2014-Heilke-MatthiasMatthias Heilke

My colleagues asked me to write a retrospective of my twelve weeks at CEHURD. Much as I am looking forward to cheese curds, CanLII, and public transit, it has been a spectacular summer. I came to Uganda hoping to learn about how law interacts with ground realities to produce good or bad outcomes. My experiences here taught me a great many things about working in law, and the issues surrounding ground realities were chief among them. The real lessons tend to be fairly specific, so this summary is slightly trite, but bear with me anyway.

Let’s start out really obvious: ground realities are shocking. I spent some time on a lawsuit against a hospital whose doctor took several hours to attend to a woman named Irene, even though she had a ruptured uterus. Irene ended her life begging for mercy while her husband watched helpless. Around a quarter of HIV-positive Ugandans do not receive public anti-retroviral treatment — yet HIV-positive mothers are sometimes forced by their families to breast-feed their children, giving them HIV in turn. I have read hundreds of pages of Ugandan health policy, and much of it is first-rate. But policy solves nothing without implementation, in which case it isn’t much comfort to Irene’s family.

People are varied and pragmatic, and Ugandans are as varied and pragmatic as anyone. At a trivial level, people’s response to a mzungu varied from cynical opportunism to kind hospitality — more of the latter, happily! Less trivially: many doctors in Uganda demand bribes from the patients, even when the patients’ conditions are life-threatening. However, there are also Ugandan doctors who travel long distances by motorcycle to deliver urgent care to patients who cannot reach the hospital. Others even pay for emergency treatments out of pocket when the patient is destitute. Health interventions tend to aim at the median of the target group — that isn’t a bad thing — but it is worth remembering that generalizations about a country of thirty million are, well, generalizations.

Gender relations and other inequalities have an enormous impact on access to health, especially as it relates to combatting HIV. Both women and men hate to get tested, and rarely tell sexual partners their HIV status — men because nobody will sleep with an HIV-positive person, and women both for that reason and because they are afraid their husbands will throw them out. Wives don’t always have a choice about whether to sleep with their husbands, which also transmits HIV. Health centres try to overcome the testing barrier by including HIV testing with regular services like antenatal care — but men see ANC as a women’s job, don’t like sitting in waiting rooms full of women, and don’t come. Then the health centres resort to discrimination to try to bring in the men. NGO’s, incidentally, make the problem worse — NGO’s usually present testing men as just another way to protect women and children, so men don’t perceive the health benefit to themselves. Poverty has comparable effects: the impoverished lack resources to protect themselves against exploitation, and yet cannot afford to be exploited. Reduce inequality, and the right to health improves.

However, the dominant issue I have seen everywhere this summer is limited capacities. I went on a field visit in June to meet with doctors. They complained of lacking surgical gloves, blades, and essential medicines. Boxes of pharmaceuticals reach health centres almost empty. Health centres never receive the beds they need. There are never any funds to repair equipment — if something breaks, it just rusts. Private health providers pop up everywhere to fill the gaps, but many people cannot afford to pay — so they die instead. Private clinics are often run by public doctors; doctors barely earn a subsistence wage, so they illicitly open private clinics and try to force patients to use their clinics instead of the health centres. Policies can ameliorate such problems: for instance, donors should always budget for training and repairs, and good lines of accountability keep corruption in check. That said, funding levels always limit services, and that in turn limits outcomes.

Limited capacities also affect the law. Good policymaking takes time and expertise, and time and expertise cost money. Uganda does not always end up with the laws, regulations, and programmes it deserves, simply because the funds are lacking to create innovative solutions. CSO’s are constrained, too — there are ideas and strategies that CEHURD would undoubtedly pursue much further if there were donors to support them. Just like doctors and patients, policymakers, lawyers and CSO’s have to make do with what they have.

However, there is reason to hope. At a grand level, Uganda’s health is improving: more people are getting vaccines, ARV’s, etc.; health facilities are slowly improving; people are living longer. At the ground level, the people I met, from elites to subsistence farmers, pay attention to health issues, are learning how to make the most of their situations, and are ready to hold the authorities accountable for upholding Ugandans’ right to health. Dear authorities, take note. People are unusually afraid of the future in Uganda — Milton Obote, Idi Amin, and Joseph Kony (among many others) have given people good reasons to think of the current peace as an aberration — but Uganda is getting wealthier, and its people increasingly want a hard look at how that wealth is spent. Health is improving, and expect it to improve a whole lot more.

A Light Comment on Small Change

2014-Heilke-MatthiasMatthias Heilke

The stuff I have been working on the last couple weeks is a bit intense. Also, I already wrote a blog post about it for CEHURD, which you can (and totally should!) read here. So let’s talk about currency instead.

Uganda has a fairly annoying system of money to handle. The smallest bill is worth 1000/= (“/=” means “shillings”), which is the equivalent of about forty cents. The bills go up to 50,000/= ($20); they are all different colours, but the actual colour of a given denomination might vary depending on age, the 1000/= and 2000/= bills are often too dirty to see well, and anyway I’m colour-blind. Coins run from the diminutive 50/= to the two-piece 1000/=, though the 1000/= coin is less common than the 1000/= bill. The 100/= and 200/= coin are most common, and annoying to distinguish from each other — they’re just very slightly different sizes.

All bills and coins, arranged small-to-large, left-to-right.

All bills and coins, arranged small-to-large, left-to-right.

This is not a wealthy country. If I am walking down the street with 100,000/= ($40) in my pocket, I’m pretty loaded by local standards. Breaking a 50,000/= note is a chore. Any time I have to use the equivalent of a two-dollar bill to pay a fruit vendor, I know she will probably have to run into the nearest shop for change. One of my friends once used a 2,000/= bill (80¢) to pay a fruit vendor, and the vendor commented on what a large bill that is.

I bring this up because of what you don’t see on the street: the 50/= coin. Nobody ever prices anything, down to the tiniest piece of fruit, to divisions smaller than 100/=. In a place where the boda-boda drivers (which is a comparatively well-paying profession) will haggle endlessly over a 2000/= fare, nobody would think to worry about 50/=.  And 50/= is worth twice as much as a penny.

I’m just saying, America.

We don’t have antimalarial injections, so if they can’t swallow, too bad.

2014-Heilke-Matthias Matthias Heilke

I spent most of this week on a “field visit”. With a few colleagues, I went to a remote district of Uganda to interview doctors and residents about the state of healthcare in their district and what they wanted to improve. Being the junior member of the team, I acted as a photographer and occasional recorder.

Healthcare in Uganda is, in principle, universal and public. There are government health centres throughout the rural districts, varying in size from the tiny Health Centre I, which provides basic counselling, injections, and tests, to the Health Centre IV, which is effectively a mini-hospital. We interviewed the “in-charge” at several health centres of sizes II to IV.

7% of the babies this health centre delivered in April died. (In fairness, two deaths were probably premature births.)

7% of the pregnancies this health centre managed in April led to the child’s death.

~The standard line~
The in-charge of a health centre is always a doctor or a nurse — a civil servant. When you ask Ugandan civil servants about their situation, their responses follows a standard formula. They share a comprehensive list of problems, which are both numerous and drastic, but their tone treats each problem as a little storm that they are weathering in an otherwise smooth sea, even when the problem means patients dying en masse.

We don’t have enough of the vital medications, says every in-charge we interview. We have an anaesthetic machine, but no nitrogen or oxygen, or for that matter anaesthetic. If we refer the patient like we’re supposed to, the next centre won’t have supplies either, and the patient will die before they reach someplace that does. We have no water, just a cistern. There’s an electrical pole on the grounds, but we haven’t been connected. There is no incinerator, so if an epidemic starts in the hospital it will spread to the whole district as birds carry away the medical waste.

Then, at any given health centre, the in-charges give us a tour of the health facility. He shows us crumbling buildings with beds either missing (never delivered) or broken and filthy. He points out the gurney that, for lack of a spare, has to run between the operating theatre and the ward, so that germs travel with it between the rooms. He shows us the enormous crowds of listless patients.

A maternity ward.

A maternity ward.

And all the in-charges smile helplessly, and sometimes they laugh.

~Throwing up your hands~
My last interview is with the in-charge at a higher-level health centre.[1] We read him our normal questions: what do you think about the legislative Health Care Package, how should we change the Millennium Development Goals, what problems do you face, etc. The doctor responds with the normal answers and follows the standard line.

About thirty seconds after we have asked our last question, the in-charge suddenly gets angry.

— There are procedures that I know how to do, but I can’t do them, because I don’t have the materials I’m supposed to get. And they send us the right number of cartons, but then you open the carton, and there’s just one tin of medicine in the bottom and the rest is empty. The people see I get boxes and boxes of medicine, so they think I am holding out on them, but I don’t have what they need.

What the in-charge means is, his patients think he either is stealing the medicine for profit or wants a bribe. Both happen regularly in Uganda, though the government is trying to crack down on it.

— The test kits for malaria are low-quality — they keep giving false negatives. We aren’t supposed to treat someone unless it’s positive — but I know what malaria symptoms are! And if you send someone home, they’ll just come back the next day with complications. So what to do?

The in-charge and my colleague digress into their experiences with malaria before the in-charge returns to his complaint.

— I have IV equipment, but I don’t have any saline solution. So what am I supposed to do if someone is dehydrated? I can do great work if I have surgical gloves. But I don’t have any. I tell my patients to bring them to me, but they cost three thousand shillings,[2] and they can’t afford that. So I can’t help them. What do you say about that?

The doctor and my colleague look at me expectantly. Happily, six years of education at McGill have honed my impromptu analytical skills.

— It’s crazy, I say. The other two accept the answer.

With the interview completed, we follow the in-charge outside, where a pair of women are waiting awkwardly in the shade.

— I bet they brought razor blades.

The in-charge snaps at the younger woman in the local language, and sure enough, she hands the doctor a safety-razor blade in a paper wrapper. He unwraps one edge and holds it up to my camera.


— She has sutures that have to come out. But do you think this razor is sanitary? I’m not allowed to use it. But I don’t have any surgical blades, and the sutures will start tearing soon. So what am I supposed to do?

My colleague says that he probably shouldn’t use the razor blade — if there is an infection afterward, the woman might discover that she can sue him, and win. But the in-charge rewraps the blade carefully and hands it back to the woman before we walk away. The sutures have to come out.

As we say our goodbyes, the in-charge remembers that he is Ugandan.

— We’re facing the challenges, but we’re working through it, he says, shaking our hands.

I am not Ugandan; I believe his anger more.

~Weekly miscellany~
• Rural doctors generally assume that Mulago Hospital, the national referral hospital in Kampala, will have adequate medical supplies. When I mentioned to an in-charge that Mulago regularly runs out of basic necessities, he was surprised and unimpressed.
• Some highways have enormous, bold-lettered signs along the road providing such sage advice as “SAFETY FIRST”, “DRIVING ON SHOULDER PROHIBITED”, “SPEED KILLS; DIVORCE IT” and, oddly, “AIDS KILLS”. Just in case drivers are having unprotected sex as they drive down the highway, I guess.
• Uganda has a government newspaper, the New Vision. It publishes a weekly children’s supplement, consisting of the sort of kids’ games you would expect. One such game is a “spot-the-difference”, in which the two pictures are of “your hero”, President Museveni.
• Among African countries, the national football team’s jersey reads like a commentary on the country’s state of governance. Uganda’s jersey is okay but changes constantly to meet the advertising needs of the team’s sponsors, Nigeria’s is quite professional, South Africa’s is European-level, South Sudan’s is really just a logo on a plain jersey, and the DRC’s makes elementary school jerseys look high-quality by comparison.[3]
• Another tasty soft drink: Stoney Tangawizi, a Coca-Cola product. It’s essentially ginger beer. I’m not generally a ginger beer fan, but this one tastes a bit different.

[1] I do not have the recording of this interview, and it was not written down verbatim — I am going off memory and basic notes as best I can. Hence, this account is impressionistically faithful but ultimately consists of paraphrases, not actual quotes. It is also compressed, for the sake of space.
[2] About $1.20. A high-up district leader we interviewed earlier in the week figured a poorer family of six might earn 700,000 shillings per year — about 15¢ per person per day — so $1.20 is serious money.
[3] And you can totally expect to see me wearing my red DRC jersey proudly in the halls of McGill next year. Or either of two Uganda jerseys, or a long-sleeved South Sudan jersey. Or any of several non-African jerseys. They’re really cheap, okay?

An Introductory Post

2014-Heilke-MatthiasMatthias Heilke

Since this is my first post — the blog just started functioning a few minutes ago! — please allow me to introduce myself. I just finished my second year at McGill Law, and I am pleased to be spending my summer in Kampala, the capital of Uganda. I will mostly be working at the Centre for Health, Human Rights, and Development (CEHURD), a local health-law NGO that does everything from lobbying to community education to strategic litigation.

There are lots of blogs about what it is like to be a clueless muzungu (white person) making his first visit to a developing country, so do not expect too many words about it here. Just compose something in your head about gruelling poverty, getting lost for lack of road signs and addresses, and the dangers of riding a boda-boda (motorcycle taxi), and you will probably get the right idea. (And please try to make me look good in whatever you think up!)

~What I’m up to~

As of writing, I have spent exactly three weeks working at CEHURD — it would be a day more, except I couldn’t find the CEHURD office on my first day of work. Google Maps lied to me! I have done a whole bunch of things, so I’ll just list them:

• Intellectual property rights. Patents especially have an enormous and mostly negative effect on access to medicine in developing countries. I spent a couple days in meetings at the Ministry of Justice, going through their draft regulations on patents with the aim of promoting access to medicine. As of those meetings, I have influenced Ugandan government far more than Canadian government! Now we are meeting with some of the stakeholders, especially other health NGO’s and local generic pharmaceutical producers.

• Strategic litigation. CEHURD has a substantial strategic litigation department, and I have done [privileged] with them. We’re [privileged]ing. It’s really [privileged]!

• Also some strategic litigation that I can actually talk about, as we held a press conference about it this morning at our office. Long story short, there are two villages near Kampala whose source of drinking water is being contaminated by a Chinese quarrying company. They also are getting covered in stone dust and being subjected to the noise of explosions, all of which is leading to serious health problems. The local government and the responsible national governmental body refused to do anything about it. CEHURD is filing a suit against all three actors. I got to help edit the plaint.

CEHURD's press conference venue, a.k.a. the courtyard of our office.

CEHURD’s press conference venue, a.k.a. the courtyard of our office.

• Non-communicable diseases. CEHURD is following up on a study it did last year for the UNDP on NCD awareness and prevention at Kampalan universities, and I am helping coordinate ideas, prepare documents and so-on. It is an enormous challenge: I have no experience with this kind of work or programme, and I have literally never stepped foot on a Ugandan campus. On the other hand, it turns out students are pretty much the same everywhere (read: underslept, undernourished, and oversexed).

• Communicable diseases. I have listened rather than participated, per se, in various conversations about HIV advocacy. I also had a lively debate with one of my coworkers as to whether being HIV-positive increases one’s duty of care toward others to not get your blood on them. I said yes morally but was agnostic legally; my coworker said no to both. People suffering from HIV also suffer outrageous discrimination and ill will here, so there is a very emotional context.

 ~What I’m not up to~

There are a couple items currently in the news related to CEHURD’s work in which I have not in any sense participated:

• An HIV-positive nurse was convicted a few days ago of criminal negligence after she pricked herself with a needle and then, after going to clean up, allegedly accidentally used the needle on her infant patient. The hospital administered anti-retrovirals, and the child is HIV-free, but the nurse was nonetheless sentenced to three years imprisonment (prosecution requested six years). The case has turned into a public litmus test as to how one sees people with HIV. The nurse was represented by CEHURD’s very own Counsellor David (though, I should emphasize, I have not heard him talk about the case, and what I mention here is all public information.)

• A public interest lawyer has filed a suit against the government regarding this year’s budget, on the grounds that the budget provides so little funding to primary education that it violates the right to education. It will be a very interesting case, but sadly not one in which CEHURD is involved — the lady who filed the petition is not with our organization.

I’m afraid this blog post is less incisive than I might hope for. Such is the way of introductions. I promise the next post will be about just one topic!

~Weekly Miscellany~

• Many thanks to Prof. Richard Gold for teaching me intellectual property law. I had no trouble keeping up with the discussions at the Ministry, even though I had been in Uganda for less than a week. In a job where I know basically nothing about most of the topics I work on, that is a major victory.

• Currently trending in Kampala: “TGE”. It’s an acronym for a Lugundu phrase that means, “The government should intervene!” You say it if you cut your finger, for example.

• One Ugandan beer company, Tusker’s, advertises itself as “authentically American”. I doubt whether its customers have caught on to the joke. I have not had the opportunity to try it for myself, yet, being preoccupied with waragi (the local millet gin), but I will get back to you with my thoughts when I do.

• Novida. It’s a non-alcoholic malt beverage that tastes like pineapples. Why Schweppes (the maker) doesn’t sell it worldwide is beyond me. So good.

• My coworkers are seriously nice. Not that amusing an observation or anything, but true and worth saying.

• Habs sweaters seen in Kampala: 1. [Update: 2. The latter was for sale in Owino Market starting at 10,000 shillings, rather stained, but with its Village des valeurs tag still attached.]

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