Optimism in Africa, With Caveats
The Formation of a Three-Month Course in Tropical Medicine for Early-Career Physicians in East Africa
by Christopher Sanford
Every October I fly to Uganda to teach in a tropical medicine course. I arrive in Entebbe, on Lake Victoria, an ocean-sized lake that glitters like molten aluminum. At the airport travelers yell and gesticulate like traders on the floor of a stock exchange on a day of volatile trading. A coarse staticy voice roars unintelligible dictates overhead. I’m jostled by the vehement crowd. Traditions to which I am not privy determine the flow of events. My luggage appears or it doesn’t.
I spot the hotel driver in the crowd outside the airport. There is an eleven-hour time difference between Seattle and Uganda and by the time I arrive at the hotel I’m fairly zotzed. My head is lolling, lagging, rolling and I am blurry and far from home.
I often stay at a smallish hotel on the shore of Lake Victoria. In the throes of First Hour Euphoria the vast expanse of water connotes possibilities beyond the continuum of comprehension and I want to live here for the rest of my life. The color of the lake varies with the weather—now pea green, now cerulean with sparkles like cellophane. You cannot see its far shore. Many irregular green islands, large and small, say come visit me. The weather is perfect, warm not hot. There’s a faint breeze. A variety of lake birds—cranes, storks, terns—make small talk, chucka-chuckas and woota-wootas. Small black-faced vervet monkeys climb on trees, hedges, buildings. Not infrequently dark clouds appear and roil on the horizon like a large curse has been set into motion, presaging a sudden rain and thunder loud like bombs, like tumbling temples. At night lightning illuminates the lake at intervals like a giant strobe light and after some hours I fall into bed and sleep as solid and still as a figure atop a tomb.
I hire a taxi driver to take me to Kampala, Uganda’s capital. I’m newly arrived and my attitude is good. I’m happy to be in motion. The breeze from the motion of the car feels like luxury. The Entebbe-Kampala road is slow, narrow, dusty, potholed. Russet dirt flecked with litter at roadside. Men sweep leaves with brooms consisting of bundles of sticks. Tethered goats nibble crab grass under palm trees. Men push bicycles laden with taut sacks of charcoal, women balance baskets on their heads, no one moving quickly.
Low and irregular concrete shops with roofs of rusting ruffled tin, interspersed between small plots of corn and clumps of papyrus, line the road. A wet lethargy permeates the neighborhoods. Nothing is clean, precise, completed. It seems that if you found the right place to kick you could flatten an entire neighborhood. Shops sell tile, brick, big black plastic water cisterns, wood bedframes, lengths of concrete pipe. Hardware stores, beauty parlors. Women’s clothing shops with dresses displayed on mannequins with Caucasian features.
Many of the roadside shops are painted per their corporate sponsor. Yellow is MTN Airtime. “Authorized dealer. To do the things you love.” Deep blue: “Plascon Colour Your World.” Blood red is Coca-Cola. “A billion reasons to believe in Africa.” Gas stations are Petro City, MoPetro, Gaz, Mogas, Totalgaz.
A hovering swarm of rattling, whining boda bodas (motorcycle taxis) and chugging matatus (passenger vans utilized as inexpensive taxis) surrounds our car. As we approach Kampala, buildings transition to multi-story concrete lattices with irregular wood scaffolding. We pass under a traffic light, a rare sight in Kampala. It isn’t working: drivers negotiate willy-nilly as at other Kampala intersections. Road safety features—median dividers, sidewalks—all absent.
You have not seen disorder until you have seen a roundabout in Kampala, each a lawless laneless swirl of ill-will with intimations of mayhem. The driver is invariably skilled as he threads our aged sedan through the thick intermingled riot of pedestrians, bicyclists, boda bodas, and matatus. Placid strolling vendors sell bananas, peanuts, toilet paper, mosquito nets. My driver’s advice on driving in Kampala: “You have to drive rough. No one will give way.” On surviving as a pedestrian in Kampala: “You have to be wise. They just drive anyhow.”
And we ooze into Kampala, a big vile town. Before I traveled to Kampala I said I love all cities; now I say I love most. Buildings are dirty and dilapidated, crammed together, an extended concrete slum. The continual bombastic roar of gridlock traffic —coarse, ratcheting—surges and falls in jagged bursts. Birds croak and groan like hungover dinosaurs. The view to every direction fades to tan-gray haze. Kampala is situated a stone’s throw from the equator, the seam of the hemispheres, and the air is cloying and close and you are immediately sweaty. Most everyone is poor, the rich few cloistered and absent from view. It is a town in which, upon arrival, you immediately plan your departure.
Actually, as with other clotted megalopolises, Kampala possesses islands of charm and repose. Once you are settled, and stop sweating, and drink some water, and catch your breath, and begin to acclimate to the noise, pollution, and heat, you realize that, viewed with a charitable so-bad-it’s-interesting eye, Kampala possesses the oblique charms of a densely populated, smoggy, muggy, traffic-clogged, cacophonous hellhole. With the right attitude, you may have your touristic moment, even here.
I often stay at the Kolping, an inexpensive hotel on Bombo Road to the north of downtown. It doesn’t have AC but a ceiling fan prevents desperation. During any excursion into town I am enveloped by grime, noise, crowds, poverty, and no task is straightforward and trying to cross busy roads with no stoplights is near-impossible and returning to my hotel room feels like I’ve dropped into my foxhole during a fierce battle.
The Kampala Ballet
Now at the Coffee Terrace of the Kampala Grand Imperial restaurant, an open patio restaurant above a street in downtown Kampala. I am seated at a corner table, giving me an unobstructed view of traffic just a few feet below. An unending stream of boda bodas, matatus, small cheap import sedans, once-white Isuzu trucks with green tarps pulled taut over unknown goods, and buses circle a small roundabout and chug out of sight. Men—complacent, gripping nothing—sit or stand in the rear of open trucks.
Most bodas carry two or three people. Some riders and passengers wear helmets, some don’t. Sometimes a large clump of motorcyclists fleetingly aggregate as debris in a river coalesces into floating islands of similar stuff; these motorcycle packs form and dissolve as riders continually join and turn off onto different streets. Some of the motorcycles carry loads so large—piles of big cardboard boxes, stacks of sacks, a ladder, a mattress—as to be incompatible with negotiating the traffic. But somehow the geometry of snaking through the traffic is successfully computed; collisions are averted.
The rules necessarily and continually employed to avoid collisions are not immediately apparent. There is no squealing of brakes, only the rapid start-stop interweavings of the sedans and motorcycles. The motion of the motorbikes is continuous; hence the popularity, despite their statistical lethality, of the boda boda.
Pedestrians—well-dressed men in slacks and short-sleeved shirts, women in knee-length skirts and blouses, some with light sweater or coat, men in Islamic throbe and kufi, women in niqab—step between the moving traffic, their faces revealing no indication of alarm, concern, anxiety; their pace is unhurried, not so slow as to be leisurely, but almost languid contrast to the frenzied vehicles. And businessmen in black, gray, and navy blue two-piece suits, and soldiers in olive fatigues with colored epaulets on their shoulders and black boots, and nuns in white and pale blue habits with wimple, and janitorial workers in yellow and teal jumpsuits, and young men in soccer jerseys, and street venders selling shirts and newspapers, and a man wearing a US flag like Superman’s cape—all thread between the creeping vehicles. Some walk with crutches; some are missing a limb. Their clothes are clean.
No tourists. Few children. This is a downtown commuter crowd. Dogs on the sidewalk—skinny, watchful—do not venture to cross the road.
The ambient noise is so loud you don’t hear it; you’re numbed; you are only aware of a continual mechanical holler: throaty, ratcheting, rising and falling like the wheeze of a big pissed-off mechanical beast or a beach assault under heavy resistance, interspersed with fleeting horns and the quick high-pitched keening sound of metal on metal. No sound from nature: no birds, no voices. Loud low-pitched ascending tones as motorbikes with particularly loud mufflers accelerate. But no one goes very fast. The siren of an ambulance must be very loud to be audible above the din. Nonetheless the effect of the sirens is nil; the ambulance sits in traffic with everyone else.
All commuters are in a hurry and their mood is not good. No vehicle willingly slows to allow a pedestrian or another vehicle into traffic. These are utilitarian commuters, their only regard is pragmatic, logistical: for how long can this city keep me from where I want to be? The general impression is one of frustration grown into hatred and fury expressed as an unceasing attempt at merciless efficiency.
It’s the five p.m. Kampala Ballet: performances daily, admission free, audience participation mandatory.
Kampala Sheraton Hotel
I suppose that it was inevitable that I would come here, sooner or later. I’m white, I’m wealthy relative to most Ugandans; this is the hotel where the white wealthy businesspersons and tourists go.
I’m not staying here but only visiting its ritzy lobby. Now sitting in a comfy big chair near a grand piano in the bar and coffee house, Park Square, by the entrance. Slices of cake on plates are on display in a glass display case at the entrance to the bar, each illuminated like a prized gem. Clientele, both black and white, are sparse. A couple of white men, older, sit alone and drink beer and tap on laptops. African men talk on cell phones. Everyone is well-dressed. The AC is set to an optimal temperature.
A low marble fountain in the lobby creates a subtle, soothing continuous crash. Light pop plays overhead, not Muzak, but an upgrade thereof, a contemporary female Caucasian vocalist with acoustic guitar, low-key, unkitschy. Sofas and easy chairs, in crimson and beige, and lamps with contemporary square shades on wooden legs surround the fountain. The wall behind the reception desk is a stone marble relief of flowers. The lobby is ringed with shops: House of Walker, a Johnny Walker outlet; Temptation, a desert restaurant; Park Square; and the Equator Bar.
To what extent, in this land of evergrim privation, is it profane to live so high?
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In 2000 I enrolled in the Gorgas Course in Tropical Medicine, an intensive nine-week course based in Lima, Peru. At the time the Gorgas Course was one of twelve courses offering a post-graduate degree in tropical medicine accredited by ASTMH (American Society of Tropical Medicine & Hygiene). Of the twelve, only two—the Gorgas Course, and one in Bangkok—were being conducted outside high-income countries. I wondered why none was in Africa.
There are obvious advantages to conducting a class in tropical medicine in a low-income nation in the tropics. First and foremost, students are able to see an abundance of patients with the illnesses under study. In the Global North clinical faculty are excellent but patients with salient medical conditions—malaria, malnutrition, etc.—are rare. In a course based in Africa, students would round in African hospitals on African patients with African diseases.
When I returned from Peru I began to discuss a course set in Africa with colleagues at the University of Washington, including Drs. Paul Pottinger and David Roesel. The Chair and Vice-Chair of UW’s Department of Global Health, Drs. King Holmes and Judy Wasserheit, told us that two other institutions, the London School of Hygiene and Tropical Medicine and Johns Hopkins University, were also looking into establishing a course in tropical medicine in Africa. Maybe we should partner with them?
The project quickly coalesced into a five-institution consortium: UW, the London School of Hygiene and Tropical Medicine, Johns Hopkins University, Makerere University in Uganda, and Kilimanjaro Christian Medical Center in Tanzania. I recall innumerable conference calls over eleven time zones, Seattle to Uganda and Tanzania, with staticy echoing voices and wet chomping sounds as though metal monsters were taking big spitty bites from transmission wire towers.
In 2009 I flew to Uganda to talk with administrators at Makerere University in Kampala. All were enthusiastic about cooperating in a DTM&H course. Dr. Nelson Sewankambo, a prominent HIV researcher and educator, said, “Definitely. We’ve been talking about a DTM&H program over the past ten years. Hosting one here is extremely reasonable.” Dr. Alex Coutinho, Executive Director of the Infectious Diseases Institute, told me that a DTM&H program would be entirely appropriate for Makerere; its absence was a “major gap” in Makerere’s curriculum. Dr. Jackson Orem, a young oncologist, noted that as many as half of the malignancies seen at his clinic, including Kaposi’s sarcoma, Burkett’s lymphoma, and liver cancer, were tied to infectious diseases. He said that a DTM&H course “could blend very well” with educational priorities at Makerere, and that establishing a course could be facilitated by an “existing relationship” between the Uganda Cancer Institute and the Hutch (Fred Hutchinson Cancer Research Center) in Seattle.
Dr. David Surwadda, Dean of School of Public Health, on learning I was from the United States, first addressed the global economy and the role of the US therein. This was early in the recovery from the Global Financial Crisis of 2007-8, and he noted that lax lending practices in the US had precipitated the entire mess. “Your lending policies, the downturn, it affects us too you know.” He glared at me. “You have a responsibility.” He added that Uganda’s export economy had been hit particularly hard by the recession. After telling the United States, via me as messenger, to get its act together, he allowed that a DTM&H program was long overdue at Makerere, and that he would be happy to participate.
In 2010 Paul Pottinger, David Rosel, and I received a small grant from UW’s Department of Global Health to develop the course. And, as we continued to work with administrators and faculty from the other four institutions, the course transitioned from speculation and chit-chat to students enrolling and then arriving in East Africa. We conducted the first course, for six weeks only, in 2010. The following year we began the annual three-month course.
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In Kampala I meet up with the students. All are physicians, most are early-career. About two-thirds are European and North American, one-third are African. They are, as a rule, upbeat and smart. The three-month course, Professional Diploma in Tropical Medicine & Hygiene (East African Partnership) is offered annually, September to November. The first six weeks are conducted at Kilimanjaro Christian Medical Centre in Moshi, Tanzania, a town on the slopes of Mt. Kilimanjaro. At 5,895 meters (19,341 feet), Kili is the highest point in Africa. Its rapidly-diminishing snow-covered cap can be seen from all over town. Many students tack an extra week onto the beginning or end of the course to ascend Kili. Although it’s high, it’s not a technical climb. You don’t need to rope up. It’s essentially a very long hike into increasingly thin air.
The second half of the course is conducted at Makerere University in Kampala. Utilizing lectures, hospital rounds, lab sessions, and field placements, it addresses scores of illnesses endemic to this area: malaria, tuberculosis, HIV, assorted parasites. Students learn how to read malaria smears, examine stool for parasites, and care for patients in settings in which most treatment options are absent.
The business model is simple. The course charges £6,600 (about US $11,000) tuition to students from the Global North. The African physicians pay only about US $100 each; the students from the Global North essentially subsidize the African physicians.
Uganda has the misfortune of being an excellent country in which to study infectious diseases. In addition to the usual common tropical diseases, Uganda saw the biggest outbreak of Ebola prior to the West African epidemic of 2014-16. Marburg, a hemorrhagic fever closely related to Ebola, is intermittently transmitted as well. Large outbreaks of cholera occur at refugee camps and elsewhere. Uganda is the only country in the world in which both types of African sleeping sickness, T. b. gambiense and T. b. rhodesiense, are transmitted. West Nile virus was discovered in Uganda. Similarly, Zika was first isolated in Uganda, in the Zika Forest, outside Entebbe.
I see the same faculty every year: Saba Lambert from Ethiopia, and Steve Walker from the UK, both dermatologists with expertise in treating leprosy. Amaya Bustinduy—born in Spain, trained in Ohio, now a London ID doc specializing in schistosomiasis (bilharzia)—takes students for a week to Lake Albert on the Democratic Republic of Congo border. Natalie Prevatt, a UK pediatrician, takes students every year to Gulu to study complex humanitarian crises, and the residua of the years of terrorism of the Lord’s Resistance Army. David Renner, a neurologist based in Salt Lake City and London, leads a module on nodding syndrome and onchocerciasis (river blindness). Kate Woods, an infectious disease and microbiology physician who works in the London Borough of Hackney, takes a group of students to a hospital that cares for pygmies from the Impenetrable Forest in southwest Uganda. Alex Mentzer, a vaccine researcher at Oxford, works with students at the Ugandan Viral Research Institute, which monitors diseases including Ebola and Zika. Phil Gothard, an infectious disease physician based in London, is course director. He coordinates the many guest lecturers; he flies frequently between London, Tanzania, and Uganda during the course. Francis Mumbowa, a Ugandan, is a long-term course administrator; he enables course activities to occur as scheduled, no small feat in a country where not much occurs on “English time” (on-time); most events take place on “African time” (whenever). I see the faculty who teach primarily in Tanzania, including the ever-ebullient US infectious disease specialist Paul Pottinger, less often.
Balcony, Kolping Hotel
It’s Sunday morning. You assume it’s a religious service. You can’t tell, at first, if the music is live or recorded. Nor can you discern to what degree the distortion—the uneven time signature, off-key rising and falling tones—is due to your distance from the music, or the crude amplification. The music is equally loud to all directions. Voices—slow, a chorus, a hymn, patient and optimistic. An uneven drum, syncopated, at odds with the melody. And a musical instrument, possibly an organ, something electronic, it’s difficult to tell. The three elements—chorus, percussion, musical instrument—play without regard for one another. The overall effect, although veering toward anarchy, is something pleasant, soothing, comforting. It is relaxed, unhurried, repetitive, lulling. Simple but not simplistic. It says be patient, good things will come. It says we are in this together. It says things are not so bad now. It says I am here for you.
At times you hear interspersed cheers, involuntary roars of enthusiasm. You wonder if spectators are dancing. The music seems too compelling for any audience to sit motionless. It is at times bizarrely joyous, something akin to a circus Wurlitzer with delirious trills, the entire production a maniacal frenzy of optimism and euphoria.
At intervals the music fades and disappears and you wonder if the service is over. You hear traffic and you wish the music would start up again. And then the music surges and you wonder where it’s coming from, and who is in attendance, and what sect—Christian, indigenous, other—is producing it. You wonder what their conception is of God, of themselves. It is clear they find solace and strength in gathering, in music, and you are a little jealous. You sit and listen and wonder what your role is. You feel you are eavesdropping, an acoustic voyeur. And the music contracts into itself and disappears and you try to remember what it sounded like in all of its complexity but the song does not echo in your mind; you are regretful, sorrowful, that you will never hear that song again. You wish the music would go on for a very long time; you wish you had a recording of it you could play in times of weakness, loneliness, despair.
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Hospital rounds are educational and grim. We round at University Hospital, a large boxy concrete structure on the campus of Makerere University in Kampala, and other hospitals. A single ward holds as many as fifty beds. Paint peels from walls and metal bedframes. Bedding is dirty and flies are thick. Cats wander between wards. Families sleep on the floor next to their relatives. Electricity and running water are intermittent. Supplies and medicines are rudimentary. We see technology—manual typewriters, carbon copy paper—absent from high-income nations for decades.
Patients and their families look at us with neither hope nor optimism. No one has just one diagnosis. A man with malaria will also have parasites and tuberculosis. A woman with a blood clot in her leg or lung will also have newly-undiagnosed HIV. Someone with a stroke from undiagnosed, untreated hypertension will also have the skin lesions of leishmaniasis. Our student trainees see illness after illness, including measles and tetanus, that they have heretofore only read about. There is a paucity of elderly patients.
At one hospital ward, getting better and getting worse are termed going to the right and going to the left, respectively, which I don’t understand until I stand in the corridor just beyond the cinderblock entrance to the ward and look both ways. To the right: the hospital entrance. To the left: the morgue.
The beds in pediatric wards are filled with children with malaria, pneumonia, meningitis, congenital heart malformations. Kids with diabetes face near-insurmountable challenges. Their parents can’t afford the insulin and needles; the family doesn’t have electricity to refrigerate the insulin; the parents are illiterate and can’t read the numbers on the test kit they can’t afford. These children not infrequently show up at the hospital in DKA, diabetic ketoacidosis, deeply comatose, near death.
Malnutrition, concurrent infections, and indoor and outdoor air pollution all contribute to the high occurrence of pneumonia in children which is not infrequently fatal. We care for children so anemic from malaria, or parasites—hookworm, other—and other causes that I’m surprised they’re alive. But we can’t transfuse them; there’s a perennial shortage of blood due to the persistent belief among many Africans that donating blood can transmit HIV. And babies with hydrocephalus, their heads bigger than the rest of their bodies; and kids with severe burns, sometimes from having a seizure and falling into a cooking fire. Babies who were found abandoned. Kids with huge spleens that can be felt down to their belly buttons, from schistosomiasis or another cause.
Sometimes we see evidence of folk cures. A girl, twelve, pulls up her shirt to reveal an elaborate and extensive lattice of scars on her abdomen. Her parents treated her abdominal pain by heating a wire and touching it to her belly, causing a series of small burns. On a boy’s foot, swollen by a puff adder bite, we see a circle of linear marks in an exact. circle about the fang marks, superficial incisions made by a traditional healer.
Like the adults, none of the children have a single diagnosis. A kid with a huge spleen from schistosomiasis will also have HIV, or congestive heart failure from rheumatic heart disease. A kid admitted for broken legs from being smacked by a car will be found to have chronic hepatitis B. As with the adults, children frequently die from medical conditions easily prevented or cured in the U.S. The Ugandan physicians are competent but hamstrung by their lack of diagnostic and treatment options.
Some hospitals have dedicated wards for malnourished children. Our physician students become adept at diagnosing the various forms of malnutrition: the wasted limbs of marasmus, the swollen bellies and peeling skin of kwashiorkor, the bowed legs of rickets.
Everything is more difficult. The patients are sicker, poorer, less literate, less compliant. Drugs, when they can be found, are sometimes substandard or fake. Even vaccine cards are sometimes forged, for a variety of reasons.
We write in the charts that our patients are ill with malaria, or malnutrition, or a particular parasite, or whatever but it would be equally accurate to say that they are ill because they are poor.
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It is always with relief that I exit Kampala, always with a sense of escaping hostile urban pressure. Despite the heat, bad traffic, and overcrowded bus I enjoy the drive from Kampala to Jinja with the students. They are excited to be off to somewhere new. We have the my-life-in-five-minutes conversation; we share gum, chips (crisps per the UK and African students), water. When we start out I have no idea if our trip will be ninety minutes or four hours or longer or shorter. No one complains about the traffic, the heat, the smell of diesel. We converse, or don’t. Some students—not a few hungover from late night revelry—sleep. Scratchy reggae on the bus’s sound system.
It takes an hour or so the clear the outskirts of Kampala, a city with more outskirts than inskirts. Most of Uganda is one of two colors: dense green foliage, ochre soil matched by the rusting ruffled tin roofs of the mud and wood plank shacks. Coils of barbed wire rest atop brick fences. As a rule nothing is complete. Houses are under construction, or half-built and abandoned, or abandoned long ago, collapsing and reclaimed by dense verdure. We drive through fields of corn and sugar cane, and huge tea plantations, then stretches of dense Victoria Basin forest-savannah mosaic.
Children, thin and bent, carry heavy sacks of charcoal at roadside. Men push bicycles laden with yellow plastic jerricans and bunches of green bananas. Advertising on buildings: Switch to Airtel 4G. Solstar: Your partner for life. The MTN smart series. Choose your kind of smart. Sayara Japanese quality hygiene solutions. Sun Top. Only DStv has the most sport. A new world of fruity freshness. A big billboard: Ask to be started on ARVs the day you test positive for HIV.
We note the construction of infrastructure, bridges and such, often built by the Chinese, and wonder what the Chinese are getting in return. The students ask me about my training, my career, my writing, looking for tips for their nascent careers.
And after some hours we come to the big suspension bridge over the Victoria Nile, on the far side of which lies the city of Jinja, famous for being at the site at which the Nile begins its four-thousand mile course from Lake Victoria to Cairo and the Mediterranean. After Kampala, Jinja strikes the newcomer as a bucolic oasis. You feel you are being rewarded for having survived Kampala. Tidy avenues are lined with jacaranda trees in loud violet bloom, hedges of hibiscus, and a profusion of red amaryllis and yellow Jerusalem thorn. The air is clear, the pace is slower. It’s quiet, or at least quieter than Kampala.
We stay at the hotel Paradise on the Nile, which, as I tell the students, isn’t on the Nile, and is no paradise. In its lobby, as in every other hotel lobby in Uganda, a framed photo of President Museveni hangs above the reception desk. He is younger in the photo than he appears in contemporary news clips. Every year I hope that The Dog That Barks All Night has died in the previous year (natural causes or dogicide, I don’t care) and every year I’m disappointed. And actually, the hotel restaurant has a good view of the Nile, and the hotel staff are friendly. Rooms are clean. There’s electricity more often than not.
It’s a pleasant twenty-minute walk between the Paradise on the Nile and downtown Jinja. The sun is bright and hot. Butterflies and dragonflies swoop and drop; cicadas holler and grind. Traffic is sparse. I pass through a herd of horned cattle, or goats feeding at roadside. The young men on boda bodas try to make eye contact with me and if they do they give a little jerk with their heads to say hey you want a ride? I say no. They’re perplexed; most tourists take the bodas, which are cheap. Why walk if you can afford a boda? I see kids in school uniforms, who say hi if I do first. Sometimes they trot out their English: “Hello! How are you! I am fine! Have a good day!”
Houses once architecturally intact, now sagging, rusted, overgrown. Some seem abandoned, then a form in motion behind a broken window informs me that the house is inhabited. I walk past hotels, restaurants, bars and white-water rafting concerns, some well-kept and some falling down. I smell burning leaves, a pleasant smell I associate with my childhood summers in East Texas.
There are two routes to town. One goes by the Jinja War Cemetery, at which perhaps two hundred World War II King’s African Rifles solders are buried. It’s the only cemetery in town which is tended regularly. Down a long slope from the cemetery stands a long row of wood shacks selling chipatis and soda pop. The other route, Bridge Street, is lined with tall fat-trunked trees that provide shade. Marabou storks—huge, slow, ugly birds, almost waist-high when they land, reminiscent of pterodactyls—pace at roadside. One must never walk under a tree in which marabou storks are perching. One student, a woman from the UK, was known during her entire three-month course as The Woman Who Was Pooped On By a Marabou Stork.
Downtown Jinja doesn’t change much from year to year. Dogs motionless as though dropped by nerve gas. Many of the buildings were built in the 1920s and 1930s by Indian businessmen and retain their original decorative columns, latticework, and cornices. Other buildings are low, concrete, blocky. Little is new. Sidewalks are broken, roofs rusting. Bored uniformed men with rifles with wood stocks sit outside banks. Men and women on the sidewalk at sewing machines operated by foot treadles. Women walk with baskets containing fruit and baked goods balanced on their heads.
Cars and bodas cruise Main Street, which is lined with every manner of shop—clothing, grocery, stationary, cell phones. The owners of the grocery shops are Indian. Only the cell phone shops are new, slick, well-lit. Because of the availability of whitewater rafting, Jinja is more mzunguized than most towns in Uganda. (Muzungu is the Swahili and Ganda term for foreigner, or, literally, someone who wanders around aimlessly.) On Main Street a stretch of shops sells wood carvings, baskets, textiles, paintings, jewelry, and other African handicrafts to tourists.
I like to sit at a café in Jinja and watch the passers-by, the infrequent traffic. After the walk into town, to drink water in the shade is a surprisingly satisfying activity. And I drink coffee, but paradoxically, coffee as served at restaurants in Uganda—a country that grows considerable high-quality coffee—usually tastes like something that dripped from a truck. The great majority of coffee grown in Uganda is sold overseas. One suspects that only coffee too crummy to be sold is left for local consumption. The coffee addict learns to pack instant and to consume the resultant room-temperature product with minimal grimacing. You decide it’s not bad. I mean, it’s bad, but not bad bad. It isn’t horrible. It’s only somewhat unpleasant. You wouldn’t drink it on purpose if you had any other option, but you might be surprised by how little you hate it. If you expect very little you will not be disappointed.
Nor does one travel to Uganda for the cuisine. Goat soup contains chunks of bone with gristle. More bleat than meat. Beef is tough, suggesting that cows live an unpampered existence.
Once, when I broke a suspiciously stiff hamburger bun into two a beetle scurried out. Chapatis and lentils, and manioc are relatively tasteless.
Some days I walk from downtown to the Brisk, formerly the Triangle, a huge ungainly concrete hotel with a panoramic view of the Nile. It’s Indian-owned, as are most businesses in Jinja, and its food is pleasantly not bad. Between the hotel and the Nile stand a number of tall palm trees, and at regular intervals, all at once, at some prompt invisible to me, big fruit bats—hundreds, thousands— stream out of a particular palm tree and form a swirling hoard that cheeps and chatters, loud, quick, agitated, perturbed. The sky is filled to all directions, a veritable cloud of fluttering, swooping, dropping bats like some convocation of Satan’s ill-tempered minions. They swarm chaotically in a sort of bat holding pattern then after several minutes of jabber and flight they rapidly alight on a different palm tree, climb between the fronds interiorly, and are quiet.
Even in Jinja a good night’s sleep is the exception. Fireworks to celebrate the Hindu festival of light, Diwali, booming and close, and a dog barks all night, then loud thunder; the thunder sets off car alarms which blare for hours. And often, throughout the day, I hear random slow smashing blows from somewhere within the hotel, like a lackadaisical carpenter is trying to tear down a brick wall or bust up a tile floor, but he’s fatigued, indifferent, only going through the motions, not invested in his project’s outcome.
The sleep deprivation, circadian disruption, thick wet air, and tepid hypocaffeinated coffee combine to create a vague state in which one is neither fully asleep nor awake. I fall into a tropical torpor, a latitude zero lassitude. I’m awake but not sharp. Somewhat resigned, blasé. Nothing is remarkable. I have no intense longings. I am not infrequently frustrated, frazzled.
Not all sounds are noxious. The muezzins’ call to prayer is broadcast from speakers atop mosques five times a day: dawn, noon, midafternoon, sunset, and nightfall. The calls are complex and intense, lovely a cappella voices, languid, fluid, variegated, resonant, warbles and modulations at unexpected intervals with no respect, to my ear, of 4/4 or any other regular time signature, evocative, able to convince even unbelievers that Islam knows something other religions do not.
It’s quiet in the mornings. I hear random knocks and thumps from the courtyard below and within the hotel proper, and the distant sound of men singing acapella, two-part harmony, perhaps a church service. Their song is slow, repetitive, patient, sweet, optimistic. The song says we are here and much is good and things may get better, you never know. And cooing doves, and loud insects, rhythmic reedy surges, and occasional loud honks and grunts, possibly frogs, and birds tweeting in an unperturbed manner, and the metallic squeak of wheels of a passing train.
I walk to the nearby hotel restaurant. The morning is cool, comfortable, the ground wet with recent rain. Uniformed hotel workers sweep the road with bunches of sticks. A soccer match plays on the restaurant telly. I check on the state of the Nile. It is, as it was the day before, huge, near-motionless, impassive. In the distance fishermen throw nets from dugout canoes.
I settle into a routine with the students assigned to my module. Monday morning we discuss travel medicine: pre-travel advice for international travelers, including immunizations and malaria prophylaxis. Tuesday is post-travel medicine: care of the returned traveler with GI symptoms, fever, rash, other. Wednesday: disaster medicine, including a discussion of my deployments on a U.S. federal disaster response team to New Orleans following Katrina and Port-au-Prince, Haiti, after the 2010 earthquake. Thursday: medical response to terrorism, including conventional explosives, chemical attacks, radiation exposure, and bioterrorism. Friday: students present on their area of expertise. One year Yvonne Wekesa, a Kenyan Air Force ob-gyn doc presents on her years working at a refugee camp in Sudan. In 2016 two Sierra Leone military physicians detailed their experiences working in Ebola Treatment Centers during the large West African outbreak. And afternoons the students perform a research study on the attitudes of tourists in Jinja on a variety of topics relating to travel health.
One night we meet at a Jinja outdoor restaurant, AllFriends, for Ethics Night. As a starter I ask: can medical volunteerism have negative consequences—and if so, what can we do to minimize the downside? The discussion in surprisingly vehement. The African docs, particularly, once prompted, state repeatedly that Africans know what Africans need more than do outsiders. They detail example after example of the downside of foreign docs showing up, working briefly, then disappearing. For example: A western doctor volunteers in a rural district hospital. On his first day he sees a middle-aged man dying of emphysema. The dying man is not on oxygen, doesn’t have an IV. The new doctor immediately spurs his staff to action. The dying man is placed on oxygen, an IV is started, he is put on antibiotics; x-rays and other labs are ordered. He dies a couple of days later regardless. But then, due to charges incurred in the final two days of the man’s life, the family is unable to pay the hospital bill, and the hospital won’t release the body until they do, so they can’t hold the funeral, an important ritual.
It’s good for the western docs to hear. Many of them assume, prior to this discussion, that overseas volunteering must be welcomed with open arms, and can only benefit the locales in which the volunteer staff are working. And after our talk we walk back to the hotel, bright stars above, fireflies dotting and streaking like drunk meteors.
The final Saturday is free for white-water rafting on the Nile, or renting four-wheelers, or hiking in nearby Mabira Forest, or whatever else students want to do. And the next day we bus back to Kampala.
On the Monday following the rural placements each module gives a presentation that summarizes what they’ve learned. Competition is keen for the award given to the best presentation. The presentations often include songs and not infrequently dancing which while not always exactly relevant to the material at hand are always entertaining. One year the Lake Albert/schistosomiasis group presented a graphic dance enacting the copulation of the schistosoma parasites, to the delight of those in attendance. I am impressed that a student lyricist is able to rhyme a word with melarsoprol, a medication used to treat African sleeping sickness.
My travel medicine group might perform a skit in which tourists make a number of Touristic Errors—take an herb to prevent malaria instead of a prescription medication, or fail to wear seat belts.
There is a similarity to the video presentations. Many end with a montage of photos of the students in a variety of rural settings, set to upbeat African music, amateur travelogues. They don’t sing Kumbaya per se but it’s not far off.
One year, during class presentations—a year during which there are extensive student protests on the Makerere campus—we hear muffled booms and wonder if police or soldiers are firing tear gas. The muffled booms grow louder. We hear screams. One of the faculty receives a WhatsApp note from one of his African students who is staying on the Makerere campus. The student apologizes for not attending today’s session, because “Tear gas with ongoing riot could not allow me to leave…” And after a while the booms fade and we return our attention to the ongoing presentations.
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Back as the Kolping on Bombo Road, as I prepare to fly back to the US, I hear a man’s voice—distant, amplified, throbbing—so distorted by distance, by amplification, as to be unintelligible even if you speak the language. He speaks rapidly. His tone is impassioned, incredulous, almost shocked. His topic is astounding. At intervals his tone rises to a near-howl, as though he is in physical pain. Possibly a second speaker speaks in counterpoint, or possibly the doubling of voices is an echo, a result of the distance from which he speaks.
At times the breeze carries it away altogether. The voice is followed by an uneven sound which may be music. It rises and falls jaggedly, without tempo. It seems more ordered than inadvertent noise, less sensical than communication or art. And the uneven noise ceases.
Following Uganda’s independence from Britain in 1962 it has never once experienced a peaceful transfer of power. The current president, Yoweri Museveni, himself took power by force in 1986. Museveni, a corrupt autocrat who regularly jails his political opponents, has enriched himself, his political cronies, his family. He is an improvement over Idi Amin, President of Uganda between 1971 and 1979, but this is a small compliment.
It is interesting to note the differing editorial stances of Uganda’s newspapers on the affairs of state. In the pages of the New Vision, an organ of the government, Museveni is a revered and wise statesman whose sole concern is the welfare of his fellow Ugandans. In 2017, after having been President for thirty-one years, he bribed members of parliament to vote to remove term limits for the office of President. The New Vision wrote that these payments were not bribes, but funds to “facilitate consultation in their respective constituencies.” It described the lifting of term limits as a prudent measure. Wouldn’t it be foolish to not avail ourselves of Museveni’s experience? Why risk turbulent times?
In other publications, such as the Daily Monitor, an independent newspaper, some criticism of the government is permitted but not too much. Sometimes it goes no further than asking questions, as with its headline on the 2017 lifting of presidential term limits: “Age limit debate: Will people’s views matter?”
The journalistic style of the Red Pepper, a gossip and scandal rag, must be described as saucy. From an article on an attempt to kill Janet Museveni, the president’s wife, by one her bodyguards, Major Charity Dainebaabo: “Dainebaabo is a mother of two, being the fruits of bonking a flamboyant city lawyer. However, she separated with the lawyer and currently bonks Lt. Lauben Kurubakamya…”
Page seven headline: Suspected Notorious Goon Held.
Page one headline in the Sunday Red Pepper: “Flavia: I only bonk millionaires.” An article elaborates: “…[S]exy radio presenter and Television news anchor Flavia Tumusiime does not serve wet ‘goodies’ on a dry plate.”
Every Ugandan has an opinion on Museveni. Uganda is a young country; seventy-five percent Ugandans are under age thirty; most have no recollection of another president. They worry that there is no peaceful plan of succession; that when he dies there will be turmoil or worse. I am told that had Museveni stepped down a decade ago, with a peaceful transfer of power, there would have been dancing in the streets in appreciation of all he’s done. But now…
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Despite my fourteen trips to Africa I do not have Answers, Solutions, Large Conclusions. I have learned that whenever I think that I comprehend an aspect of Africa it is only because I have yet to dig to the level where I am again baffled.
I have arrived only at questions and observations. Why do so many African nations have awful governments? Why is poverty so rampant and persistent? The textbook answer for the cause of Africa’s poverty and other ills is the residua of colonialism. Certainly its history of colonialism is contributory, but this this seems too pat, too simplistic to explain the totality of today’s complex mess.
And why are most of the shop owners in Jinja Indian? What will be the result of the pervasive, continent-wide Chinese investment into infrastructure?
Nor are my observations profound. We are rich and they are poor. Outside Kampala Uganda is lovely. Most people are good and decent, kind and reasonable. Their priorities are akin to ours in the United States: family, a reasonable job with a livable wage. A hope for honest government that they know they do not have and may not have in their lifetime. Many—most?—would leave for better opportunities abroad if they could.
It seems I should be tumbling to more than this. But anyone with a pat solution to a problem in Africa is new in town, ignorant, deluded. Solutions need to come from Africans, not outsiders, but Africans don’t generate effective solutions, and the dysfunctions continue.
I don’t belong here but I’ve visited so many times that perhaps I do. So I return, again and again, and observe and ask questions and hope that even as little as this is a small step in the right direction.
January 2021
Christopher Sanford
Copyright © 2021 by Christopher Allen Sanford
This essay is part of a larger work in progress with Clyde Hill Publishing.