Rakai Community Cohort Study (RCCS)
Yesterday was the first day of our one week in-depth tour of the Rakai Health Sciences Program. Essentially, we started at the beginning of the Project by spending the morning with the Rakai Community Cohort Study (RCCS) team, which was established in 1994/1995. The Study currently enrolls all resident, consenting adults (ages 15-49) who are followed annually with surveys and biological samples for the detection of HIV, STDs, and other infections. It is an open cohort—enrolling new immigrants and new age appropriate residents at each annual survey visit. There are around 12,000 participants under surveillance on an annual basis. The RCCS has provided an important framework within which multiple studies are implemented without much added cost. Through the prospective cohort study design, the Project has conducted everything from large-scale randomized trials to studies of molecular epidemiology. The cohort has also provided a mechanism for evaluating the impact of ARVs on HIV epidemiology and risk behaviors at a population level. In other words, the RCCS is the “mother study” of the RHSP…..

Currently, the RCCS team is conducting annual census evaluations of households in the cohort. The census teams collect comprehensive family and household information that allows subsequent survey teams to appropriately target study participants. Jake and I were escorted into the field to observe census teams in both an “urban” or “town” area and in a rural area. It was pouring outside when we finally located the first team of 8 interviewers moving in a big group under the cover of umbrellas. We were taken to the first home, a structure partially hidden behind a large matoke tree, made of cement with a corrugated metal roof. We were invited inside….I have spent many hours inside homes in the rural areas of Uganda, but this was Jake’s first experience in a typical Ugandan home….It can be quite shocking. It is one thing to speed by homesteads in a car and mentally note the poverty, imagining what it is like for people to live in such conditions, but it is totally different to step through the door and into a domestic world that is so different, so unbelievable, so upsetting…..It was dark inside the home, the sound of the rain on the metal roof making it difficult to hear the interview being conducted with the head of the household, a fifty year old man who had 6 other household members, all under the age of 27. The walls were decorated with great pride with a dirty water-stained calendar from 1999 and a portrait of Museveni. I am not sure why I described the calendar as dirty—the truth is that the entire home is caked in a layer of red dirt, dust, and animal feces despite the presence of a cement floor. The head of the household was very welcoming and made room for us to sit on the two other wooden chairs in the front room. We observed awkwardly, trying not to look around us in disbelief. The reality is that the home that I am describing is actually the home of a family with greater than average resources….cement homes with cement flooring signify a great (and expensive) improvement over traditional mud thatch homes. This particular household head has participated in multiple Project research studies, as evidenced by the informed consents that he carefully pulled out of a plastic bag that he retrieved from a safe place in smaller back room of the home. For some reason, I found this man’s continued participation in the research of the Project fascinating….does he know that he participates in research that has changed the way we approach HIV prevention and treatment across the world…….Immediately following the completion of the household census, the interviewer hands over the paperwork to the editing team, a team of reviewers who sit in a truck in the field, combing through each and every question looking for errors and inconsistencies. It is the first level of quality control in this research process. The census forms are then taken to the data management center at the Project where the data is entered twice by two different data entry employees with random error computer cross checking. It is quite a meticulous and impressive system. Our morning spent with the RCCS, the “mother” research study, was very valuable in terms of understanding the overwhelmingly impressive research machine that is the RHSP. It is like an army of researchers that has been (as far as I can tell) successfully integrated into the communities of the Rakai District. The teams of researchers and trucks just seem to be part of the landscape…..

VTC Department
Today, Jake and I spent several hours with the coordinators of the voluntary testing and counseling department. It was quite informal and both of us found it to be a fascinating conversation. The main objective of the VCT department is to offer psychosocial support to cohort participants. The department provides counseling for circumcision patients, discordant couples, and children with HIV. They also partner with the ARV department to provide follow-up counseling of HIV+ clients in the biweekly community clinics where patients are introduced to ART and treated for OIs. I focused my questions on child counseling…..According to the coordinators, the introduction of ART through the Program created a immense need for counseling around HIV status and treatment among children. Until a child reaches the age of 8, all counseling is directed towards the child’s biological parent or guardian. After age 8, trained counselors begin to assess the child’s understanding of HIV and their own status. The counseling becomes a continuing dialogue between a child and a therapist, focusing on how and when to reveal HIV status and deals with issues of medication adherence. I must admit that I am disappointed in myself for never really thinking about all of the complicated psychosocial issues associated with being an HIV+ child in Uganda during this new era of freely accessible ART. Prior to ART, HIV+ children in Uganda would spend their short lives fighting death one opportunistic infection at a time. It is very different now…..with life extending ARV drugs, these children must learn to process the meaning of their lifelong disease through different developmental and life stages. They must learn to negotiate a very adult world in which there are unspoken expectations and rules about disclosure of HIV status. Most importantly, during adolescence, they must learn to understand their sexuality in the context of their disease. That is one of the many things about HIV that makes it so different than living with another lifelong, life-threatening medical condition—it has a profound effect on sexual intimacy which can effect the way that love is perceived and experienced and that would be especially hard to understand and deal with as an adolescent. For the first time in many years, I talked to the coordinators about the research project I piloted at Rakai way back in college (they were actually really interested). At the time (2002), I was trying to explore the impact of being orphaned by AIDS on the sexual behavior patterns and mental health status of adolescent boys. Although the research itself was primarily a learning exercise (well, an extraordinarily stressful crash-course in international research really), I do think I was asking some important questions that are still relevant today…..In any case, this morning’s meeting brought up a lot of very interesting facets of HIV treatment and care that I have not yet contemplated and I left very impressed by the staff and scope of practice of the counseling department at the Project.

It is a sun-drenched evening following another dark and cloudy cool day. The warm breeze feels amazing—it sweeps through my mind, clearing out all of the cobwebs of my brief afternoon nap. Jake is bathing in the light and wind, the birds are singing, the flowers are glowing, and I can hear the laughter of school children beyond the edge of the gate. I want to package this moment and open it every time I get frustrated or angry or sad….

We spent the day in Kampala yesterday, starting out under a heavy threatening sky…..Fading in and out of sleep as our vehicle cruised through the papyrus lined road from Masaka to Kampala, finally waking as we entered the outskirts of Kampala. Outside, the rain pounded down, creating rivers of thick red mud that rushed through streets clogged with the commerce of human life….

First stop was Garden City, a glittery “modern mall”, a mirage of development rising from the poverty that surrounds it…a watering hole where wealthy Ugandans and sunburned ex-pats go to bathe in the familiarity of well-stocked grocery stores, expensive boutiques, and coffee shops, where drivers of “safari vehicles” wait while clients sip on tall iced lattes and discuss the best way to “develop” the red-caked world beyond the mall boundaries, the best way to “bring God” to those less fortunate, the best way to “experience Uganda”…..I write this with disdain, but also with the guilt that comes with being one of those people enjoying every sip of my $3 iced latte while our driver searches for a quick, cheap lunch before he takes us shopping for souvenirs…..Sometimes, it makes me hate myself. But I am who I am and I am comparatively privileged and there is nothing inherently wrong about it. At least that is what I keep telling myself.

The rain clouds evaporated, revealing the intense familiar steamy heat of our first 2 weeks in Kampala and we moved on to the craft village to pick our way through mountains of “Ugandan crafts” and haggled over mere coins, experiencing annoyance as we are charged $.25 too much for one particular item or another. I still love the craft village in Kampala and the familiar baskets and masks and trinkets…I looked for little things this time like cheap scarves that reminded me of the colors of the country, ones that I can use to wrap myself in the imagery of a drive through the Ugandan countryside. I also enjoyed picking out small household items with Jake, knowing that these items will populate the space we decide to call home….

Hours passed while we lazed around like sleepy lions, sipping on exorbitantly expensive coffee and coke at a shady table at a fancy hotel until it was time for dinner…A feast of Indian we had been dreaming about all week in Kalisizo…

By that time, the sun had faded, taking away my serenity and filling me with dread. I knew we had a long drive back to Kalisizo and I have always been scared of the roads here at night, especially the road that runs between Kampala and Masaka, the original trans-African highway. I pretty much ruined the dinner we had waited all day for by my anxiety. The streets of Kampala were, as always, jammed with people….but moving around here at night is like moving around in an entirely different world. In the dark, dusty, smog, there is movement everywhere—people and bikes and goats and bota-botas and buses competing for space on narrow roads that are flooded with roadside vendors selling sticks of meat and vegetables and cell phones and shoes….there is so much noise and smoke and dust and chaos and people…so many people, so many kids….I feel as if we are not going to be able move through this dense human sea. We finally escaped Kampala and started out on the terrifying drive home. It was like an obstacle course in darkness—large, dangerous areas of broken road alight with the flickering headlights of old, rusted trucks weaving in and out of cars, disappearing in clouds of black exhaust so thick that they obliterated the world around us so that we were in total blinding darkness. Somewhere in the darkness, people were walking along the side of the road, dogs would run out in front of the car, and herds of cattle threatened to wander into our path. I alternately clung to the car and to Jake, and then I slept (it is what I do best in times of stress, waking only when my head hit the window after particularly large road bumps). I blocked out the rest of the drive and said a little atheist prayer when we pulled into the guesthouse driveway. Although I would not choose to be on the road late at night here, I am kind of glad we made the trek…..the landscape and life of a place is not fully known until you experience it at night.

A more typical day in Uganda…woke up at 5am to prepare for a car to come pick us up at 6am. 7:30am rolls around, no car, no electricity, no breakfast, no coffee, and no numbers to call…..moments of panic set in when we realize we might get stranded here at the guest house for the day…..language barriers, traffic, hunger……things eventually work out and zebras are seen and Pringles are popped and sunburns happen and electricity comes back on and rice and beans dinner is about the best thing we have ever eaten…..

Something about staying in Kalisizo makes me feel like I have had the emotional wind knocked out of me….it is not a sudden thing, this loneliness….it creeps like the creeping dampness in london, slowly climbing up my body until it invades my thoughts, until it hurts to think…..I remember this loneliness well from years ago when I had much less strength to fight it….I don’t know why it happens here, but I have some theories….

One of my favorite things to do in Uganda is to ride around the countryside, taking in scenes of daily life—people collecting water, cooking food, fixing bicycles, drying laundry, sleeping under shady trees, bathing babies—the currents of life as it is lived day in and day out. I find the predictability of these flashes of daily life somewhat soothing. But when I really think about these drives, I am horrified by how sensitized I have become to the poverty around me. The reality behind my collecting water—the reality is that there is a long line (of mostly women and children), some of whom travel miles to collect cans of dirty water from a single pump, water which will inevitably claim the lives of many children vulnerable to diarrheal diseases. The reality behind the scenes of cooking can be seen in the children in the villages, who run around with swollen stomachs and popsicle stick limbs as a result of protein malnutrition. Without proper nutrition, these children will never reach their potential, never be able to concentrate enough to excel in school, never grow properly, never be completely healthy. They will never have a chance. How have I become so used to these images? Why am I not outraged every minute of everyday here? I know the answer—because it is too hard. If I were to allow my outrage and disbelief to the surface, I fear it would consume me. It is easier not to think about it, easier to see this world as if I was blind to it. See it as a tourist—someone who takes all that is beautiful about this place and packs it into photographs, briefly acknowledging the parallel human world and then pushes it into the shadows of memory. But I will never be just a tourist in this country. These images exploded into my life when I was fifteen and have haunted me ever since. I have attempted to understand this world through an intellectual exploration of history, anthropology, sociology, public health, and medicine and I have found no answers. In fact, as I have become more and more educated, I feel as if I have moved farther and farther away from understanding….Instead of turning my intellectual inquiries into action, I have built a wall around myself. I can’t feel in this prison in my mind and when I can’t feel, I can’t learn and I am disconnected from the outrage that is required to be an agent of change.

Staying in Kalisizo, we are actually physically isolated from the world beyond the armed guards and heavy locked gates. In this physical isolation, much of my days and nights are spent inside my head and I alternate between being profoundly bored and being profoundly anxious about all the things I don’t know and don’t understand about life and death. No wonder I feel the desperate need to escape–not Kalisizo but my own thoughts. Part of the goal of this month in Uganda was to apply my newly acquired medical knowledge and I realize now that was a joke. My knowledge of medicine means nothing and once again, all that I am doing here is taking away…..Learning far more about myself than anything else.

Last weekend, Jake and I had an epic Ugandan weekend filled with beautiful mountain drives, gorillas, lions, and luxury…..

The weekend started at dawn on Friday as we (Jake, myself, and another medical student) piled into the car at Makerere and started our journey westward towards Bwindi Impenetrable Forest. About three hours outside of Kampala, I began to worry….we were climbing north and although the drive to Fort Portal is quite beautiful, it seemed very much out of the way….(we were supposed to be heading to the southwestern corner of Uganda near the Rwandan/Congolese border). I brought up my concern, but we continued on (there are not that many roads in Uganda and it is quite difficult to change routes). Six hours later, we arrived in Fort Portal and prepared ourselves for another seven-hour drive south on a bumpy dirt road through Queen Elizabeth National Park. It is hard to complain about long drives through stunning landscapes, but the last 30 km of bone breaking rough riding through Bwindi to the lodge was painfully never-ending…..

We arrived at the Buhoma Homestead at the foot of the forest and were greeted by tall glasses of delicious juice and an incredible treehouse suite with a huge verandah overlooking Bwindi. It was very exciting—I have never stayed in any place quite like it. I sat down, finally still and took in the forest world around me. It was overcast, the dense dark green mountains seeming to be both erupting from the earth and suspended in misty clouds at the same time. It had recently rained and the forest world was dripping, screaming with the noise of life. To be honest, I found the forest scary….a world unknown to me, a world that held life that I both wanted to know and run away from. After a perfect hot shower and a delicious four course meal complete with a bottle of wine, I went to bed happy and anxious for what I hoped was a challenging but leisurely hike to see one of the world’s most endangered species, the mountain gorilla.

The morning started out well enough with orientation—until we were separated into our respective permitted trekking groups. We had permits for the “R” group, a group that is notorious for residing close to camp (i.e. a short trek). However, we were immediately informed that the group was last seen yesterday about 12 km from camp (the rangers use GPS to locate and trek the different gorilla groups). The ranger went on to explain that we should expect at least a 20km hike and encouraged us all to employ porters to help with carrying bags and water. I was thinking….hmmmm…20km is not too bad and my bag is not too heavy…..but I am out of shape and I don’t know what the terrain is like…..We decided to hire a porter just in case and we set off. Our trekking group was funny…..we had 3 wildly hairy Croatians and an awesome couple from Canada. The group leader was Ranger David and the team was bookmarked by two guards armed with AK-47s. For some reason, I still felt unsafe as we entered (or as Jake would say penetrated) the impenetrable forest. We immediately started to climb….yes, climb at about an 80 degree angle in dense jungle with no trails. After 10 minutes, I felt like my heart was going to explode, my lungs were going to collapse, and my knees were going to give out. The intensity of the exercise and the density of the forest was suffocating. There were sounds everywhere—the forest breathing on us as we scrambled, using thorny branches to pull ourselves up the mountain. The accomplishment and relief I felt when we arrived at the top was overwhelming—until Ranger David congratulated us on finishing the first 4 km and hurried us along….down another mountain and then up again…it was brutal and neverending, but we had the goal in site (well, the gorillas were on the move and we were moving fast to try to reach them in time—if you do not reach the gorillas by 3pm, the ranger forces you back to camp—being in Bwindi in the dark is not an option…).

The gorillas were finally sighted at around 2pm (we started our hike at 8:30pm). Humans are allowed one hour maximum with the gorillas and time started ticking…They continued to move once we found them and we scrambled through thick vines and trees to catch glimpses of them. It was hard…they moved quickly through the dark forest and although they were all around us (in the trees and on the ground), they were elusive…until they stopped. When they stopped, we finally stopped and sat and watched and it was undescribable. The “R” group had several babies and young adults and I observed for an hour as they played, explored, and experimented with each other. They are so human in their interactions and I was overwhelmed by the extraordinary opportunity to view these majestic yet ecologically fragile creatures in their natural environment. I could have observed them for hours.

An hour passed quickly and I snapped back into reality—we were at least 12 km away from camp, the afternoon was fading into evening quickly and every part of my body was shaky and angry. For all of those who know my “feeling as if I can’t go on”—this was the feeling that I had (times 200). I could probably write a whole short story about the trek back to camp, but for now I will just say that it was much, much harder than hiking up the mountains. Legs like jello, ankles unsupported, slippery alive earth beneath my feet, dodging large colonies of biting ants, grabbing onto thorny branches that get stuck in clothing, hair (and Jake’s eyelid)……I basically stumbled down the mountain, too tired to be aware of the creepy surroundings, pushing ahead without looking back, running out of water, running out of energy. We are all drenched in sweat, encouraging each other to continue moving as we tried to avoid dangerous mountain elephants. Part of me thought that I just wasn’t going to make it back to camp—the gorilla viewing seemed like a dream, an afterthought to the intensity of hiking through Bwindi. I was cold and hot and shaky and then it was over. It was 5:30pm, the sky was heavy with rain, and Jake and I survived without any major injuries (only a thorn in an eyelid, a handful of thorns, and stronger hearts and only about 10 usable pictures of the gorillas). When Ranger David handed me a certificate of completion, I actually felt proud and thought—this was fucking harder than medical school. I deserve this. Apparently, it is not unusual that tourists have to be carried back down during treks like ours……I felt like I conquered Bwindi and some of my own fears and it was an amazing feeling. That said, I don’t think I ever want to do that again…..the images of the gorillas are burned into my memory and that is enough….

And so the weekend continued…..we started out the next morning for Lake Bunyonyi and Queen Elizabeth National Park. Another long day of driving, but certainly this is one of the most beautiful drives in the world. The road winds through mountains that stretch for hundreds of miles, through rainforests and small mountain villages. Butterflies surrounded the car and the air smelled like rain and dirt and sun and smoke and life……It smelled like Africa. On this road, Uganda and Congo and Rwanda stretch out in the distance and volcanoes climb towards to sky. It is incredibly lush and Ugandans have managed to harness the rich soil of the rainforest and cultivate the land so that the rolling hills beneath the mountains look like patchwork quilts—alternating square patches of floating matoke plantations, brilliant, glowing green tea plantations, and deep red earth. The fields are dotted with people—bright flashes of color (reds and purples and blues) that peak out through a verdant sea of controlled vegetation. This drive is Uganda for me. Here the poverty and injustice and cruelty in the world of human development is silenced by the forces of natural beauty. It is spectacular.

We raced against the sun to arrive at Katara Lodge in Queen Elizabeth National Park (QENP) before dark and just barely succeeded. As we pulled up, the earth was exhaling its last breath of day but we had enough light to appreciate the incredible expansion of savannah beneath the Rwenzori mountains, the mountains of the moon. Katara Lodge is a new ecolodge perched on a cliff near the entrance to QENP. It only has 5 cottages that are all equipped with spectacular facilities—a bathroom (shower and tub) overlooking the savannah and a verandah made especially for sleeping outside under the stars. Settling into a hot bath at the Lodge, I felt like the luckiest person in the world…..and I felt very much like the almost 30 year old adult that I am. I have been to QENP several times before and have stayed at some great places with my family but that was a very long time ago….This was my first adult trip and I was experiencing it with a little bit (no a lot) of luxury. Part of me feels a little guilty traveling in luxury…but I have experienced this part of the world as most young travelers do (24 hour dusty, unsafe bus rides, squat toilets, and basic accommodations) and I feel I have reached the point in life when in which being comfortable is important. In any case, I loved every minute of our time at Katara and QENP. I was even happy when it rained for half of our one day in the park—the cold rainy weather was a license to curl up, take a hot bath, and fall asleep to the sound of rain. It was the best nap I have had in Uganda. On Sunday night, we were essentially the only guests at the lodge (with the exception of a very strange pediatrician from Texas who works 3 months out of the year doing medical mission work, a young student from the Netherlands who is doing a case study on Katara as part of her dissertation on international tourism, and a pushy wannabe Julia Childs ex-pat from Rwanda). I love the diversity of people one meets when traveling…..

Our last night at Katara was spent camped outside beneath the stars. We watched in awe as the Cheshire-shaped moon sank behind the Rwenzori peaks, revealing a glowing sky. I have never seen so many stars. I tried to ignore all of the strange sounds and potential insects and ended up sleeping well, waking only to the alarm calls of the morning birds. It was the perfect ending to an amazing weekend.

February 25, 2010
Kalisizo, Rakai District, Uganda

First Day at Rakai
I must admit I was nervous for our first day at the Rakai Health Sciences Program. It has been 8 years since I was last here and, while many things about me have changed, I am still the overly anxious, totally self-conscious, pathologically insecure person that I was when I was doing research here in college……

[A little background on Rakai for those of you who are reading who are unfamiliar with the Program (http://www.jhsph.edu/rakai/). In 2005, the Rakai Health Sciences Program opened a new complex, which is a state-of-the-art research center with extensive space for laboratories, data management, and data storage, as well as clinical facilities, training facilities, and offices for scientists. Funding for the building was received from the Doris Duke Charitable Foundation, the Bill & Melinda Gates Foundation, the Gates Institute for Population and Reproductive Health at Johns Hopkins University, and through University loans. A contract through NIH/NIAID International Center for Excellence in Research is equipping the laboratory. The laboratory is an air-conditioned, 3,600-square-foot, state-of–the-art facility. It includes rooms designated for lab accession, clinical microbiology, tissue culture, serology, nucleic acid amplification, and laboratory support. The clinical facility includes a patient waiting and reception area, an outpatient clinic, a pharmacy, an x-ray room, four examination rooms, two operating theaters, a sluice, an autoclave, and storage, as well as patient changing rooms and offices for surgical staff. The two theaters, designed for outpatient surgery, are mainly used for male circumcision at this time, but will provide facilities for colposcopy and other procedures. (all this descriptive information taken directly from http://www.jhsph.edu/rakai/about/where_we_work.html)%5D

Anyway……Jake and I walked down the hill on our first day—it is a nice walk through sleepy Kalisizo, much different than the walk to Mulago in Kampala. There is barely any traffic (human or machine), the surrounding matoke plantations are beautiful, and the air is easy to breathe……it is also the kind of place where little kids in brightly colored uniforms run after you in groups yelling “muzungu, muzungu”……

Upon arrival, we were given a tour of each department and orientation to each of the many research studies happening here (these include the Rakai Community Cohort Study; Male Circumcision for HIV Prevention; Randomized Trial of Male Circumcision, STD, HIV and Behavioral Effects in Men, Women and the Community; ARV Effects on HIV Epidemiology and Behaviors; Impact of Peer Educators and Mobile
Phones on HIV Care; and Assessing the Impact of a Community-Based Intervention Designed to Reduce Levels of Physical and Sexual Domestic Violence in Rakai District, Uganda). That is all that I want to say about each department and study for now—next week, we spend a day with each research study and I will write about them as I experience them….

After our introductions, we traveled to one of the local community clinics where the Rakai Project provides free ARV treatment. In comparison to the clinic in Kawaale, this was a quiet clinic with about 75 patients. The morning started with an education session, which happens before every clinic. The topic of discussion was prevention of maternal-child transmission—unfortunately, the education session was conducted in the local language and Jake and I just sat in front of the audience (after a big formal introduction) looking stupidly out across the faces trying not to stare or be stared at. There were flashes of the brilliant color of African fabric amidst the sounds of laughter, baby cries, silence, worry, impatience….I forgot how these experiences are both incredibly interesting and extraordinarily awkward at the same time. I had such a hard time not studying the faces of the patients in front of me as they listened intently to the health educator….the faces are old and young, all carved by experiences that I will never understand and never fully appreciate. We were then guided through the research paperwork that must completed during each patient encounter—pages of paperwork that condense the life histories of these patients into a series of boxes and codes. It is a meticulous, impressive, and I would argue somewhat dehumanizing process. We left as dark rainclouds began to gather, taking with us only passive observations of the surprisingly mundane nature of HIV care and research in action.

After lunch, we headed out in the field with the education/community organizing team for a community drama production focused on education around circumcision, voluntary HIV testing and counseling, ARV treatment, and getting involved in the Rakai Cohort study. Based on the groundbreaking results (from Rakai) showing the efficacy of circumcision on reducing HIV transmission, the Rakai Health Sciences Program now offers circumcision surgery and post-op care to all men in the region and the Program uses drama to educate communities on the health benefits of the procedure. When we arrived, there was a crowd of at least 100 villagers gathered under a tree in the center of the village. We were immediately greeted by the leader of the community and escorted to our seats on very small wooden benches in the very front of the crowd. Jake was seated next to a group of elders who all wanted to shake his hand—he looked totally bewildered (and it was really cute). The drumming started as children pushed their way to the front of the crowd and plopped themselves down timidly next to us. Everyone was, once again, staring at us (some with amusement, some with curiosity, and some with distrust). However, once the signing and dancing began, all eyes were fixated on the local group of actors. Although we could not understand a word of what was being said, the audience was captivated and engaged…apparently, the drama was hilarious. I wish I could have understood the messages that they were giving—especially about circumcision (I can imagine that it might be challenging to convince grown men to have a circumcision). I have always loved these moments in Uganda—the moments that are filled with energy and music and laughter, when people of all ages gather together for a collective human experience. Despite the fact that Ugandans are some of the most welcoming people I have ever encountered, these are also the moments that make me feel the most vulnerable and exposed—an outsider, an observer—disconnected and in disbelief of the reality around me. The drama lasted for hours and as the sun began to set, I must admit that I grew impatient and anxious to return home to my own reality—my own comfort zone where the people around me don’t stare and whisper and wonder and touch….In any case, it was an extraordinary way to begin this part of my last 2 weeks in Uganda.

Moving on to dinner, which was as surreal as the afternoon drama…..It was a dinner full of sexy science. The setting was the dining room at one of the Rakai Health Sciences Project guesthouses. The guests included a luminary in the field of HIV research—a lifetime NIH employee who has repeatedly revolutionized our understanding of HIV, a junior infectious disease physician-researcher, a public health worker, a young Canadian PhD candidate, and Jake and I. The meal was traditional Uganda with a splash of red South African wine, a homemade tossed green salad (rare in Uganda) and dark almond chocolate. The conversation covered the scientific history of the discovery of HIV in Africa (firsthand account), followed by a debate surrounding the anatomy of the foreskin, the sharing of gorilla hike adventures, and the viewing of You Tube videos showing a new laboratory sequencing technique. The contrast between the afternoon and the evening was extraordinary and I found the juxtaposition between the grassroots community HIV prevention work and dangerous, exciting HIV laboratory science fascinating….both types of work are absolutely essential pieces in the history and future of HIV in Africa. Reflecting back on my experience with the clinic and the seemingly mundane nature of HIV research and clinical care in action, I realized that it was not mundane at all… all of these activities are, of course, part of a continuum of care and each part is equally important. The real question that I keep asking myself is where do I fit in this continuum or rather where do I want to fit in this continuum? I am not a lab scientist and have no desire to do lab science (although I immensely respect it). I am not a pure clinician and have no desire to limit myself just to clinical practice. At this point in life, I think I know who I am not—but I don’t yet know who I am…

This extraordinary first day was also the day that our rank order list was due for residency. I barely even remembered. On another personal note, I am sick. I have been for the past 5 days. And as I sign off for tonight (with a promise to write about our weekend trekking gorillas and stalking lions in queen Elizabeth national park), I am very much wishing I was home, curled up in bed, looking out over central park….

Spent this morning in the Department of Family Medicine, interviewing a young family practice resident. I must admit it was refreshing and exciting to find that we spoke the same language of medicine after a week with infectious disease physicians. The Department of Family Medicine at Makerere was founded way back in 1989 under the title of Community Medicine and currently has 5 full-time faculty and 4 residents (2 first year, 1 second year, and 1 third year). There are 30 family medicine physicians in the country of Uganda—that is 30 family med docs/30 million people. Residency is structured a little differently than in the United States—students are required to complete one year of general internship followed by 3 years of post-graduate training in the “specialty” of family medicine. Two years of family medicine residency are spent in 10-week rotations through internal medicine, pediatrics, obstetrics and gynecology, and surgery followed by one year of community practice, during which residents staff government health centers and work on community organizing activities. According to the resident I spoke with, the “science” of family medicine is rooted in patient-centered and community-centered care with an emphasis on understanding how communities impact health. I was elated by his description of the science of family medicine and felt such a kinship with him as he described his interest in qualitative, community-based research (he has recently submitted a research proposal to investigate perceptions of family medicine in Uganda). I kept thinking about how much we have to learn from each other and I am a bit frustrated that I was unable to spend more time in the department. Through our discussion, I learned that the specialty of family medicine in Uganda faces many of the same challenges as in the United States—for example, family medicine is not well-recognized within the specialty driven culture of Mulago Hospital, high specialty attrition rates (many family medicine physicians are pulled away from government health center and community work by NGOs willing to pay much higher salaries), insufficient funding for education and research, and the perception that students who pursue family medicine do so only because they cannot do the other specialties. The resident, who originally planned on pursuing neurosurgery, decided to specialize in family medicine because he feels that it is the specialty most relevant to the health of his country. I could not agree more….One of the things that really frustrates me is the global lack of recognition of the role of a family medicine physician in resource-poor settings. Family medicine physicians are broadly trained to provide comprehensive care and have the potential to be the foundation of a health system built on primary care. Why would it make sense to staff a rural health center in Uganda (that lacks most specialty services) with a general internist or general pediatrician? Why not employ a family medicine physician, who can handle up to 80% of reproductive, surgical, obstetric, pediatric, and adult medical issues (and pay them accordingly)? Why do family medicine physicians, here and in the United States, have to convince other medical professionals that they are capable and essential players in health systems? Europe recognizes this……Ahhh, the healthcare system is so incredibly frustrating in the United States….That said, it is an interesting time in history to be starting my training in family medicine. What will our health system look like in 10 years? Will my clinical practice be obsolete or essential? In any case, it was a great morning and I feel re-energized about starting my career and hopeful about continuing a meaningful dialogue and (maybe) partnership with my new colleagues. I also received a much-needed infusion of excitement regarding research. In an environment dominated by bench and quantitative research, I often get discouraged that my research interests and questions are best addressed using qualitative research methods.

On a much more personal note, Jake and I have had incredible Indian food here in Uganda and I will miss it when we move to Kalisizo. This weekend should be quite an adventure—one that I am a little nervous about. We leave at dawn tomorrow for 2 days in Bwindi Impenetrable Forest, where we will embark on a day long gorilla trek followed by a day or so in Queen Elizabeth National Park for another game drive. I don’t know why I am nervous for the gorilla trek—it has been safe for years, but to me it still seems like an unpredictable part of the world. We end our extra long weekend in Kalisizo, where we start our rotation at the Rakai Health Sciences Program. I suspect internet access will be limited until we arrive in Kalisizo, but will post again as soon as I can.

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.

Back in Kampala for the start of another week. I have been feeling quite homesick today and generally exhausted by the effort it takes to do simple things like laundry. I have also never been to Uganda when it is this hot and humid—the damp heat is reminiscent of SE Asia. However, the evenings are amazingly breezy and cool and as the sun sets in the city, I feel like I can breathe again.

Last Friday, we took a tour the different wards of Mulago Hospital. Although I have seen the hospital before, I found it upsetting in an entirely new way. Mulago has over 1,000 beds and is almost filled to capacity. The fragility of life is overwhelming. You can see and smell death everywhere and I wonder how patients emerge alive. Due to a lack of resources, it is a environment of communal suffering and healing, with patients and their families sharing the same small emotional spaces that exist between life and death. I think that I found the gynecologic oncology ward the most upsetting. Women, young and old lying side by side–90% of them dying of cervical cancer. This is not supposed to happen, this does not have to happen. The disparity in resources is outrageous and unacceptable, but I hate to admit that it does not enrage me as much as the health disparities that exist in the United States. Most of the patients at Mulago live their lives in conditions of crushing poverty, with little or no access to things as basic as clean water…but at Mulago at least they are treated and cared for with the resources that are available. The same cannot be said of the United States. I have lost track of the progress of healthcare reform in the United States, but I can say that I am leaving this country with a renewed vow to use my voice as a physician to fight like hell for universal healthcare.

On a more personal note–I have been feeling slightly unsettled since starting at IDI last week and I do not know why. I am not sure what I expected out of this rotation—out of this return trip to Uganda. Seven years ago, I left this country convinced that a medical degree was the answer to the feelings of personal and professional impotence that I experienced in this country. Now I feel handicapped by my lack of experience in public health. It is almost as if I have lived in this strange slightly unpleasant educational vacuum for the past seven years—driven towards the single goal of achieving a medical school diploma. Out of necessity, I have focused almost entirely on learning the language of medicine and now I feel like I cannot communicate in a way that is essential and important in global public health. I have come full circle back to my senior year of college when I was at a professional crossroads—contemplating whether or not to pursue public health or medicine. I realize that I can and need to do both, but I feel a little stuck. Residency stretches out before me—another three years (thankfully short) of total and brutal immersion in the culture of medicine. I am mostly excited for residency, but am feeling a little frustrated that I still do not know how I want to use my medical degree. This is a weird time and I am sort of stuck in an uncertain netherworld between a beginning and an end. I experience moments of overwhelming excitement and extreme apprehension and I cycle between these emotional moments on a daily basis (poor Jake—he has to deal with it). Here, in Uganda, I feel very far from where I began and very far from where I am going.…..

Not sure what this week holds in terms of clinical assignments, but it is the week when I/we need to finalize our residency rank list. This is the hardest and most purposeful decision Jake and I have ever made (both individually and as a couple) and I hope we are making the right decision. I think we are.

Tonight, I will go to sleep with a silent mind, dreaming of snow.

Just arrived back from our weekend in Murchison Falls….Amazing.

I felt an overwhelming sense of relief as we left the smog and heat of Kampala early Saturday morning–the chaos and noise of the city dissolving into the intense green hills and red earth of rural Uganda. We zoomed past the familiar scenes of everyday life in Uganda–naked children playing by the side of the road, people pushing bicycles laden with bananas, women standing in line at town water pumps, men laughing in groups under the shade of trees, boys herding cows, women digging in their gardens….

Started the weekend with the boat trip down the Nile to see Murchison Falls. Could not help but doze off in the heat and sun–waking up every once in awhile to catch glimpses of hippos. Only one elephant spotted on the water–a single male whose trunk had been ripped off by a poacher trap. Left behind by the others because of his disability. Very sad. Enjoyed watching Jake’s excitement. Ended the day with a stop at the top of the falls–the power of the water juxtaposed with the peaceful scene of the sun setting over the Nile. Had forgotten how incredibly beautiful Murchison Falls are. Had my first wonderfully hot shower and fell asleep under the breeze of a fan. It was heaven.

This morning started before dawn as we rushed to catch the ferry for our early morning game drive. Picked up a ranger who jumped in our car and immediately directed us to a male lion who was spotted lying under a tree. Our Valentine simba:) We stayed for awhile, watching the lion rest–the sun rising over the savanna behind us, the scent and sounds of morning pulsing around us. It was a perfect way to start a day filled with elephants (including a baby), giraffe, and a rare leopard sighting. Spectacular. An altogether amazing weekend.

Friday. Exhausted. Feel like I have been hit by a ton of bricks. The heat is oppressive here. I don’t remember it ever being this hot. Maybe it feels hotter because I know that I am missing the amazing snowstorms back home. I am a bit homesick today.

Finished our first week at the IDI with an examination, truly my last medical school exam:) The work is not as clinical as I had hoped, but I still think it has been a valuable week. For most of the week, we sat stuffed into a small examination room with four Ugandan medical students learning the principles of ART treatment. It was a crash course in ARV drugs, side effects, and management of side effects. Yesterday, our instructor (whom I shall call Dr. Sublime Steven) saw patients and taught us at the same time. The physician-patient interaction is very different here and sometimes it was as if the patient was invisible. We discussed the patient’s case–personal details of the patient’s life and then we switched to a discussion of specific ART drugs and then we switched to talking about religion (yes, Jake was clearly present)……all of this while the patient sat quietly in the corner. Once again, the patient interviews were cursory and cold. It was upsetting. Although the week was composed of primarily didactic sessions, I did find it to be a valuable learning experience. After the exam today, the Ugandan medical students had to present cases from home visits with patients from the IDI clinic. I was quite impressed by the emphasis on the psychosocial and environmental determinants of health among HIV patients that were presented. The case presentations certainly highlighted the impact of poverty on HIV treatment in Kampala.

Need to head to dinner now…..Big day tomorrow–heading to Murchison Falls for a unique Valentine’s Day weekend…Have much more to say about our first week…stay tuned. No internet until Monday.