Back in Durham

Back in Durham...sorely missing Kampala, but feeling invigorated by the experiences of the past week. We were fortunate to have met 3rd and 5th year medical students from Makerere School of Medicine last Thursday. We had a great time comparing our curriculum's (they have been practicing with "problem based learning" for a few years now) and talking about medical outreach projects they conduct in rural Uganda. In their own way, they are addressing the HRH issue by committing to long-term projects in these respective communities. The students are responsible for identifying a medical/public health issue and coming up with solutions which they implement over the course of 2-3 years (the projects start in the 3rd year; students complete 5 years of medical school).



On another note, I was quite pleased with the various public health messages displayed across billboards in Kampala! Among the more common ads were ones that alerted viewers against cross-generational sex in order to fight the spread of HIV among girls and women. New Vision, a Ugandan daily newspaper reported in August 2007 that several studies have found HIV prevalence among girls ages 15 to 24 to be four times higher than boys in the same age group in Uganda.

On our way out...

A hectic schedule and lack of convenient internet access have kept me from posting since arriving. Although the official conference ended Wednesday night, there have been additional sessions over the past two days. Some highlights included developing an International NGO Code of Conduct for Health Systems Strengthening (paying tribute to the sometimes detrimental impact international NGOs can have on the health care worker shortage or situation in many developing countries) and hearing the experiences of the Strathmore Business School in Nairobi, Kenya in developing health management training programs. With 1000+ participants here in one place our research and learning has really been at maximum capacity and efficiency!! It was without a doubt a great decision to spend the week here and connect with so many interesting individuals.

This morning I also had the chance to leave the conference "bubble" and experience some realities of downtown Kampala... markets, rolexes, bora-boras, and more. I'm racing against a low battery so next report later (perhaps from Durham!)

Wednesday in Kampala

Wednesday was a busy day. We continued networking and the Session on how the private sector can help the manpower shortage in health care workers was wonderfully led by Kathy Cahill from the Gates Foundation. Certainly the whole Duke team is to be congratulated for organizing such an interesting and informative panel and session. There were 60 minutes of prepared comments by the panel followed by an hour of discussion - a real interaction between the audience and the panel. We were left with the reminder that "the big trees need to nurture the little trees". The afternoon was spent in conversation - the students continuing their interviews and Dr. Merson rekindling old relationships and making new ones. There is a great sense of optimism that new collaborations and programs will originate from this meeting. Geelea Seaford is also to be thanked for her seemingly effortless manner in keeping us all in line and on track.

Being a student in this part of the world...

...is not so different, I find, from being a student at Duke.  Okay, so I should've prefaced the title statement by saying, "Other than the massive differences in tuition, the excruciatingly small chance of being accepted into a grad program in healthcare (or even making it past secondary school),  the small amount of job mobility, and the striking difference in salary and working conditions, being a student in this part of the world is not so different..."

I was extremely lucky to be contacted by a woman at the WHO last week, and she asked me to be on a panel during the conference related to strengthening the pipeline of healthcare professionals (mainly by easing the entrance of students into academic settings & supporting them during the educational process).  Today, I met the other students on tomorrow's panel, and the five of us sat talking for nearly 3 hours about the similarities, differences, challenges, and motivating factors of being a healthcare student. What was so striking to me was how all 5 of us - a 5th year medical student from Rwanda, a 4th year nursing student from Ghana, a 4th year pharmacy student from Swaziland, a NP/MPH student from Hopkins (my alma matter for nursing school as well...which was a fun small-world connection), and me, a registered nurse & first-year MBA student in Health Sector Management - are motivated predominantly by the same factors in terms of our career. Upward mobility, ongoing education, keeping all career doors open, and making a difference in the world (and especially in healthcare) were the themes that were continually repeated in the conversation. Salary, certainly, is a motivating factor as well, but there's a real feeling that having possibilities to effect change in this world and to effect it in different capacities throughout our lives, is extremely important.

The three African colleagues in the discussion talked of migration (a theme that the conference is examining in detail), and all of them plan to work or pursue advanced degrees abroad. We heard last night from the Minister of Finance in Ghana that there are more Ghanaian doctors working in the state of New York today than are working in the Ghanaian public health system.  In Ethiopia, we've been told, 70% of clinicians leave the public sector (some to private sector and most to other countries). The "brain drain" is severe in almost every African nation, but I cannot blame a single student or practitioner for taking advantage of the activities.  It was really interesting though, to leave the high-level, officially sanctioned panel discussions about migration and the health worker shortage and speak openly, honestly, and student-to-student about the challenges and opportunities that lie ahead for us.

So, perhaps it is a generational trend (young 20- & 30-somethings wanting to have a variety of career options and choices), or maybe it's just a human need (to better oneself and feel challenged).  In either case, I felt really inspired by the discussion and interaction today between colleagues from around the world - a great afternoon.

Discussions in the corridor

I have heard it said a few times already: It’s not what is being said at panel discussions that necessarily make an impact; rather, it is the discussions taking place in the hallways that make a difference. Attending my first WHO-sponsored conference has been eye-opening, to say the least. I have been an avid observer of the dynamics dictating a conference of this nature. The panel discussions have had their engaging moments—especially with distinguished speakers such as Anarfi-Asamoa Baah, Deputy-Director General WHO, whose humor has drawn many a laugh during serious matters; Rajat Gupta, Chair of the Global Fund to fight AIDS, Tuberculosis, and Malaria, and Bience Gawanas, the Commissioner for Social Affairs for the African Union and Task Force. However, the more fruitful conversations take place during our breaks and after planned sessions when we have a chance to approach such individuals and speak to them more about their projects. I’ve been amazed by the number of innovative projects and collaborations. Yesterday, I listened to a representative from Touch speak of collaboration with McKinsey and Co. and the Tanzanian government to scale up HRH training and capacity in schools across the country.
Being in this environment has been both tempering and invigorating. It has been tempering in the sense that in witnessing the dampening effects of bureaucracy and politics on effective policy change, I have started questioning my desire to be directly involved with organizations such as the WHO in my future career. Invigorating, given the innovation, research, and advocacy that is occurring globally among individuals and organizations
Just a few thoughts on the matter…this post hardly does justice to the past few days in Kampala. More to come soon.

Tuesday in the Pearl of East Africa

I continue to be amazed at the steady progress that Uganda has made in the last 35 years in spite of incredible adversity - particularly in the HIV/AIDS area. There has been steady progress in disease treatment, expansion of public health and an increasing percentage of students who gradtuate from high school and who subsequently complete technical and professional education. The people are friendly and hospitable and we are welcomed everywhere we go. The taxi drivers are full of information and conversation as are the wait staff. We hope that our endeavors here will pay off with collaborations in the future. We feel we have a lot to learn from each other.
The conference began in earnest today with morning plenary sessions that were very well attended and Kevin Schulman represented us very well. His comments were very well received. There was a parallel Human Resources for Health Research in Africa meeting in the morning and those attending were impressed with the initiation of the new Coordinated Research Group (ISHReCA) being formed across Africa that is chaired by Professor Nelson Sewankambo - the dean of the medical school at Makerere. The group was founded on the idea that it should be African led and based on problems that that are African - whether or not they cross borders. The Wellcome Trust gave a great overview of its philanthropy in Africa (they give 1 billion dollars a year in grants). The lunch and afternoon were spent in breakout sessions and networking interviews. It was a full day.
Many spent the evening at a small Turkish restaurant in town - see photo. We are certainly eating well on this trip. But we need the calories to be able to attend all the meetings - of course.

Reflections

The past 2 days of conferences have been both inspiring and disheartening. Inspiring because of the plainly visible passion and hard work very intelligent people have poured into their work; disheartening because despite all that passion and insight, human resources for healthcare (HRH) still remains such a big problem throughout the world.

A number of good points about HRH have been raised which I had previously not considered. One that was especially pertinent for the research we are doing was the point that in working to increase the supply of private sector doctors, one should ensure that those doctors aren’t simply being poached from the public sector. In other words, measuring increases in the quantities of doctors in a health system should take into account that some of them may simply have been redistributed. What this means for our work is that in identifying and accessing these high-quality models of, in my case, insurance schemes, some kind of metrics measuring this exact issue should be included.

Another point raised in a number of talks was the idea that monetary compensation isn’t the only factor in retaining healthcare workers. To be sure it is an important factor, but after a certain level other factors such as working environment, sufficiency of medical supplies, and the prospect for further advancement come into play. This means that those vertically integrated insurance schemes we have identified should be accessed through these work-quality lenses as well-- all things to reflect more upon in the coming days.

Monday at the University

Dennis Clements, Mike Merson and Geelea Seaford travelled to the Medical School at Makerere University to talk with the deans of the Medical School and the School of Public Health (photo). After an early morning discussion about possible areas of collaboration - nutrition research being high on their list - 2 lectures were given to the Medical Staff and separately to the medical students. They seemed to be well received and the question and answer period was lively and enjoyable. We ate in the medical student lounge - run by the medical students actually - it was pretty good although we weren't able to spend much time there. Dr. clements also visited the Nutrition Unit where children with malnutrition and kwashiorkor are admitted. The treatment protocols are intricate and they have a very high success rate. The children with HIV are of course the hardest to treat - see photo.

The evening began with the opening ceremony with speeches from prominent health authorities (the president of Uganda for some reason was a last minute cancellation but perhaps he will be at the closing ceremony). The speeches were interspersed with local music or vignettes describing the needs for more health care workers or the benefits to treatments provided. The reception afterward provided time for networking and the appointment schedules for the next few days filled quickly.

For dinner we travelled (less perilously this time) to a local restaurant to sample matoke a local starch made from green bananas - which they were out of but some of us braved goat and others a chicken curry made from a well-travelled bird. The vegetable dishes were voted the best - but then again meals are just an excuse for conversation - which was lively and entertaining. "When have you been the most frightened in your life?" - was the table game. Kevin Schulman arrived in the evening and with that we all prepared for the next day's events.

Red, Green, With Sprinkles on Top

No, it’s not a Christmas cookie – It’s how I would describe my early impressions of Uganda. The country is vibrant with colors. The earth is red, the luscious forests and farmlands are green, and the sprinkles represent the thousands of stars that are visible on a clear night. Today, we explored Uganda and ventured to the source of the Nile – Jinja. This is my second day in Uganda and more and more questions continue to enter my mind. At dinner tonight, we discussed access to healthcare with our two local taxi drivers. The premise of this conference is the healthcare worker shortage and I wanted to hear the viewpoint of the locals. Did they have access to healthcare services? Interestingly enough, the felt that care facilities were available and ample in the private sector. The major obstacle to care was cost. Is this a function of supply and demand? High prices due to limited supply? If there are more healthcare workers, will prices come down? We also talked about the ethics of providing free testing tonight. Is it better to provide free testing for diseases such as AIDS/HIV and malaria and leave treatments costs to the patient to resolve? Or is the onus on health facility – provide testing, a treatment plan, and medication? And if this solution is not available is paid testing, whereby the patient incurs testing costs if s/he wants to know, better than no testing?

Sunday in Kampala

The first day of real work - the constituency meeting chaired by Jeff Moe. Jeff presented a nice summary of the November meeting in Durham and the thinking behind the follow-up request for the technical working group (TWG) at this meeting. Over the next few days Jeff asked those present (from Zimbabwe, Ethiopia, India, Ghana, Scotland, USA, Bangladesh) to discuss projects that they know about which are trying to relieve the healthworker shortage and the issues related to both the problems and the potential solutions. Hopefully over the next few days there could be more discussion about possible solutions. Much conversation then ensued and cards and phone numbers were exchanged. It was considered a successful meeting. A part of our group then took off to see the headwaters of the Nile in Jinja before sunset while one of us battled with the internet connection to post these blogs. And we wait with eager anticipation for Mike Merson who is scheduled to arrive tonight. Tomorrow will be a busy day - meetings in town and at the conference.

Saturday in Kampala

We began our first full day in Kampala with a sumptuous breakfast in the dining room. A harbinger of the meals to come. At 11am we departed in a well-loved van with Richard who was to show us the sights of town. We traversed the business district on a Saturday morning which was interesting and cardiac arresting at moments. We eventually arrived at Makerere University which began in 1922 as a technical college and in 1949 became a university affiliated with the University of London. It now has 30,000 undergraduate and 3,000 graduate students. It sits on one of several hills in Kampala facing Mulago Hospital on an adjacent hill, which we toured next. Dr. Michael Hagland visited Mulago a few months ago and brought them 9 tons of equipment for the operating rooms and other areas of the hospital. He will be here tomorrow to begin talks on possible colaboration for neurosurgery training. We also visited the Uganda Cancer Institute where Dennis Clements worked in 1972. After 35 years it looked pretty much the same – the medical staff were kind and invited us into the clinic and the little 6 year old patient and his family greeted us with courtesy and a smile. We had a relaxing (read long) lunch beginning at 3pm and enjoyed the Indian cuisine of the resort. After lunch we split into 2 groups – one to visit friends in town and the other to go find something else to eat (what else?). We ate at Mama Mia’s and laughed that we traveled 8,000 miles to eat Indian and Italian food. But it was good. After a circuitous but less alarming taxi ride back to the resort (at midnight) we found Geelea in mortal combat with the computer and internet (she eventually prevailed) and Caroline was welcomed to a construction gang in her bathroom trying to fix something – mentioned 24 hours previously. She said something like “I’m tired already” or words to that effect. It was a good day.

Amsterdam Sunrise

Thanks to the 240 MPH tailwinds we arrived in foggy Amsterdam in 6 hours. We immediately found Nazaneen, Amelia, Gretchen and Tim who has just arrived from Boston. We've enjoyed the Amsterdam sunrise, and all is well despite being a bit tired. Only 8 more hours flying over the Sahara and we'll be in Entebbe. See you in Africa.-Geelea

On our way

Jeff, Caroline, Geelea and Dennis are absorbing the ambience in the Detroit airport, preparing for the trip ahead. So far so good. It is a brisk 22 degrees here. Looking forward to 82 degrees in Kampala. More from the other side of the Atlantic.

Ready to go!

With four hours to departure, excitement and anticipation is beginning to take over from the exhaustion of preparing for an international voyage while a full time medical student! We've been getting messages over the past 24hours from different constituency groups that will hold sessions at the conference, and seeing other folks' responses and comments is a little glimpse into the interactions that we can expect in a day or two. I've printed out a crash-course in Luganda for the plane ride, but who knows how much time we'll have to try out the local language. More once we're on the ground in Kampala!

2 days to go

With only 2 days left we are trying to get the Uganda phones to work and remember everything we need to take. The schedule for the meeting has changed a few times - and may change again. Important to take it all in stride. Hopefully we can get some sleep on the plane on the way there. We will send messages from the Equator, assuming the internet connection is working. Sometimes it is easier to text on the phone. Debbie will have our numbers. See you all after the trip. Dennis

Eight Days and Counting...

Eight days and counting... still a million details to take care of like finalizing travel arrangments, inviting technical working group members, writing new proposals, etc. AND new opportunities are popping up every day. Today's new opportunity: Mayanja Hospital in Mbarara. More on this later... Geelea

Trip to the Equator

going back to my clinic after 35 years. Will be interesting to see how it has changed. Dennis

Preparing to leave

Just when I thought I could give my attention to packing, arranging meetings with staff from exemplary projects, we have another proposal to write and a draft of an article is due to my co-authors. I have to finish all my writing before I leave for Africa but I'm running out of time................