The pollution here is suffocating—the air pregnant with thick black fumes. It hurts to breathe and there is no relief in the rush hour traffic. I never remember there being so many people, so many cars, such bad smog in Kampala and I am saddened by the fact that there are no emission laws to counter the inevitable environmental consequences of such pollution. The air pollution is not all that is concerning—I heard a statistic today regarding population growth in Uganda. According to a public health expert, the average birth rate has increased to 6.9 children/woman. No wonder this city seems like it is bursting at the seams. This is slightly frightening—especially when one considers the fact that this type of population growth and consequent environmental destruction is happening in cities all over the world. I have never been a huge environmental activist but that might be changing. The budding primary care physician in me shudders at the thought of the inevitably increasing rates of asthma in children in cities like Kampala and this is something that I need to do more research on…..
In my second to last night in Kampala, I think it is important to reflect on how much this city has changed since I first came here in 1995. The growth and development of the downtown region has exploded, with new high-rise business and shopping centers sprouting up everywhere—they are like steel flowers rising from an earthy red human layer of slums that emerge from sewage and garbage filled streets. In the shadow of economic growth, most of the millions of people in Kampala live brutally impoverished lives. That said, there seems to be a burgeoning middle class of Ugandans who are feeding the economy like never before. I spent the afternoon at one of the two new malls in town—enjoying a tuna melt and cappuccino at a very Western coffee shop, sharing the space with young Ugandan businessmen and women. This would not have been the case 15 years ago—at least from what I remember. What I do remember about Kampala from that time were all of the coffin shops that lined the roads–coffin shops that filled the needs of millions who were dying from AIDS. It was a much more sober city, cautious with a more uncertain future. Today, there is a chaotic, palpable energy in the city that reverberates even in the poorest of slums. Change is happening and it is occurring in spite of all of the things that stand to threaten it—government corruption, poverty, disease, lack of infrastructure, etc. But what will happen to the millions who are left behind? I feel intellectually ill equipped to even ask the question….
Although the streets of Kampala are no longer lined with coffin shops (prevalence of HIV dropped from 15% in 1991 to 5% in 2001—a decline in prevalence that is unique worldwide and one that I will probably discuss in future posts), the threat of HIV/AIDS on the growth of the country is still real–as evidenced by the omnipresent aggressive public health safe sex messages. In 1995, the major public health message was “zero grazing” and condom use. It is the same today in terms of the concept of “zero grazing”. On the radio and billboards, commercials and advertisements urge Ugandans to have more fun by “trying out many positions with one woman than one position with many women”. However, from what I can tell, the use of condoms as a prevention strategy seems to have been de-emphasized. I think, but am not sure, that this is partly cultural (cultural beliefs about condom use) and partly a result of many years (Bush years) of damaging restrictions on HIV prevention strategies (i.e. when U.S. government funding for HIV prevention was technically limited to abstinence-only education). This too is something I need to look into more….
Tonight on television, I heard my first news/talk show on the issue of homosexuality in Uganda. For those of you reading this who are unfamiliar with this issue—there was a recent, terrifying bill (the Anti-Homosexuality Bill of 2009) that imposes the death sentence (by hanging) for homosexuality (which can be link to American Evangelicals—although I will not comment more because I do not know enough to do so). The United States and other donor countries have demanded that Uganda drop the bill because it is an outrageous (my word) violation of human rights, but Uganda has refused to back down. According to a New York Times article, [insert link], Uganda’s minister of ethics and integrity recently said, “homosexuals can forget about human rights”. Although this issue has made headlines because of the recent legal criminalization of homosexuality, anti-gay sentiment has been strong for many years and I was aware of it even as a teenage visitor. I am sure I will have more to say about this issue because it enrages me beyond belief, but I just wanted to mention it now because it finally came up after almost two weeks in country. This type of bigotry has cultural and social roots in Uganda, but it has grown into law as a result of Evangelical religious teachings that are manipulative, hateful, intolerant, and dangerous (and primarily American….). As much as this enrages me, it also saddens me very much. Ugandans, in general, are some of the kindest people I have ever met and watching friends walk down the street literally hand in hand (especially men), it seems unthinkable to me that this type of violent bigotry is common. From a public health/medical perspective, the legal criminalization of homosexuality probably has and definitely will have a profound impact on prevention and treatment of HIV/AIDS in MSM.
These first two weeks in Uganda have reinforced the necessity of understanding the health needs of the country in the context of its history, traditional and contemporary culture and social structure, politics, economic development, religion, etc…I have come to realize that the first part of this rotation at the IDI was not really about learning how to provide clinical care to persons with HIV/AIDS…..It was about rediscovering the country at this specific point in its history and my life history….It was about seeing Uganda through new eyes and applying what I have learned in the past 15 years about myself and the world to readdress my old questions and ask new ones. It was about seeing and experiencing this world with Jake.
Globe Napper 