My Journey to Uganda as a Mental Health Humanitarian

I went to the Nebbi District of Uganda for two weeks with Rotary International. This was a humanitarian trip where I served as a trauma counselor. I was part of a nine-member team from the Northwest Illinois, US Rotary district. The team members consisted of three doctors, two nurses, two counselors, one literacy specialist, and one librarian.

Day One: 2/7/14

I met up with the team at 3:00 a.m. at O’Hare to coordinate luggage. We each brought a checked bag with our personal belongings, and a second checked bag with our humanitarian supplies. We connected through DC where we picked up the flight to Ethiopia, then connect to Kampala, Uganda which is a total of 17 hours in the air.

I’m interested in the young woman I share seats with. She is a nurse from Minnesota who has caught “the humanitarian bug” in that this is her fifth trip to provide nursing care to undeveloped areas. She will join Mercy Ships, a hospital cruise ship, to provide medical care in the Democratic Republic of Congo.

Apparently, if I’m not careful, I could catch the “humanitarian bug” and dedicate all future travel to humanitarian service. I can understand how one could feel deep satisfaction in helping others, combined with adventure. Visiting new, perhaps exotic, countries could be enticing.

Day Two: 2/8/14

It was a miserably long flight with little sleep. I got a slight headache from lack of sleep. Note to self: don’t put so much into carry-on luggage if it has no wheels. I had to lug that thing from city to city. But we made it! Rotary members were here to greet us. We were each invited to stay with a Rotary member overnight. My host has a PhD in Social Anthropology and Women Studies from University of Minnesota who then returned to Uganda and co-founded MEMPRO with her husband. MEMPROW is an organization for the empowerment of women and girls. It is an honor to stay in their home. It feels so good to get a shower and fresh clothes!

I’m struck by the sounds of Kampala: roosters crowing, turkeys, music. The weather is warmish, not hot, and fragrant. I was served fresh pineapple and bananas as well as juice for a snack before we met the team and other Kampala Rotarians for dinner. We’ll get an early start tomorrow for a 9-hour drive to Nebbi.

I miss my husband terribly. We’ve never been apart for two weeks. I depend on him for quite a lot. It took three of us to turn on my phone and get the SIM card working. This is a task that he would normally handle.

We joined the Gaba Rotarians for a meeting and dinner. They gave us a warm reception and we exchanged banners. One of our members, Jim, presented $150 from his home Rotary club to MEMPROW to use for the girls. It was decided that the funds will purchase sanitary items for the girls with the hopes that it will keep them in school for a longer period.

Day Three: 2/9/14

We drove eight hours northwest to the Nebbi district of Uganda. Along the route we saw animals: three elephants, from quite a distance, were visible due to white birds on their backs, lots of baboons, two different kinds of antelope, and a cluster of hippos in the water. We crossed the Nile in two locations. We were not able to get many photos. It is prohibited by the government to take photos of the Nile. If we were stopped, they could have taken our cameras or destroyed the photos. We did not stop to see the animals, even away from the Nile, but took photos from the car.

The government has plans to develop hydroelectric power in the Nile. This will help the northwest populations who have very limited electricity. Additionally, Uganda has found oil in the northern districts. We saw signs of drilling and development. There is concern about the effects on animals, many of whom are already displaced further west and south. There are fears that subsistence farming will disappear. Another concern is that as the area is developed, girls will be exploited for the sex industry.

Scattered along the highway, and some set back from the highway, are clusters of housing. The housing is primarily grass thatched huts. There are two grass types of thatches: one needs replacement every two years, the other every five years. They are of a slightly different configuration. I was told that when boys reach the age of 18, they build their own huts. Presumably, the more huts in a village, the larger the family. I was surprised to see signs of technology next to primitive structures. I saw solar panels now and then next to huts. A solar panel is reasonably priced and will power a cell phone and lights.

During discussion on the trip, I asked about mental health services. I’m told that mental illness is viewed as “devil possession” and treatment is not valued. Witch doctors are not well intentioned, wanting to benefit from payment for services. A mental health facility in the city is sometimes a dumping ground for persons who have become a burden on their families. Their families may not respect treatment or don’t live near the hospital and therefore don’t visit. Medical care in Uganda sometimes depends upon family to feed and care for their loved ones. I’m told that the food is inadequate. Mental health is highly dependent upon a support system. If one lacks their support, they will not thrive. Some may leave the hospital without resources and have to rely on themselves to find employment and housing. Ugandans could benefit from education about the efficacy of mental health treatment. Most disorders are treatable.

We walked to the market. The market is open air, selling food products and general merchandise. I purchased a tool for hanging wet clothes and some more water. I’ve been careful not to drink water that isn’t from a bottle, including brushing my teeth. And I’ve remembered to take my anti-Malaria medication.

The hotel is equipped with running water, flush toilets, a shower, a fan (yeah!) and a TV. The full size bed has netting. Although the bedding is adequate, I was pleased to bring my own sheet and pillow case. It lacked a top sheet as is customary in the US. My pillow case, lovingly provided by my husband, reminds me of home. I’m told that the hotel provides internet connection, although it is unreliable. I’m waiting on the password.

Day Four: 2/10/14

It is now 4:15 a.m. and I can’t recall being this miserable before. I have not slept all night due to blaring music. The walls shake with dance beats. I have unsuccessfully tried to sleep, read and play solitaire to no avail. I was later informed that there was a wedding nearby that was cause for music. But really? The music stopped at 5:30, I got about 45 mins of sleep before having to start my day. After complaining a bit, we left for meetings. I found myself sleep deprived, maybe also mixed with jet lag, that left me emotionally drained. I was quick to come to tears out of exhaustion and also when moved by acts of beauty. I later found that the hotel owner called the mayor who stopped the music. The music was from a wedding in process. Weddings in Uganda are traditionally five days long!

Our first stop was to meet the LC5 District Administrator – equivalent to US state governors. He welcomed us and we were given education on the system of government in Uganda. There had been, and in five cases in this area, still are, Kings in addition to government officials. The Kings were enfolded into the governmental system and preside over cultural issues. Ugandan country boundaries have shifted over time. This region actually includes population in the Democratic Republic of Congo in terms of its kingdom and includes everything west of the Nile if I heard correctly.

The Governor accompanied us to the school. The children had organized a welcome for us that included a parade, music and dance. It was very moving. This was followed by a meeting with the Governor, the King’s minister, eight Chiefs from the Ugandan region (there are others located in Congo), hospital staff and school staff. There were many speeches from each that included a warm welcome. Ugandans use the phrase “you’re welcome” in a literal sense – as in “you are welcome in Uganda,” not in response to “thank you.” I’ve never been welcomed so many times in my life. At the end of the meeting, the Governor official welcomed us, which marked the beginning of our work. We needed this official sanction in order to be recognized by the community before our work could begin.

Our team then split up to meet with our counterparts. I joined the team at the hospital where we were given a tour of the hospital and where I met two of six counselors. My trauma counselor cohort from Rotary went to the school to work with MEMPROW students and staff. This was a spontaneous decision that worked out well. She will continue to focus her role on supporting Memprow and I will mentor and train hospital counselors.

I met with Palma, HIV counselor, and two Rotarian members who have training and experience in social services to plan our two week agenda. It was decided that I will mentor individual counselors for some time each morning, and train them as a group in the afternoon for 1-2 hours, as many as are able to attend.

While on the hospital tour, a man handed me a printed sheet. I thought it was an advertisement of some sort so I handed it to another counselor. I saw that he reacted with amusement. Upon inquiry, I was told that this man is mentally ill and has AIDS. He is on medication that causes psychosis. I was pleased to see that the counselor and a nurse have an understanding of diagnostic categories. This man was not on an anti-psychotic medication because it was a secondary condition to HIV medications and because he is functioning well. He continues to provide for his family and is not a danger to himself or others as far as they are aware. He frequents the hospital, presumably for his medications, and because he feels comfortable there. This assessment shows evidence of fairly good training in psychiatric care, or at least good hands on learning.

The tour of the hospital was interesting. The facility has 261 beds and is quite old and lacks a high level of cleanliness. I’m told that the infection rate is high following surgery. For example, at the entrance to the surgery theater a sign requests that you take off your shoes. You are to replace your shoes with existing clogs that appear only a bit less dirty. The tour was given by a doctor and included our team of doctors, nurses and me as well as about a dozen of their nurses. I was uncomfortable entering most patient rooms and lagged behind. In the US, we have respect for the privacy of the patient and wouldn’t unnecessarily overwhelm a patient by being observed by a group of strangers. There are no partitions between patients and procedures are done with all to see.

The hospital is an open campus. Family members provide food to the patients. There is a large outdoor area in which cooking is done. They can either bring food with them, or purchase food to prepare. Most families travel a long distance to get to the hospital.  Therefore, are more likely to purchase food. There are no nutrition protocols that I am aware of. I’m also told that the hospital lacks necessary life-sustaining materials such as plasma and oxygen and has limited pain medications. Our team feels overwhelmed and unprepared to address the high degree of needs presented them.

Many members of the team feel overwhelmed. They feel grossly unprepared for the magnitude of the tasks before them. They could’ve/would’ve brought more supplies and equipment if they had known what to expect.

Apparently, I used too much of my SIM data and lost the ability to email my husband. Crap. Note to self: purchase a larger capacity SIM card in the future.

One of my pre-existing ideas for mental health care is the development of peer run support groups. In discussion I was pleased to hear that there is an existing HIV support group that meets weekly. There was also a rape support group that met for three years before disbanding. I’m told that victims won’t share their experience out of shame. I wonder if it will be more appealing to join a group designed to help others, not self. Instead of “support groups,” perhaps “helping groups.”

I was also told that a barrier to participation in support groups is lack of spousal support. For example, if a woman attends a meeting without having prepared a meal or doing other tasks, she will be beaten. I wonder if we can build spousal incentives into participation such as a voucher of some kind to bring value into the home.

Day Five: 2/11/14

I began a discussion this morning about micro-finance. I was told that some people in this area have received micro-finance loans for entrepreneurial projects. For those who are unable to secure such a loan, they form a group who shares their savings to start projects.

I suggested that we tie support groups to micro-finance projects. Men need to see added value before allowing their wives to attend group activities. The value for both men and women is in micro-finance. We could structure group meetings in such a way that they are required to sit through education on various topics, such as domestic violence, sexual assault, trauma of war, etc., prior to shifting discussion to micro-finance. I believe I could generate interest in US small loans to Nebbi. For example, perhaps we could make Nebbi or Gaba a sister Rotarian club to Galena Rotary with the understanding that Gaba Rotarians would manage the loans. Just an idea .

I taught a class of six psychiatric nurses today. They are all HIV counselors who provide counseling as well as dispense medicines. I provided an overview of my readings of the war and current psycho-social issues in Nebbi. They concurred that my readings were accurate. I defined traumatic stress, provided diagnostic criteria for PTSD, with which they were not familiar. I then identified suggested interventions from my reading. I identified a number of lecture topics that could benefit them in their counseling as well as the development of community interventions. I find that we have a communication, in spite of the fact that we are all speaking English. Their dialect is difficult to track and I can’t pronounce their names. They have the same problem with me.

This afternoon I took a walk with two other team members. I’m sorry I didn’t have my camera but the other two did. White people are a curiosity to Ugandans in this area. Lots of children showed an interest in us and some asked us to take their pictures. They were thrilled to see the photos. One young boy, probably one year old, was encouraged by his older siblings to approach me. He was initially frightened and backed off. I crouched down and let him touch my hand. Then others came.

I tried to engage two women who were carrying heavy weights on their heads. They removed their baskets to show me their headpieces, or folded scarves, to soften and balance their loads. We saw young children carrying wood that equaled their height. Some carry large wide loads on bicycles. I had previously seen an adult driving a motorcycle while carrying four young children. Geez.

I heard a sad story today from the doctors. A woman died of AIDS in the field three weeks ago. Her newborn baby was brought to the hospital today by his grandmother who had tried to keep him alive on tea. He was near death with his eyes rolled back and had an unresponsive body. The doctors were surprised that he responded somewhat to their interventions and are unsure if he will live. Postscript: he did survive.

Day Six: 2/12/14

I met with a nurse HIV counselor one on one this morning for a couple hours. I educated him on how to develop a genogram using his own family as an example. We then discussed a counseling case using an assessment form that includes an overview of the presenting problem, family, medical and psychiatric history, goals, planned interventions, mental status exam, suicide/homicide, and referrals. He seemed pleased and appreciative of a new means of conceptualizing cases and organizing information. I found that most of these counselors have received a minimum, if any, of class work related to psychotherapy, and most of their education was specific to HIV. I hope to enable them to do a full psycho-social assessment in order to rule out mental health issues. Otherwise, they see what is in front of them (HIV patient) and do not conceptualize beyond the presenting issue.

I then taught a class of three other HIV nurse counselors and one pastoral counselor. I again taught them genogram diagraming. Before starting the genogram however, we had a discussion of confidentiality issues. I’m all for confidentiality, but they believe it is best not to have written charts and to keep everything in their mind. They fear that others will see their notes and compromise privacy. In addition they think it is disrespectful to take notes while in a session. They saw the benefit of genograms and enjoyed this way of organizing information from a systems perspective. At the end one counselor asked if it might be appropriate to keep notes in a private and secure drawer in case the patient returns in the future. The wheels are turning.

This issue has come up previously within the hospital. Standard operating procedure within the hospital is that when a patient is discharged, they receive a handwritten record of the diagnosis, treatment and medications on a notepad. It is written in English. There are many tribal languages represented in this area and the literacy rate is quite low, in any language. The medical note is given to the patient, not for the patient’s benefit, but for the next doctor they may see. They are expected to take it with them. I was told that minimal and multiple (three?) charts exist within the hospital. I’m not sure what function that serves.

I mentioned earlier that patient’s families come to the hospital and provide food and basic care. I was told today that this is a requirement for admission unless they have no family. Interesting.

Several of us took a walk again through the village where children and some adults wanted us to take their picture. I took a photo of a child, less than one year old, holding her mother’s cell phone. Picture extreme poverty, thatched huts with dirt floors and cell phones. This is further evidence of this undeveloped country leap frogging into the future. Cool.

Day Seven: 2/13/14

I met with Alba-Rose this morning, an HIV counselor. As with other nurses, I had her complete a psycho-social assessment that included goals and a treatment plan. She presented a case study of a particularly difficult patient that she saw. This case presented with a 15-year-old girl who came to the hospital in a borderline psychotic state following multiple losses. She never knew her father, her mother died when she was six years old, she then lived with her aunt who died when she was eight years old, then lived with her uncle who died when she was 10, then lived with another uncle who died when she was 12, then lived with her grandmother who recently died. I was pleased to find that the hospital started her on a sedative medication. She was aggressive toward women, and was calmer with men but for the most part was uncommunicative. By the end of her stay, she was more communicative but continued to have symptoms. She left the hospital to live with an uncle in a different village but will have access to a health center to continue medications for as long as she needs it and may have access to a counselor.

She told me of another difficult patient, a child, who had classic PTSD following the trauma of watching her father being murdered with a knife. She and her father were the only ones at home when robbers came to their home. They immediately killed her father. They told the child to show them where her father had money in the house, then told her to run or they would kill her also. She ran as far as she was able. She was told that if she identified any of the robbers to the police or community, they will kill her, which prohibits her from taking protective steps. She sees one of the robbers in the community and each time has reactive symptoms of PTSD which no one can understand because she can’t reveal what happened. This case is similar to those that I had read about in my trip preparation.

In addition to the assessment, I showed Alba-Rose how to use the DSM IV, which I am donating to the hospital, to make differential diagnoses and formulate ideas about how to treat patients.

In the afternoon I taught a class of eight. I presented on anxiety by having two counselors give case examples of anxious people, then read the DSM IV criteria for generalized anxiety, then asked them how they would treat such a patient. I received blank looks. Although they are familiar with a wide variety of mental illnesses, they have never been taught treatment tools to address them. I taught them relaxation tools and they seemed engaged.

One our way back to the hotel, I asked our driver if he could stop along the street so I could take a photo. He did so and the car was immediately swarmed by women trying to sell their wares. I bought a couple of bananas out of guilt.

I asked why so many people have cell phones when the poverty rate is so high. I was told that these cell phones are made in China and cost about $15. Some, but not many, have cameras which explains why the kids are so fascinated with our picture taking.

I was also told that the hospital caps out charges for any and all services at about $24. The hospital and beneficiaries fund the remainder. That is why patients are required to bring a family member as assistants. It keeps the costs down. That also explains why the hospital has inadequate medical equipment. They are making due with so little. Did I mention that they have no oxygen? and no plasma?

One of our doctors, an OBGYN, told me of his day. I will spare you details, let’s just say it’s gruesome. He is documenting his surgeries and showed me photos. Wow.

By the way, I had thought that some of the counselors were more than bachelor level trained. It turns out it is not true. They have minimal training in counseling. It appears that they have hands on experience because they are the front line in mental illness, but they have not been given any training in therapeutic techniques.

Because domestic violence is a serious problem in Uganda, I was pleased to hear that one of the male counselors addresses family issues, such as violence, in a weekly radio program. He said the program is suspended right now due to funding shortages but he hopes they will resume it.

One of the Rotary coordinators has expressed an interest in the treatment of male batterers. She said this is an area that is untouched in Africa and may consider developing a program.

Day Eight: 2/14/14 Happy Valentine’s Day

My morning class was cancelled due to another scheduled meeting so I sat in on an impromptu talk with people from the community that are at the hospital as family members/care givers to patients. This consisted primarily of women and children. They do not speak English so one of the counselors translated. The presenter was late. The community members thought I was the one they were waiting for, since I’m a new face, the only white person around, and kept looking at me expectantly. My counselors encouraged me to lead them in the relaxation exercises that we did yesterday in class. So I did. They seemed to really enjoy it, with giggling. I was able to teach them some Tai Chi, Emotionally Focused Therapy, therapeutic holds and belly breathing. When the presenter came, I turned over the crowd to her. How fun!

The majority of these women farm to produce food to feed their family, however, do not consider themselves workers. They rise before their husbands, feed the family and do household chores and go to bed after their husbands, yet they think their husbands work, but not themselves. They think this because their husbands buy school uniforms and other things for their children once every two years. The speaker challenged this belief, stating that they work to feed their families every day, and the money the husband saves is because she farms and is able to feed their family. She addressed family management by asking how many children they have.  Some have 10 or 12 children. She asked if they know how old she is, 70, and how old they are. After having 12 children they appear quite old. She asked if she will make trouble for them if they challenge their husbands to value them as workers, or to use family planning measures to reduce pregnancy rates. They admit they will be beaten. She challenged them to keep their girls in school. One woman said she had paid for a uniform for her daughter who had to drop out of school because she became pregnant by a boy at school. It is not clear whether she meant by rape or a love relationship. Another said that girls have disappeared after leaving school and never came home. They want better security for their children after school, on their way home. I had read about the abduction of girls who become sex slaves.

I met with a counselor in a one-on-one session. He presented two cases in which alcohol problems were evident. He had one case on the adult unit in which he works, and a second case outside of the hospital. He is chairman of an association that gives social awareness talks on radio. This association provides funding for the radio broadcasts, which is now suspended. Because he is on the radio, he is contacted by people in the general community requesting help. He agreed to visit this person and his wife. His wife has threatened to leave him. He has already lost three previous wives due to his drinking. We discussed the use of CAGE as an assessment tool and screening for need for a medical detox. This counselor informed me that they don’t do a detox at the hospital but he thinks they should. I told him I had brought alcohol detox protocol material and will give it to him. He can follow up with the medical staff to encourage them to start doing detoxes. He had never heard of AA, but after discussion he said that he knows someone in Kampala who may be of help in this regard, and he asked for the contact information of AA.

I then met with the counselors to identify and treat depression using Cognitive Therapy. They seemed to grasp the concepts as evidenced by a comment that they can now “help patients help themselves.” We’ve developed a good relationship and can better understand each other and are relaxed and share humor. I get a kick out of their names, some names for example have meanings such as “The Best,” “Outdoors is bad,” “Oil,” “Leadership is the devil.”

I’ve heard two stories today that demonstrate some cultural aspects of Uganda. First, Jim, our librarian and photographer, told me of a photo he took. He saw two men trying to transport a very sick man on a motorcycle. This man had bandages around his chin and head. His feet were strapped onto the motorcycle so that they wouldn’t fall and he was bundled in a sheet. He was placed between the driver and another man behind him. It turned out that the man was not sick, but he was dead. They were taking him to his village for burial. There are few ambulances here. They make due with what resources they have. I saw an ambulance but it was ill equipped, if at all. It looked like a standard jeep and in this case, it was not in working order. None of our doctors know where the man came from, or if he was ever admitted to the hospital. It is a mystery.

Second, one of our team medical doctors told me of a patient that came to the hospital today. This was a 28-year-old woman who is seven months pregnant. She must have experienced some conflict with people in her village because she believed that they took her baby from her. She was still obviously pregnant and had not miscarried. She went to the witch doctor who found the three people who “spirited her baby from her,” tortured them, and they then returned her baby. She had come to the hospital to get confirmation that her baby was returned to her.

I’m told that the function of a witch doctor is to seek revenge on people, or some such spiritual intervention and that they do not have good intentions. Medicine men on the other hand have some knowledge of natural remedies and have good intentions. If all else fails, go to the hospital. But if you can’t be healed at the hospital, return to the witch doctor.

Day Nine: 2/15/14 We have two days off now, Sat and Sun.

Let me say a word about the food here. For breakfast each day we have bread with butter and jam, a hard-boiled egg and hot tea. They’ve served us a boxed lunch where we work which consists of things like boiled potatoes; a type of bread that is fried; a Somoza (?) which is a fried square or triangle shape with either lentils, peas or corn inside – it’s quite tasty to us Americans but too greasy; maybe another egg; perhaps cooked sausage; one day we had a sandwich made of a fried egg and tomato. Dinners usually consist of some variation of cooked bananas, rice, beans, Tilapia – which is delicious, or a beef dish which is usually in a broth sauce, cabbage, and a maize dish. There is normally a type of fruit such as pineapple or watermelon. We are served a variety of bottled sodas and water. There is no ice. We are given three bottles of water per day and can always buy more if needed.

I find that I don’t eat much because the food is unfamiliar and I don’t have a taste for it. The foods that I normally crave are not available here. I mentioned that I have a craving for chocolate and one of our team members gave me some of hers. What a treat!

We’ve been here long enough that our team has formed good relationships with the people they work with. I’ve heard several people talk of wanting to give money, or equipment to particular people. One doctor has expressed an interest in paying the expenses for a Ugandan doctor to visit the US for a modern experience of medicine in a developed country. He also agreed to fund a girl’s education because her mother died and her father doesn’t want to continue her education. I have thoughts of leaving some money to help the counselor’s radio program on family issues, and will ask that he continue discussions on domestic violence.

I met a woman who works for a NGO which provides services to domestic violence victims in the Nebbi district. In addition to counseling, they have a shelter. She provides legal counsel and will go to court with the victims. I hadn’t realized this was possible in Uganda. Hooray!

According to my research, women and men believe that violence is justified in certain circumstances. 90% of women and 70% of men viewed beating of females justifiable when a woman refused to have sex with their partner; when a woman used contraception without permission of her partner; and if the woman was unfaithful. The primary reason for DV is women neglecting their household chores; disobeying their husband/elders; refusal of sex (related to the belief that their partners are HIV+); have arguments over money; women’s insistence on the use of condoms; and women suspected to be HIV+.

We traveled to Arua today which is a one hour drive northwest, near Congo. We went to a market seeking souvenirs. This was about the size of a city block. They had beautiful fabric for sale. Most of the other items for sale were second hand items. I’ve been told that second hand stores in the US, like Goodwill, box up the items that they can’t sell and ship them to undeveloped countries for pennies on the dollar. I could have been looking at cast off items from my own closet. We saw a woman with a Chicago Cubs T-shirt. We also saw a storefront restaurant by the name of Chicago Foods, but the food didn’t look American.

One of our doctors was able to speak to his wife last night via Facetime. I tried it tonight and was able to see and speak to my husband. Technology is amazing and I am forever grateful.

Day Ten: 2/16/14

We have another day off. I did some laundry in the sink. This is the first day I asked to have my hotel room cleaned. I prepared my materials for teaching this week, went to the market twice to show others where it is, and ended the day playing Wheel of Fortune on my IPad. Wifi is off until tomorrow.

There is much discussion of going home. We are winding down and have only three more days of teaching, then an ending ceremony in which the King is expected to attend. The King has expressed an intention of making previous meetings and failed to attend, so we were told it may not happen.

Day Eleven: 2/17/14

Good day. I presented on anger management to a new group of counselors this morning. They seemed to really enjoy it. I then met in a one-on-one session with another counselor. I then presented on addictions to my usual afternoon class. This was also well received.

I spoke with one Ugandan nurse while we waited for the rest of the class to come. (“There is no hurry in Africa”) This was time well spent because I learned a lot from him. He works in the Nutrition ward. I assumed that he provided nutrition advice to patients. Wrong. He works with malnourished children. The ages on the unit today, range from six months to nine years old. The hospital goal is to increase their body weight by 20% before discharging them. We discussed how and why children are malnourished. Perhaps a mother died; a grandmother is ill equipped to raise the child due to poverty; or perhaps their mother remarried and the new husband does not want the child. They do not have an adoption agency in this area but sometimes a child can be transferred to an adoption agency. Most often however, a family member will keep the child within the family. One of the duties of this nurse is community outreach. He goes into the community every Thursday to meet with women and children to provide immunizations and check baby weight. Occasionally, a baby is admitted to the hospital.

In my one-on-one meeting with an HIV nurse counselor, we discussed boundaries. This nurse is especially kind hearted. She told me that she takes children home with her at times – similar to our foster placements. She has three kids with her now. I inquired into professional burnout and told her that dual relationships are frowned upon in America. She appeared surprised and perplexed.

I also inquired into mental illness. Do they screen for mental illness in community outreach? I found that there are more services for the mentally ill than I had thought. If the hospital cannot provide adequate care, they are referred to the Nebbi District hospital. If that hospital cannot adequately serve them, they are referred to Arua Hospital who has a psychiatrist on staff. (I am aware however, that our terms may be different. A trained psychiatrist in the US may not be what they are referring to when speaking of a psychiatrist. I was told that medical school teaches comprehensive medicine. An MD may have a bit more training in psychology, but is not a specialist.) If that doesn’t adequately care for the mentally ill patient, they are referred to Kampala. Sometimes the hospitals provide transportation. All of these facilities can, and do, provide psycho tropic medications. The image that I saw several times in preparation of this trip, was that of mentally ill people being chained to a tree or bed in order to keep them and others safe. I asked whether the material I read was wrong. I was told that it may have been true in the past, even as late as 2005, but is no longer true.

Prior to leaving for this trip, I was told by a Galena Rotary member that what one hears about a country is ten times worse than reality. That may well be accurate.

Day Twelve: 2/18/14

I have more material I would like to teach but can’t fit it all in. A 2008 survey indicated that Northern Uganda has one of the world’s highest rates of mental illness. The prevalence of PTSD in this area is higher than that ever recorded anywhere in the world. I had prepared material on mental health triage and the development of support groups as a mitigating factor against PTSD, but was unable to present it this morning.

I have several recommendations for the hospital board upon my departure:

1. The role of the counselor needs further definition. It might be helpful to separate the duties of the counselors from the duties of nurses. They currently serve both functions and have reporting duties to nurses. Therefore they are limited in the function and scope of mental illness they could serve.

2. The counselors could benefit from professional development in the area of psychotherapy. These counselors have excellent basic counseling skills of rapport building, active listening, empathy and kindness. Their training does not cover psychotherapy skills. For example, they may identify depression, grief, anxiety or PTSD but they lack sufficient intervention tools. They need continued education in intervention techniques and they need to develop a professional identity as therapist.

3. The counselors could benefit from meeting as a unit for case consultation and supervision. I found that they are treating a wide variety of problems and a population with severe conditions. Supervision can help them conceptualize issues, ensure a broad psycho-social assessment and teach therapeutic intervention skills. Meeting as a unit also provides peer support that is helpful to avoid burnout.

4. I recommend that they do community outreach in the form of developing community support groups. One study showed that Sudanese refugee children had higher levels of psychological distress compared to Ugandan children due to their lower levels of social support. “The tendency of traumatized children to report more psychological problems, diagnostic and otherwise has been found to be associated with the occurrence of more daily stressors and less perceived social support.” (African Journal of Psychiatry, Nov. 2007) Given the lack of funds available for staffing, I recommend peer led support groups be developed. Counselors could initiate and train volunteers in basic counseling skills, group facilitation skills.

5. I recommend that mental health providers in Nebbi District from the hospital and from the community attend to mental health triage. They could benefit from a crisis hotline to ensure service delivery to the mentally ill who are unable to access a hospital or health clinic. This is a service that could be shared by area hospitals and health clinics.

6. I recommend that alternative forms of outreach be supported and funded, such as radio programming on psycho-social issues. This will provide preventive care to the community and can influence undesired attitudes and behaviors such as domestic violence and sexual assault.

I met with the nursing counselors in the afternoon. I tried again, with success, to discuss the prevalence of mental illness in this area and the need for mental health triage services such as support groups and a crisis hot line. They see these as important aspects of mental health prevention but are aware of barriers. There is an expectation of reimbursement for services such as being a group leader, and an expectation of the provision of food while they meet. I wondered if there might be an over-reliance on for funds and food. We talked about possible help among church groups or government services to mobilize support groups.

We also talked about domestic violence and sexual assault utilizing Power and Control Wheels. I provided information on how to treat victims in counseling. They were unaware that there is a battered woman’s shelter and legal advocate in Nebbi.

Post-script: Prior to our trip, our team was told not to discuss LGBT issues while in Uganda. I saw a newspaper on Sunday with headlines reporting that the Ugandan President, Museveni, signed a bill outlawing same sex behaviors. If we were to discuss LGBT issues with Ugandans, it could put them in jeopardy of suspicion and possible imprisonment. To my understanding, it is expected that if one knows of another’s LGBT orientation, they are expected to inform the police. I imagine that some may seek asylum outside of Uganda or face persecution. The popular opinion on why this is happening is that right wing Christian views have taken hold in Uganda, influencing political parties.

As we left Kampala to travel north, we noticed women and adolescents carrying yellow plastic water containers either on their heads or with the aid of bicycles. They access water in wells spaced along the highway. I was told that 90% or more of the wells in this area are contaminated. We brought water filters and water purification tablets with us but even these would not make the water safe for drinking. The tablets eliminate bacteria but not parasites. The water has to be boiled a minimum of three minutes before it is usable. Our work is located in a hospital and school. I’m told that the school’s well is slowly emptying and will be dry in three years. Rotary International is working on a project to replace the water system here.

Day Thirteen: 2/19/14

We are winding down our trip and this was our final day of teaching in our areas. This was supposed to be a slow day, especially considering I only had one afternoon class on the schedule. However, I found that my day was full. I was asked to teach to a community group of women in the morning with one of our medical doctors and the adult literacy instructor. We had a translator for this group because most of them do not speak English. This was a group of approximately 60 women who came from far and wide. Many of these women walked a great distance for this program. It was organized at the last minute into a Women’s Wellness seminar. The medical doctor spoke on essential vitamins from food groups, the adult literacy teacher spoke of empowerment through literacy and I spoke on PTSD, alcoholism and gender equality (domestic violence and sexual assault). I was also able to discuss the importance of community support groups and encouraged them to start their own groups. It was well received. I was pleased because I was able to do the presentation without my materials. So glad that I have retained some knowledge over the years:)

I then taught PTSD in my afternoon class. After reading the DSM IV diagnosis criteria and giving them treatment goals, I provided an overview of a therapeutic intervention called NET, Narrative Exposure Therapy. We also discussed secondary trauma and counselor burnout. I encouraged them to meet weekly for case consultation and to do self care. To drive the point home, I gave them a frisbee that I had purchased from home. Lots of laughter and play.

I had also sorted through my suitcase and found things I wanted to leave behind. I gave prizes to the first three counselors who came to the class: water filter bottle, toothbrush, products from the last time I was at a hotel – shampoo, conditioner and lotion. After lugging my books around all week, it felt great to leave them in the hospital library. My humanitarian suitcase is now empty and ready to be filled with souvenirs.

My role as a trauma counselor has no counterpart in this hospital or school setting. Our doctors worked directly with the hospital doctors. The nurses worked directly with the hospital nurses. The literacy teacher worked directly with adults in the community. The librarian worked in the library. The other trauma counselor worked directly with MEMPROW at the school. Although I worked with counselors, they were also nurses. I was the only team member that did not have a corresponding Ugandan professional to work with. The team is leaving recommendations regarding services to their counterparts. I’m concerned that there is no direct reporting structure for me. A Memprow staff person will return to this area every three months to do follow-up on our work to see that what we’ve started will be continued. In my case, no one will likely serve this function with the counselors I trained.

Many of our team members have expressed a desire to return to continue the work they started. In some ways, this trip can be considered a research and fact finding trip. Now that the assessment is made, they can return to better address the needs here.

I don’t feel compelled to return for a number of self-serving reasons. I don’t feel physically comfortable here: I’m constantly covered in dust. I don’t particularly like the diet. It’s draining to experience this level of poverty on a daily basis. But more important, I don’t think the governing body is prepared to build a mental health infrastructure. There needs to be an Ugandan mandate for improved mental health. I might consider returning under the direction of a mental health professional who would ensure sustainability after my departure.

Tomorrow the King is coming!

Day Fourteen: 2/20/14

I inserted myself into a meeting with the hospital head nurses and administrator. I was able to present my recommendations. It appeared that the administrator understood the scope of the problems and will begin to address them. I was informed that they have a referral and consultation arrangement with a psychiatrist. The administrator expressed an interest in getting that person to come to the hospital for supervision and training. He will also consider allowing some of the nursing counselors to pick a professional identity as one or the other. He did not comment on the needs for a crisis hotline or community support groups. So I am relieved to have given my opinion and will leave the hospital with a sense of completion.

There is a woodworking shop next to the hospital. They have built shelves and chairs for the library. One of the woodworkers also makes figurines and baskets. Our team went daily to see what new items he had to sell. I purchased some hand carved animals today. Beautiful work.

We waited for the King to arrive. I and two others played Wheel of Fortune on my IPad to kill time. The King finally arrived late afternoon. Crowds lined the street. His arrival was marked by 6-8 motorcycles doing wheelies. It was really quite dangerous and kicked up a lot of dust. He was greeted by the school and community the same way we were with music and dancing. There was an official program in which we were introduced. The Alure Kingdom Prime Minister gave an educational and inspiring speech, followed by a speech from the King.

I was surprised that the King has a bit of an English accent quite unlike other Ugandans and unlike other Alure people. He was dressed in a nice suit but wore a cap with a feather in it and he was fairly young (30-ish). There are certain customs regarding the King: he is the last to enter a building, he normally stops speaking in public at 5:00 p.m., and he has two palaces. The Alure kingdom has a population of 3,000,000 and is spread between northwest Uganda and Congo. Only 800,000 of the three million live in Uganda. It was described as a “kingdom without borders” and ends with the last person speaking Alure.

We part ways with three of our team mates as they head out to a one week safari. I will miss them.

Day Fifteen: 2/21/14

We left the hotel at 6:00 a.m. and boarded a bus for Kampala. We traveled through Murchison National Park and saw animals and birds: elephants, hippos, baboons, colobus monkeys, bee-eaters (birds), 3-4 varieties of antelope, bushbuck, warthogs, bison, and I’m probably forgetting a few. We missed the giraffes and rhinos. We stopped for brunch at a high-end safari lodge which was beautiful. It was a delicious buffet that offered many foods from home. They had a gift shop where I purchased souvenirs.

We proceeded to Kampala where the Gaba Rotary club members were waiting for us to arrive to serve us dinner. At the dinner we were each given a gift. All the women received a hand-made purse. I also received an African robe and a beaded basket. Lovely.

Day Sixteen: 2/22/14

We board the plane for home today. Parting thoughts:

The mission of the trip was a success. As a team we contributed much toward the improvement of education for girls, advanced their medical knowledge and technique in the area of pediatrics and obstetrics, improved their knowledge of mental illness, impressed upon them the importance of sound nursing protocols, expanded upon their knowledge of nutrition and agriculture, greatly enhanced their library and addressed empowerment through literacy. That is a lot of work in a two-week period.

The Gaba Rotary Club is to be thanked for their dedication, vision and work to make this happen. They are located in Kampala which is a minimum of an eight-hour drive from Nebbi and yet there was always a Rotary member present with us. They took time from their jobs and lives to ensure that the project proceeded as planned. They are the leaders of their community and are especially kind.

MEMPROW staff were also kind and dedicated to the overall project as well as functioned in their respective job tasks within their organization. They were immensely helpful in translating, coordinating our transportation and giving us water each day. Hilda Tadria is an unstoppable force of energy, guidance and vision.

Carter Newton from the Galena, Illinois Rotary Club co-wrote the grant with Eunice Chidria from the Gaba Rotary Club. They envisioned the project which we enacted. It took months to write the grant.

Upon our arrival in Nebbi and throughout our stay our team heard frequent cries of “Muzungo!” This is the word for white people. Many people from Nebbi had never interacted with white people. Children had never seen white people. Those who speak English had difficulty with our speech and those who speak their native language required translation. But in any language we were welcomed and warmly treated.

Thanks also to Ken Davis, my husband, who was supportive in every way. He helped me prepare for the trip in terms of gear and technology, he covered my responsibilities at home and work and was my life line.