell sick. I didn't have options. I would take them to the hospital, but eventually they died.
I can't say that we didn't have problems before; my husband died of cancer. But before HIV we didn't have any problems like now. I have these children. When they fall sick, I have no way of treating them. Feeding them has become a big problem. As they grow, they eat more. If there were no HIV, these children would be with their parents, and I would be on my own and not be burdened with them. But as you see now, they all come to me for guidance and support. My hope is that my grandchildren get a sound education before I die.
If I die before then? It is a great pain thinking about it. All I can say is when I die, I will be dead and maybe others will also come in and help. With God's guidance, I will keep my spirit up.”
Rakai District, Uganda
Farida Nakayinga has an angelic, faraway look in her eyes. She talks with a nurse and a visitor, her eyes rarely meeting theirs. Instead, she looks down at the cement floor of a Rakai Health Sciences Program mobile clinic or peers out the door onto a dirt road and green hills beyond. Nakayinga talks softly, almost inaudibly. She keeps her hair cropped short and wears a pink dress trimmed in a white floral print. In the busy clinic, nurses draw blood, chat with people and shepherd patients to see a doctor in another room. During Nakayinga's examination, the nurse asks her to stand on a scale. The nurse stoops to read the result. Nakayinga weighs 34 kilograms, about 75 pounds. She is 16 years old and HIV positive.
“I walked to this place. I live four miles away. Today, I'm not feeling as bad as before except for some abdominal pain. I used to cough a lot, but I still have abdominal pains off and on. My mother died when I was 12. My father died when I was 14. He was a fisherman. He was a jolly man. He would sit down and talk to us. I have one brother; he is younger. He went to live with my mom's sister. I still see him. I went to live with my uncle.
I'm not angry, but it makes me sad—what I have gone through.
I would like to become a health worker. I think it's a good profession.”
Coordinator, Mobile Antiretroviral Clinic
Rakai Health Sciences Program
In her small office in the Rakai Health Sciences Program headquarters in Kalisizo, Gertrude Nakigozi is organizing the day's paperwork for the mobile antiretroviral clinic. Outside, workers load canvas-topped silver and white Mitsubishi trucks with the mobile clinic's supplies and medications, including lifesaving antiretrovirals (ARVs). While the trucks are being readied, Nakigozi steals a moment to talk about her work.
“Most patients who come here perceive themselves to be HIV positive. The majority actually come in to confirm their suspicions. But still there are a few who are surprised by HIV-positive results. We let them know that being HIV positive does not mean they need ARVs. We try to educate them about CD4 counts and tell them they can always come back and receive treatment for any illness. You find a few patients who keep saying, Don't you think I'm ready for ARVs? Or they plead to have their CD4 counts retested. We resort to ARVs only when we have to.
One thing we try to do is not become too emotionally involved. You see patients suffer, and you get really touched. You try to detach your emotions from your work and do the best you can to make their conditions better. When I was in medical school, I had patients on the wards who were very poor and suffering. They didn't have money to buy medications. Their condition was hopeless. You didn't know what you could do to make their conditions better. You found yourself almost crying on their behalf.
Here, patients look at this funding for ARVs, and they have hope. If the funding is ever cut, they will have no hope.”