Engeye Volunteer Manual – Revised Jan 2014

Engeye Volunteer Manual www.engeye.org

Engeye is a non-profit organization comprised of a small group of devoted individuals, both Ugandan and American, working to improve living conditions and reduce unnecessary suffering in rural through education and compassionate health care. Engeye Health Clinic was founded in 2006 to serve Ddegeya Village and the surrounding area, and Engeye Scholars was formed in 2009 to support the education initiatives of the clinic.

Implicit to every project that we undertake is the understanding that it will ultimately be sustainable with little or no outside assistance, and that it will be accomplished free of the imposition of any foreign social, political, or spiritual values.

Thank you for joining Team Engeye on this journey! We hope you enjoy Ddegeya as much as we do.

Never doubt that a small group of dedicated, thoughtful and committed citizens can change the world. Indeed, it’s the only thing that ever has. - Margaret Mead

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Engeye Health Clinic Inside of Observation Ward

Table of Contents Page Section 1: Contacts 3

Section 2: Airfare and Lodging 4

Section 3: Visitor Etiquette 8

Section 4: Important documentation 10

Section 5: Immunizations 12

Section 6: Comprehensive packing lists 13

Section 7: Sample Total Budget 15

Section 8: Medical Clinic Manual Abbreviated 16

Section 9: Affidavit And Declaration 26

Section 10: Learn Luganda! 27

Section 11: Goals, Wish list 28

Section 12: Recommended reading 29

Section 13: For Providence Employees 36

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Section 1

Contacts

Please use the following contact information to give to family members in case they need to reach you or other Engeye team members during your stay in Uganda.

Uganda contact

John Kalule, Engeye Clinic Operations Manager and Co-founder Phone: (011) 256-77-255-6105 Email: [email protected]

Mailing address: PO Box 26592 , Uganda

Physical location: 50 kms west of Masaka, on Mbarara-Masaka Road Plot 39, Estate 449 Nearest town is Kinoni

USA contacts

David Robinson, Executive Director Email: [email protected] Phone: 503-201-1418

Julie McMurchie, President, Board of Directors, Volunteer Coordinator Email: [email protected] Phone: 503-348-7149

Anny Su, RN, Medical Volunteer Coordinator Email: [email protected] Phone: 559-696-8531

Theresa Weinman, Engeye Scholars co-founder Albany Medical College Dept of Family and Community Medicine Administrative Coordinator E-mail: [email protected] Phone: 518-262-5797

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Section 2

AIRFARE Travelers between USA and Africa may generally check two bags without charge.

Some of the travel agencies that have been used by past volunteers: Fly For Good (www.flyforgood.com) – offers discounts for non-profit volunteers Contact: Ellen Sladick, [email protected] Save on Travels www.saveontravels.com Consolidator Webfares, Inc. http://www.consolidatorwebfares.com Golden Rule Travel www.goldenruletravel.com

EXCHANGE RATES As of January 2014, the exchange rate is $1 = 2500 Ugandan shillings. The has been depreciating rapidly, and may continue to do so. The publishes official exchange rates on their website, although you can expect street rates to differ by up to 100 shillings.

Exchange rates are better in Kampala than at the airport. We recommend crisp, non-marked, 2006 or newer, large denomination bills ($50 or $100), as they not only receive a better rate, but you may not even be able to exchange bills smaller than $50. Stamped/marked/inked, folded or heavily creased, torn, stained, or older bills have been routinely refused by money exchangers and banks. Fake bills were circulating in the past and money changers do expect that they get high quality bills. ATMs are available, and for those with Bank of America accounts, there are no card transaction fees at ATMs. Credit cards are rarely used in Uganda, even in Kampala.

If you are planning to obtain your tourist visa upon arrival at Entebbe, you should plan to have a new (2006 or later) $50 bill for your payment.

LODGING IN and AROUND KAMPALA There are a variety of lodging choices available depending on your group preference and budget. We recommend reviewing choices before departing on tripadvisor.com. Some of the lodging used by past volunteers include:

Backpacker’s Inn (Kampala) www.backpackers.co.ug

Hostel style housing and the least expensive alternative, located outside of central Kampala. For reservations, email Backpacker’s Inn ([email protected]) approximately 3-4 weeks prior to your visit and reserve either a bunk bed (in a shared room with other travelers) or an individual bungalow. To ensure the request is honored, email one very simple and straightforward reservation request for everybody in your group. You should receive a confirmation email within several days. Please CALL if you need a speedier response.

Central Inn (Entebbe) www.centralinn.co.ug

Volunteers can request resident rates, depending on whether you have a double or single room could range from about $40-$60 a room. Email: [email protected]

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Cassia Lodge www.cassialodge.com

A more deluxe accommodation with a pool and great restaurant. Volunteers can request discounted resident rates, rates are approximately $100 for single room or $120 for double room, includes breakfast and internet. Cassia Lodge is located on Buziga Hill, one of the highest hills of Kampala close to Lake Victoria and it has incredible views.

Sheraton Kampala

Centrally located and convenient for exploring the city. Complex has several restaurants, bars, a health club, spa, money exchange, and will arrange airport pickup. Concierge desk is very helpful in arranging further . Rooms begin around $150.

TRANSIT

There are a couple of recommended options for travel from the airport to your hotel or to the Engeye Clinic. Your choice depends on the size of your group and your personal budget.

Ugandan Taxi

Large vans function as taxis and are widely available, including at the airport. These “taxis” will make many stops picking up and dropping off passengers throughout the journey. The drivers will usually speak very little English. Cost is dependent on the driver; be sure to negotiate cost before your luggage is loaded on the taxi. Expect transit times to be significantly longer with a taxi than private transport.

Private Hire Vehicle

These can be prearranged to drive your group with an English speaking driver. Arrangements are most easily made through your hotel, which will contact independent operators on your behalf. The hotels will also work with you to arrange travel from the airport to your hotel and to Engeye clinic, and you can also arrange sightseeing or supply shopping along the way. Private hires cost more than taxis but are significantly more comfortable, safer, and faster.

Other options for arranging private travel:

Churchill Safari

Different size vehicles are available to match your group size. Drivers are hired based on a daily rate. They can also help with any safari arrangements you would like to make. (Please be advised there is a 6% fee if paying by credit card) www.churchillsafaris.com

Contact: Ether at [email protected] or +256 414 341815

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Charles Morgan Kisitu, private taxi – Morgan has been used by many Engeye visitors, he is safe, knowledgeable, and can assist you with any other touring you would like to do in East Africa.

President, 1000 Shades of Green Tour & Safaris Co. LTD

Tel: +256-41-459-7306 [email protected]

James’ Transportation company

Contact through Backpackers Inn

Apollo Tour and Travel Kagwa Apollo (transport officer) +256-782-728482; MOB +256-752-728482 or +256-701-728482

HOUSING AT THE CLINIC

Volunteers are housed at the clinic in one of two group bunkhouses that have 8 bunks in each. Sheets, blankets and pillows are provided. It is very important to keep the windows of the housing units closed in the evening so that bats do not enter the unit. It is also important to make sure the door to the shower room is also kept closed to keep mosquitoes out.

Please keep in mind that the bunkhouses currently house our full-time clinic staff, kitchen staff, and any long-term Fellows. Any additional interpreters and kitchen staff that are hired for your trip will also be staying in the bunkhouses with you. There is one shared shower room in each bunkhouse.

Please be considerate with sharing this space. Please be conservative about using the water for bathing/showering, especially in the dry season, as the water at the clinic is shared for all operating and residential needs.

RECREATION

Safari: The closest safari location to Engeye is Lake Mburo National Park, a compact wetland/woodland park that is the premier location for zebras and bird-watching. This park is possible as a day trip from the clinic, with about 1 hour of travel time to reach the park. There are accommodations in the park if you want to stay overnight.

Approximately 3-4 hours drive from Engeye is the impressive Queen Elizabeth National Park, which offers a full range of accommodations and safari activities.

Further options include Murchison Falls National Park and the Bwindi Impenetrable Forest (home to the endangered mountain gorillas)

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Whitewater rafting: Jinja is located about 2.5 hours from Kampala and offers whitewater rafting at the source of the Nile River. This is a minimum 2-day trip due to distance traveling from the clinic, and most visitors stay at the lodges in Jinja. There are multiple booking agencies for guided rafting trips.

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Section 3

PLEASE RESPECT THESE GUIDELINES!

VISITOR ETIQUETTE

1. HAND OUTS Please DO NOT give out any handouts (e.g. candy, money, baseball hats, pens, etc.) to the children or other villagers. This is extremely important to us. As tempting as it is to give a pen here or baseball cap there, it creates a begging mentality, especially among the children. Word spreads quickly. Let’s try our best to discourage this behavior. It will allow us to return to the village, time and time again, with the volunteers having a pleasant experience each journey. If you want to make a child smile, rather than handing out a gift, try singing with them, teach them a song, color with them, dance, bring a battery operated CD player with speakers to share music, or show them pictures of your home and family. If really you want to give something to a villager, ensure it is done through John and the clinic in an organized way.

2. DRESS Please dress modestly: knee-length shorts and skirts, and short-sleeved shirts. The culture is conservative in rural areas, and we want to be respectful of local customs. This applies to both men and women.

3. FOOD The food served at the clinic reflects the local diet: beans, rice, matooke, potatoes, ground nut sauce, and eggs. You may wish to bring power bars and small bottles of condiments (soy sauce, hot sauce, rice seasoning, etc.) to supplement depending on your taste preferences. There are a few grocery stores in Masaka. We will try to make fresh vegetables and meat available when possible. Always be gracious and respectful of the cooks. Breakfast is usually set up and available by 7am. Main meals are generally served around 1pm and 8pm.

4. PHOTOS Please ask before you take a picture of a villager. While the children usually don’t mind having their picture taken, the adults do. Be cautious and respectful by asking before you snap. Please try to reduce the number of photos taken per group, and consider appointing a team photographer to share photos upon return.

5. SLEEP Please be courteous of others’ sleep and refrain from talking or making noise when others are trying to rest. For privacy, men and women are generally in separate bunkhouses, but teams may need to share mixed space depending on the size and composition of teams. Consider bringing earplugs.

6. THEFT Keep an eye on your belongings. The majority of the community and neighbors deeply care about Engeye and watch out for us as well, but there are the occasional unknown visitors. Please also treat the clinic's belongings as carefully as your own.

7. INSIDE SHOES

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Please bring one pair of flip flops or other comfortable sandals to wear ONLY inside. It is considered rude to wear your outside shoes into the house. Always leave your dirty shoes at the front door. You may also use your inside flip flops as shower shoes.

8. MARIJUANA The use of marijuana is strictly PROHIBITED. Smoking marijuana is a serious crime in Uganda. Our clinic manager could be arrested and the clinic shut down if anybody is caught smoking on the premises. If you smoke marijuana or use drugs at the clinic, you will be asked to leave immediately.

9. SCHOOLS AND STUDENTS Engeye Scholars currently provides sponsorship for some children to attend local boarding schools. The Scholars program is currently working with a local private school—St. Gertrude’s—to provide expanded educational opportunities for children in and around Ddegeya. If you have an interest in supporting the program or if you meet children that you would like to recommend for the program, please contact: [email protected] or [email protected] . If you would like to support the schools or bring school supplies to share while visiting the clinic, please discuss your plans with Elaine or Theresa before your trip to ensure that they are coordinated with Engeye Scholars. Please do not make promises or offers to any individuals or families without first discussing with Scholars program directors.

10. PRICES Prices in Uganda are negotiated for almost everything. Before you get into a car, public or private, be sure you have negotiated the price. Even if you have been quoted a price over the phone, you must discuss the price with the driver prior to entering his/her vehicle.

11. ELECTRICITY The clinic's main source of electricity is currently from a solar panel/battery array that has limitations. The system's capacity is functioning at its limit for daily clinic operations. We have recently finalized connection to the main electric grid, but power supply is still unreliable and comes at a cost. We ask that all visiting teams help preserve the lifespan of our batteries by being aware of your power usage, turning off any unused lights, powering down and unplugging all computers during lunch and at the end of the work days, and not using unnecessary electrical devices (such as curling irons or straightening irons, hair dryers, etc.)

12. LATRINES Toilets at the clinic are latrine style stalls with doors. These are usually kept locked on the staff bathroom side, and the keys are on a shared holder at the hand washing station. It does take some getting used to for those who have not been camping before, but in the learning process, please help keep the toilet area clean for the next person after you. We expect all visitors to share in the responsibility for cleaning and restocking the bathrooms.

Section 4

Important Documentation

Like many other aspects of traveling to Engeye, this is your individual responsibility. Do not wait until the last minute.

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This website is a helpful resource for anyone, experienced or inexperienced, traveling outside of the US. http://travel.state.gov/travel/tips/tips_1232.html

Passports If you don’t have one, you need to get one. If you have one, ensure that it will not expire within 6 months of your travel date. Applying for or renewing a passport can take a month or longer to process.

This website has explicit instructions for obtaining a passport. http://www.travel.state.gov/passport/passport_1738.html

Visa You are required to have a visa to enter Uganda. They are good for 90 days after entry. US citizens may obtain a visa upon arrival at Entebbe airport in Uganda. Citizens of other countries should check with the Ugandan Embassy about visa requirements prior to departure. http://www.ugandaembassy.com/visa.html

Obtaining your visa at Entebbe airport requires your passport (cannot expire within 6 months) and a $50 USD bill. Have the address in Uganda where we intend to stay (listed below). http://travel.state.gov/travel/cis_pa_tw/cis/cis_1051.html

Your reference in the country is John Kalule His address is: Amber House Plot 29/33, Kampala Road Ground Floor PO Box 26592 Kampala, Uganda

The address in Uganda where you intend to stay is: Ddegeya Masaka-Mbarara Road Plot 39, Estate 449 Ddegeya Village, Nakateete Parish Kisekka Sub County

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Post-Uganda Travel You may need an additional visa if you plan on traveling to other countries while in Africa. Each country has different entry requirements and you will need to research this depending on your travel plans. http://travel.state.gov/travel/cis_pa_tw/cis/cis_1765.html

Travel Health Insurance We now require that you obtain travel health insurance at least to the extent that you would be able to get a "medevac" (medical evacuation) transport in case of emergency. It is inexpensive and can save you from a lot of grief and expense if something unfortunate happens while traveling. If you are an AAA member, you can get excellent coverage for a decent price. If not, any travel agent can recommend an insurance agency, or ask at your local university’s study abroad office. http://travel-insurance- review.toptenreviews.com

MedJet Assist: www.medjetassist.com (medical evac insurance to the hospital of your choice) International Volunteer Card: http://www.volunteercard.com/ International SOS: http://www.internationalsos.com/ AirMed: www.airmed.com

Travel Insurance Travel insurance covers general problems, such as trip delay, weather delays, lost luggage, etc. The ticket broker can help, as can AAA and most credit card companies. Please bring a copy along with you to Uganda.

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Section 5

Immunizations Before you depart, several immunizations are strongly recommended, and a few are required. Some take several weeks before they confer immunity, so keep that in mind when you're making your appointments. There are also some that are preferentially not given at the same time. You do not want to get these immunizations at the last minute.

Also, keep in mind that immunizations can be expensive and are generally not covered by health insurance.

The CDC website for travel to East Africa: http://wwwn.cdc.gov/travel/regionEastAfrica.aspx The Providence Travel Clinic is at the Providence Plaza Building (Sarah Slaughter), 503-215-6381.

REQUIRED IMMUNIZATIONS – YOU MUST HAVE THESE  Hepatitis A  Hepatitis B  Typhoid  Yellow fever  As needed boosters for Tetanus-Diphtheria, Measles, and Polio vaccine for adults

RECOMMENDED IMMUNIZATIONS  Meningococcal  Rabies vaccination is not required, but you should be advised that there are bats around the bunk houses and latrines. This vaccine is expensive and the risk of contact is low, but get it if you’re worried.

MALARIA You must have an anti-malarial drug to go to Uganda. These drugs can be expensive and are generally not covered by health insurance. Taking the medications does not guarantee you will not get malaria. There are three major anti-malarials used: Malarone, Larium and doxycycline

 Malarone (Atovaquone and proguanil) tends to be the most popular choice. It is once a day and relatively expensive, but side effects are rare. Start 1-2 days before departure and continue until 7 days after. Take with food/milk at same time each day.  Mefloquine (Larium) is once a week. It is cheaper, starts 1 week before exposure and continues 4 weeks after. It can have rare neuropsychiatric side effects, and it is contraindicated with depression (active/recent), generalized anxiety disorder, psychosis, schizophrenia or any other major psychiatric disorder or history of seizures. That said, most people tolerate it well, with the main side effect being vivid dreams.  Doxycycline is the cheapest option. The major side effect is sun sensitivity, which can be severe, and fairly common. Some people may be prone to yeast infections or other side effects of gut flora changes. Start 1-2 days before exposure until 4 weeks after. Do not give antacids or calcium supplementation within 2 hours of taking doxycycline.

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Be aware some immunizations require certification (i.e. Yellow Fever) and these documents will be important especially in terms of re-entry into the U.S. You should have your yellow card that certifies you have received the yellow fever vaccine to get into Uganda. We have not often been asked for it, but please keep the yellow card with you. All this information can be found at http://www.state.gov

Section 6

THE COMPREHENSIVE PACKING LIST

Note: This is overly comprehensive and you may not need most of it, especially if you know that someone else in your group is already bringing a certain item.

Tip: If you will be bringing medical supplies/equipment with you to Engeye, it is wise to pack one bag with ½ of your personal items and ½ with the clinic supplies. If one bag is lost or delayed, you will still have enough of your personal belongings to complete your trip. Your trip could be very challenging if you pack all of your personal belongings/clothing into one bag and that bag is lost or delayed.

Temperatures range from highs in the 80s to lows in the 60s. The rains are quite heavy in the wet season, and shoes and pants will be stained with red clay mud.

Documentation:  Valid passport and photocopy of front two pages (in case of loss)  $50 bill for Uganda visa  Immunization Records (yellow card)  Details of medications you are taking  Documentation regarding any pre-existing illness/allergy that might require medical treatment  Health and travel insurance information  Emergency contact information  Copy of your professional license

Clothing:  Scrubs (if you have them, 2-3 pairs)  Long sleeve and short sleeve shirts  Hiking pants (comfortable, light-weight, fast-drying)  Knee-length shorts  Knee-length, loose skirts  One 'nice' outfit for church or restaurants  A warm fleece, or hooded sweatshirt  Pajamas  Comfortable shoes for walking  Shower shoes or flip flops  Baseball cap/sun hat/bandannas

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 Rain jacket

** Please do NOT bring scrubs from your workplace to leave behind at the clinic.

Other:  Sunscreen  Camera  Crisp $50 and $100 bills  Books, cards and board games  Small musical instruments  Hand sanitizer  LED head lamp for working in the clinic and getting around at night  DEET insect repellent  Water bottle (e.g. Nalgene)  Ear plugs  Sunglasses  Hand mirror  Prescription medications in original containers  Alarm clock (battery operated)  Passport holders that hang around your neck or waist are great for airport travel  Lip balm  Pocket knife or multipurpose tool (not in carry-on!)  Tampons with no applicator to keep garbage to a minimum  Journal/notebooks, and lots of pens  Pictures of your home and family or postcards of your home town  Small first aid kit (see list below)

Travel Medical Kit: Many of these are available at local pharmacies, but getting there when they are needed is not always feasible. Be sure to bring this selection if you are planning to travel elsewhere after the clinic.

 Analgesic (acetaminophen, ibuprofen)  Antihistamine (Benadryl, etc)  Antiseptic / Antibacterial hand cleanser  Bandages, tweezers  Antimotility medication (Imodium, etc)  Antacids  Oral rehydration salts (Gastrolyte, etc)  EpiPen/Anakit (for life-threatening allergies)  Medic alert bracelet  Vitamins  Condoms – hey, you never know  Duct tape – another thing that comes in handy for all kinds of problems

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If you use certain medications for allergies (OTC or prescription), please come with them, as Sudafed, Allegra, or any decongestants are not available in Uganda, and the change in climate/location does trigger allergies for some visitors. If you need an Epi-Pen for allergic reactions, please bring 2 with you just in case.

Medical equipment: BP cuffs, thermometers and otoscopes will likely be available at the clinic. Ask your group leader for updated information, as items do need replaced from time to time. Please bring your own stethoscope; be sure it has your name on it. Don’t forget a headlamp.

Section 7

Budget and Trip Cost

The current visitor/volunteer fee for staying at the clinic is a flat fee of $30 per day for every day a bed is reserved for you at the clinic. This includes on-site meals, drinking water, electricity, internet, and a bunk bed with mosquito net. Any transportation costs to and from the clinic are not included.

Section 8

1. Health Maintenance Engeye Health Clinic Manual Abbreviated 2. Malaria Engeye Health Clinic Quick Reference Updated 3. Respiratory tract infection 1/15/2014 4. GERD / Dyspepsia / Peptic ulcer disease Introduction: This is an overview of 12 common diagnoses at the Engeye Health Clinic. The 5. Hypertension (In Appendix) manual details how these conditions are 6. Gastroenteritis / Diarrhea diagnosed and what medications are available 7. Arthralgia for treatment. While many medications are 8. Urinary tract infection inexpensive in Uganda, some of the common 9. STI / Pelvic inflammatory disease 10. Allergic Rhinitis/Eczema/Asthma Page 15 of 36 11. Diabetes Type II 12. Tinea Capitis

Origin Credit: C. Elguero, MD (2009) Engeye Volunteer Manual – Revised Jan 2014 medications used in the US are expensive in Uganda. The treatment of pneumonia and arthritis illustrates this point. Pneumonia is treated first line with amoxicillin as opposed to azithromycin. While azithromycin is available it is twice as expensive as amoxicillin. For arthritis, ibuprofen is widely available, but depending on suppliers, may be three times the cost of an equivalent dose of twice daily diclofenac.

Adhering to the protocols for common diseases will provide appropriate medical care and prevent wasting of valuable resources. If ever in doubt, please ask the local clinicians or check with the dispensary for current medication stock options or pricing.

Chronic Disease Note: Patients at the Engeye health clinic need to understand that chronic problems like HTN, DM, chronic back pain, and arthritis will last for the rest of their life. They will get better and improve with medicine but will never be cured. Once they come off the medicine, the problem will return. They should also be counseled that treatment will prevent the long term consequences of diabetes and hypertension including: heart problems, stroke, infections, kidney and vision problems. They should be reminded to follow up monthly.

** This quick reference manual does not cover all diseases seen at Engeye! When in doubt, please ask the local clinicians about common local practices and treatment options. Always use current medical treatment guidelines for best care. Medical reference texts are available in the shared library “hutch” in the clinic. Be careful to practice best medicine with the cultural and resource-limited setting in mind.

1. Health Maintenance *Note: Given risk of Vitamin A toxicity DO NOT give if there is any chance last dose was within last 6 months. < 6 months No Treatment 6 to 12 months Vitamin A 100,000 units (use syringe to remove half of capsule)* 12 months to 24 months Albendazole 200 mg (half tablet) every 6 months Vitamin A 200,000 units every 6 months* Childrens multi-vitamin 1 tab daily x 30 days 24 months to 5 years Albendazole 400 mg (one tablet) every 6 months Vitamin A 200,000 units every 6 months* Childrens multi-vitamin 1 tab daily x 30 days 5 years to Adult Albendazole 400 mg (one tablet) every 6 months Childrens multi-vitamin 1 tab daily x 30 days Adult Albendazole 400 mg (one tablet) every 6 months

2. Malaria Diagnosis: Malaria is the leading cause of death in Uganda. If a patient has subjective or objective fever within last 3 days, test for malaria with a Malaria Blood Smear. After hours, if lab is not available, a Rapid Diagnostic Test (RDT) may be used. An RDT can remain positive for up to 35 days after successful treatment; a malaria smear is the gold standard to test for recurrent disease within 14 days of treatment.

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Cultural Note: Many patients complain of having “malaria”, but the word for “malaria” and “fever” is the same in Luganda, and “fever” is used to describe multiple complaints ranging from muscle aches, to chills, to headaches, to generalized weakness, to actually feeling hot or having a raised temperature. Therefore, it is up to the clinician to clarify what the patient means by the complaint of “fever.”

Treatment of Non-Severe Malaria:

Artemether/Lumefantrine 180/1080 mg per 60 ml solution 1 kg 1.3 ml 2 kg 2.6 ml 3 kg 4 ml 4 kg 5 ml 5 kg 6 ml Given once daily x 3 days. 6 kg 8 ml Should be given with prefilled oral syringes 7 kg 9 ml from the pharmacy. 8 kg 10 ml 9 kg 12 ml Note: For a small child the solution is 9 times more expensive than tablets. Many 10 kg 13 ml small children in Uganda have no problems 11 kg 14 ml taking tablets. 12 kg 16 ml 13 kg 17 ml 14 kg 18 ml 15 kg 20 ml Artemether 120mg/Lumefantrine 20mg Tablets 5-14 kg 1 Tablet each dose Each dose with fatty meal or milk every AM 15-24 kg 2 Tablets each dose and PM x 6 doses total. First dose at clinic 25-34 kg 3 Tablets each dose counts as first AM dose. The second dose >34 kg 4 Tablets each dose should be within 8 hours of first dose.

Pregnant and Lactating Women

1. < 12 weeks pregnancy: Quinine 300mg 2 tab TID x 7 days PLUS Clindamycin 7mg/kg/dose (max 600mg per dose) three times daily x 7d

2. = 12 weeks of pregnancy: if > 34kg Artemether 120mg/ Lumefantrine 20mg 4 tabs each dose with fatty meal or milk every AM and PM x 6 doses total. First dose at clinic counts as first AM dose.

3. Lactating women: Artemether 120mg/ Lumefantrine 20mg as above.

Treatment of Severe Malaria We do have IM artemether available for vomiting, seizing, or patients otherwise unable to tolerate PO treatment. All courses of IM artemether should be followed by a full course of oral ACT (artemisinin-combination therapy) once the patient is able to tolerated PO. We are no longer Page 17 of 36 Engeye Volunteer Manual – Revised Jan 2014

recommending IV quinine therapy as first-line treatment due to risk of side effects and per updated WHO guidelines.

3. Respiratory tract infection This category encompasses viral upper respiratory tract infection, acute bronchitis, and bacterial pneumonia. When a patient presents with cough, runny nose, and/or fever, bacterial pneumonia is the important diagnosis to exclude. Radiographs are unavailable and reliance on clinical history and examination is prudent. In order for a patient to qualify for antibiotics at the health clinic, they must show some form of increased work of breathing. Purulence of sputum does not indicate bacterial infection requiring antibiotics. Excluding bacterial pneumonia: If a patient has a normal respiratory rate, no tachycardia, and is afebrile in the clinic the likely hood of bacterial pneumonia is < 1 % and antibiotics are NOT indicated. (The table below shows normal pediatric vital signs). These patients likely have a viral URI or acute bronchitis. Diagnosing bacterial pneumonia: Patients with an elevated respiratory rate, ± fever, and ± tachycardia are more likely to have bacterial pneumonia and should be treated with antibiotics. Treatment: Pediatric Bacterial Pneumonia For all: 1. Encourage PO intake, cont. breast feeding, treat fever, and do not keep covered when fever present. 2. Educate to return to clinic/hospital if worse breathing or below danger sign

Severe If one of following danger signs present: chest indrawing, not eating/drinking, lethargy, unconsciousness, convulsions, or stridor. 1. If possible give one dose and refer to hospital. 2. IM/IV ceftriaxone 50mg/kg (max dose 1 g) once daily until able to tolerate oral and complete 10 day course of below Non-severe antibiotics. 3. Ceftriaxone is preferred IM/IV treatment for clinic because it is dosed once daily as opposed to gentamicin and chloramphenicol. 4. It is safe in patients with penicillin allergy such as rash but not hives or anaphylaxis. 5. F/U 1 day

Non-severe 1. Oral amoxicillin 25mg/kg/dose (Max 500mg -1000 per dose) BID x 3-7 days 2. Alternate: Erythromycin 12.5mg/kg/dose (Max 500mg – 1000mg per dose) 4 times daily x 3-7 days 3. F/U 2 days

Adult Bacterial Pneumonia 1. Oral amoxicillin 500mg -1000mg TID x 3-7 days 2. F/U 2 days

Bronchitis and URI – Cough syrup is available at the health clinic, but it does not alter the disease course. However, patients/parents sometimes expect medication even if antibiotics are not indicated, so it is a Page 18 of 36 Engeye Volunteer Manual – Revised Jan 2014 bit of a clinical quandry to balance the prescription with education and keeping the patient/parent satisfied with their care at the same time. Cultural issues and travel cost issues should always be considered in your management of the patient.

Vital Signs at Various Ages From Nelson’s Textbook of Pediatrics

AGE HR BP RR

Premature 120–170[*] 55–75/35–45[†] 40–70

0–3 mo 100–150[*] 65–85/45–55 35–55

3–6 mo 90–120 70–90/50–65 30–45

6–12 mo 80–120 80–100/55–65 25–40

1–3 yr 70–110 90–105/55–70 20–30

3–6 yr 65–110 95–110/60–75 20–25

6–12 yr 60–95 100–120/60–75 14–22

12[*] yr 55–85 110–135/65–85 12–18

* In sleep, infant heart rates may drop significantly lower, but if perfusion is maintained, no intervention is required. † A blood pressure cuff should cover approximately ⅔ of the arm; too small a cuff yields spuriously high pressure readings, and too large a cuff yields spuriously low pressure readings.

4. GERD/PUD Stepwise GERD Rx: 1. Magnesium Trisillicate 205mg/150 mg 1-3 pills as needed for reflux Disp # 30 2. Omeprazole 20 mg 1 tablet daily as needed heartburn Disp # 15 3. Omeprazole 20 mg 1 tablet daily Disp # 30 4. Omeprazole 20 mg 1 tab twice daily Disp # 60

Peptic Ulcer Disease with H. Pylori Treatment 1. Omeprazole 20 mg 1 tab twice daily x 30 days Disp # 60 2. Amoxicillin 250mg 4 tablets twice daily x 10 days Disp # 80 3. Metronidazole 200mg 3 tabs twice daily x 10 days Disp # 60

F/U in 1 month

5. Hypertension (See Appendix)

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6. Gastroenteritis and Diarrhea Assess dehydration and treat accordingly. Follow up plan in 24 to 72 hours depending on severity. For severe vomiting Metoclopramide IV/IM 1-2 mg/kg max dose 10 to 20 mg may repeat in 2 hours. PO promethazine is also available.

Severe Dehydration 1. Lethargic or Unconscious 1. IVF Normal Saline 0.9% 2. Poor eating or drinking 20mg/kg bolus x 1 may 3. Skin pinch goes back VERY repeat as needed or start slowly 1.5 x maintenance rate (table below) 2. Aggressive Oral Rehydration Solution 3. Consider transfer to hospital Some Dehydration 1. Restless, irritable 1. Aggressive Oral 2. Sunken eyes Rehydration Solution 3. Drinks eagerly,thirsty 4. Skin pinch goes back slowly No dehydration None of above symptoms Oral Rehydration Solution to prevent dehydration Bloody Diarrhea Treat as if dysentery from Ciprofloxacin 500mg tablet Shigella Age < 1 = ¼ tablet BID x 3 days Age 1-4 = ½ tablet BID x 3 days Age > 4 = 1 tablet BID x 3 days Bolus Maintenance rate mL/hr Daily KG 20 mL/kg 1 X 1.5 X mL 2 40 8 13 200 3 60 13 19 300 4 80 17 25 400 5 100 21 31 500 6 120 25 38 600 7 140 29 44 700 8 160 33 50 800 9 180 38 56 900 10 200 40 60 960 15 300 50 75 1200 20 400 60 90 1440 25 500 65 98 1560 30 600 70 105 1680 35 700 75 113 1800 40 800 80 120 1920 50 1000 90 135 2160

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7. Arthralgia: Osteoarthritis, Joint pain, and Back pain No Epigastric Pain and Not Pregnant Step 1: Diclofenac 50 mg 1 tab twice daily x 30 days as needed for pain Disp. # 30 Step 2: Diclofenac 50 mg 2 tabs twice daily x 30 days PRN as needed for pain Disp. # 60 Epigastric Pain or Pregnant Paracetamol 500 mg 2 tab PO BID x 30 days PRN pain Dispense # 60

8. Urinary Tract Infection: Acute Cystitis and Pyelonephritis Diagnosis: Clinical symptoms dysuria, urgency or frequency with positive nitrates or leukocytes on urine dip stick analysis. If fever or flank pain present, extend treatment course. Fever is more predictive of pyelonephritis then flank pain. Co-trimoxazole is equivalent to TMP-SMX or Bactrim, and it comes in 800/160 (DS) mg or 400/80 mg (SS) tabs. Stock prices change and it may be marginally cheaper for DS tabs now.

Cultural note: Keep in mind that TMP-SMX is ubiquitous and used for not only PCP prophylaxis after HIV diagnosis, but patients also self-diagnose and treat with various antibiotics (very commonly TMP-SMX, chloramphenicol, etc.) since essentially all of them are available without a prescription from local drug shops. You may also see TMP-SMX doses written as “480” for the SS 400/80mg or “960” for the DS 800/160mg doses.

Treatment: Acute Cystitis: Co-trimoxazole 400/80mg 2 tabs twice daily x 3 days Disp # 12 (Or Co-trimoxazole 800/160mg 1 tab twice daily x 3 days Disp # 6) Sulfa allergy: Ciprofloxacin 500mg twice daily x 3 days Disp # 6 Pyelonephritis Co-trimoxazole 400/80mg 2 tabs twice daily x 7 days Disp # 28 (Or Co-trimoxazole 800/160mg 1 tab twice daily x 7 days Disp # 14) Sulfa allergy: Ciprofloxacin 500mg twice daily x 7 days Disp # 14 Pregnancy Cephalexin 500mg four times daily x 7 days Disp # 28

9. Sexually Transmitted Infection and Pelvic Inflammatory Disease Locally in Uganda it is common for patients to complain of having “syphilis.” They associate syphilis with many symptoms including headaches, weakness, discharge, genital lesions, or any skin rash at all. Minimal testing is available aside from a wet mount to diagnose: trichomonas, candidiasis, or bacterial vaginosis. RPR testing is available, but may show falsely positive if the patient has active malaria, HIV, or other autoimmune or acute infectious disease.

STI: Any patient presenting with discharge or urethritis found not to have bacterial vaginosis or vaginal candidiasis. Treatment:  Treat sexual partners and give 4 pathogen/drug regimen empirically 1. Doxycycline 100 mg BID x 7 days (Chlamydia)

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2. Ceftriaxone 250mg IM x 1 (Gonorrhea) 3. Metronidazole 2 g PO single dose (Trichomonas) 4. Benzathine penicillin 2.4 million units IM single dose (Syphillis)  If pt is pregnant, use the following tx regimen: 1. Ceftriaxone 250 mg IM x 1 (Gonorrhea) 2. Azithromycin 500 mg 2 tabs x 1 (Chlamydia) $$$ Expensive 3. Metronidazole 2 g PO single dose (Trichomonas) 4. Benzathine penicillin 2.4 million units IM single dose (Syphillis)

PID: Vaginal discharge with cervical motion tenderness. Treatment: 1. Ceftriaxone 250 mg IM x 1 (gonorrhea) 2. Doxycycline 100mg PO twice daily x 14 days Disp # 28 (chlamydia) 3. Metronidazole 200mg 2 tabs twice daily x 14 days Disp # 56 (anerobes)

Syphilis: Treatment: Primary, secondary, early latent syphilis: Benzathine penicillin 2.4 million units IM single dose Tertiary, late latent syphilis: Benzathine penicillin 2.4 million units IM every week x 3 doses

10. Allergic Rhinitis/Eczema/Asthma Allergic Rhinitis: Avoid what caused allergic symptoms 1. Reduce exposure to cooking smoke 2. Reduce exposure to automobile exhaust fumes 3. Consider a mask if pt cannot decrease daily exposure

Step 1: Cetirizine 10mg ½ tab daily as needed for allergies x 30 days Disp #15

Step 2: Cetirizine 10mg 1 tab daily daily as needed for allergies x 30 days Disp #15

Step 3: Cetirizine 10mg 1 tab daily x 30 days Disp #15 daily and Chlorpheniramine 4mg 1 tab daily at night as needed for allergies Disp # 15

Eczema: Fungal infections are much more common than eczema in rural Uganda. Treat eczema with medium potency steroid. Betamethasone 0.1% Cream BID x 7 to 14 days Disp # 1 tube apply thin layer to affected area. Lower potency Hydrocortisone 1% is also available.

Asthma:  Salbutamol oral is equally effective as inhaled but causes more tachycardia. (Salbutamol is equivalent to albuterol.)

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 Well controlled = Asthma symptoms or salbutamol use ≤ 2 times per week and night time symptoms ≤ 2 per month.  If not well controlled go to next step.

Stepwise therapy: Step 1: Salbutamol 2-4 mg PO every 4 hours as needed for cough or difficulty breathing Disp # 30 Step 2: Add Beclomethasone 50 mcg inhaler 1 puffs to 2 puffs twice daily Disp # 1 canister $$$ Expensive Step 3: Add Beclomethasone 50 mcg inhaler 4 puffs twice daily Disp # 1 canister $$$ Expensive Step 4: Add Aminophylline 200 mg PO BID or Pediatric dose: 15 mg/kg/day *Dose can be higher but given severe side effects and inability to monitor must weigh risk vs. benefits.

Asthma Exacerbation: 1. Aggressive salbutamol inhaler or oral tablets ** Salbutamol inhalers are available but are much more expensive than oral, and patients sometimes associated any inhalers with “risk of death” because of delayed presentation association. Salbutamol solution is also available for use with the nebulizer machine, though tubing and med chambers are in short supply and the solution has to be mixed manually.

2. Prednisone 1 mg /kg twice daily in children or once daily in adults x 10 days. Max dose 60mg per day.

3. Dexamethasone 0.5 mg/kg q 6 hours. Upper limit dose: 10 mg

11. Diabetes Type II Diagnosis: Blood glucose > 200 non-fasting or fasting blood glucose > 126 Units Conversion: multiply the # mmol/L by 18 to get # mg/dL

Treatment: Step wise therapy for a target premeal (before breakfast, dinner, and supper) blood glucose of 8.3 mmol/L or 150mg/dL. Step 1: Glibenclamide 5 mg once daily with largest meal Disp # 30 Step 2: Glibenclamide 5 mg once daily # 30+ Metformin 500mg twice daily # 60 Step 3: Glibenclamide 5 mg once daily # 30 + Metformin 1000mg twice daily # 120 Step 4: Glibenclamide 5 mg twice daily # 60 + Metformin 1000mg twice daily # 120

We do see some patients requiring insulin therapy, with or without DM type 1, which is very expensive and generally not affordable for most patients. The majority of patients also cannot afford glucose monitor and testing supplies. There is a Diabetes Referral Center in Masaka.

We started carrying regular insulin in the fridge, but usual course is ONE dose to bring HIGH glucose readings down into better range, then referring the patient or establishing other meds for d/c home if appropriate. Soluble insulin = regular insulin; Insulatard = NPH insulin; Mixtard = NPH/regular insulins mixed.

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12. Tinea Capitis Griseofulvin 20mg/kg once daily with fatty meal x 6 weeks. Revaluate at 6 weeks. If there are no longer white patches and there is new hair growth, consider treatment successful. If white patches persist, continue therapy for another 6 weeks, then reevaluate. Second line treatment will be Fluconazole 6mg/kg given once daily for 4 to 6 weeks or once weekly for 8 to 12 weeks. NOTE: Griseofulvin approved for children age > 2 years

Topical treatment with clotrimazole cream is also available.

Weight Dose 6 to 12 kg Griseofulvin 500mg 1/4 tab daily x 6 weeks Dispense QTY 42 13 to 20 kg Griseofulvin 500mg 1/2 tab daily x 6 weeks Dispense QTY 42 20 kg and above Griseofulvin 500mg 1 tab daily x 6 weeks Dispense QTY 42

** This treatment course is very expensive, and if patients are unable to afford the full amount of medications, it is the clinician's responsibility to educate them on the importance of full treatment course adherence for success.

Section 9

AFFIDAVIT AND DECLARATION

Date Page 24 of 36 Engeye Volunteer Manual – Revised Jan 2014

To whom it may concern,

This is to verify that the goods being hand-carried into Uganda by representatives of the Engeye Health Clinic will be donated to charitable organizations in the Lwengo District and not be sold at any price.

The members of the Engeye, Inc. are dedicated to assisting in health and development projects organized for the poor. The Engeye Health Clinic is a 501(c)(3) registered nonprofit in the United States, as well as a registered NGO in Uganda.

The trip participants listed below will be transporting these supplies from Entebbe, Uganda en route to the Lwengo District, where they will be donated to and utilized by village clinics throughout the Lwengo District. The following goods are being carried: medical supplies, school supplies, pharmaceuticals, and books.

Trip participants are as follows:

We certify that these goods were donated to the Engeye Health Clinic free of charge, are being transported free of charge, and will be donated to worthy people free of charge.

Thank you for your consideration and assistance in helping to ensure that these goods are delivered to those people most in need.

Sincerely,

______Engeye Health Project, LTD. Ddegeya Village Masaka-Mbarara Road Lwengo District

Section 10 Learn Luganda

Easy to use common words

Greetings Response

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Oli otya - Hello/how are you? Bulungi – I’m fine Osibye otya – How was the day? Wasuze otya – How was the night? Kale – you’re welcome/fine Ssebo/Nyabo – sir/miss

***A common beginning to any conversation will follow this pattern Person #1 (woman) Oli otya? Person #2 (man) Bulungi Nyabo. hmm (high pitched hum) Oli otya? Person #1 Bulungi Ssebo!

This may be repeated a few times Weebale – Way-ba-lay - Thank-you Kale – Kah-lay - You're Welcome

Osibye Bulungi - Have a nice day!

Yee – Yes Nedda – No

Nnyo – very much i.e. ‘Weebale nnyo!’ Mpola – slowly (Mwatto yogera mpola mpola “Please speak slowly!”)

#1-10 emu, bbiri, ssatu, nnya, ttanu, mukaaga, musanvu, munaana, mwenda, kumi

Balaza or Lwakusooka - Monday Lwakubiri - Tuesday Lwakusatu - Wednesday Lwakunnya - Thursday Lwakutaano - Friday Lwamukaaga - Saturday Sabiti or Lwasande - Sunday

Embuzi - Goat Enkoko - Chicken Ente - Cow Akatele - Market

Omuwana - Baby Omuwala - Young Girl Omulenzi - Young boy See the web site, www.engeye.org, for news and current goals.

Clinic Supply Wish List

1. Bandaging/rolled gauze, band-aids 2. Crutches/canes/wheelchairs 3. Pill counters and crushers 4. Adult scale, Pediatric/infant scale 5. Penlights, pens 6. Growth charts (wall) Page 26 of 36 Engeye Volunteer Manual – Revised Jan 2014

7. Bed pans, vomit containers, instrument 8. Bag ventilator, masks trays 9. Containers to organize clinic and stock 10. Lancets (fingerstick) room (Tupperware) 11. Thermometers (ear/tympanic) 12. Pediatric blood pressure cuffs 13. Urine dipsticks 14. Glucose meter w/strips (non-expired) (clinic uses Optium Exceed brand) 15. I.V. stand, any type of stand 16. Pessaries (for non-surgical cystocele) 17. Triple antibiotic ointment packets 18. 4x4, 2x2 gauze, absorbent wound pads 19. Nebulizer tubing sets 20. Otoscope/ophthalmoscope sets 21. Oral syringes (10mL or 12mL) 22. Autoclave sterile packaging 23. Children's chewable vitamins 24. Silk, cloth, or other good tape

Please do not bring any expired supplies or medications, as we cannot dispense or stock them at the clinic.

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Section 12

Recommended Reading List

 Facts for Life, UNICEF  Where There Is No Doctor, Werner  Where Women Have No Doctor, Burns  Mountains Beyond Mountains, Kidder  Sexual Practices of Adolescents in Iganga, Schilsky  Pathologies of Power, Farmer  Health Care Co-Ops in Uganda, George Halvorson  The End of Poverty, Sachs  Poor Economics, Banerjee and Duflo  Medical Reference Text: Oxford's Handbook of Tropical Medicine

Recommended List From Dr. Michael Westerhaus

* Dr. Westerhaus is a resident at Harvard Medical School and Director of their immersion-focused Social Medicine Course taught in Northern Uganda.

I. HEALTH BEYOND BIOLOGY: SOCIAL AND ECONOMIC CAUSATION OF DISEASE

Films: 1. Uganda Rising 2. This Magnificent African Cake

Readings: 1. Farmer, Paul. 2005. Pathologies of Power: Health, Human Rights and the New War on the Poor. Berkeley: University of California Press. [read before course begins] 2. Galtung, Johann. 1969. “Violence, Peace, and Peace Research.” Journal of Peace Research 6 (3): 167-91. 3. Patel, Vikram, Saraceno, Benedetto, and Kleinman, Arthur. 2006. “Beyond Evidence: The Moral Case for International Mental Health.” American Journal of Psychiatry, 168: 1312-1315. 4. Rothenberg, Paula. 2005. “Map: Colonialism in Africa, 1914.” In Beyond Borders: Thinking Critically About Global Issues. Macmillan Press. 5. Boahen, A. Adu. 1989. “The Imposition of the Colonial System: Initiatives and Responses” and “The Colonial Impact.” In: African Perspectives on Colonialism. JHU Press, pp: 27-57, 94-112. 6. Allen, Tim. 2006. “The coming of the Lord’s Resistance Army” and “Displacement and Abduction.” In: Trial Justice: The International Criminal Court and the Lord’s Resistance Army. London: Zed Books, Limited, pp: 25-54, 53-72. 7. Allen, Tim. 2006. “AIDS and Evidence: interrogating some Ugandan myths.” Journal of Biosocial Science 38(1): 7-28. 8. Finnström, Sverker. 2005. “For God & My Life: War and Cosmology in Northern Uganda.” In: Richards, Paul (ed.) No Peace, No War: An Anthropology of Contemporary Armed Conflicts. Athens: Ohio University Press, pp 98-116.

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9. Kaiser, Paul. 1996. “Structural Adjustment and the Fragile Nation: The Demise of Social Unity in .” The Journal of Modern African Studies 34(2): 227-237. 10. Westerhaus, Michael and Castro, Arachu. 2009. “Inverting the Killer Commodity Model: Withholding Medicines from the Poor.” In: Singer, Merrill and Baer, Hans (Eds.) Killer Commodities: Public Health and The Corporate Production of Harm. New York: AltaMira Press, pp 367-397. 11. Ekobu, Caroline. “The Poverty Trap: A Ugandan Perspective on Globalization.” Online at http://mcc.org/economicglobalization/viewpoints/perspectives/globaleyes/international/povertytrap.html 12. Mao, Norbert. 2003. “Unevenly Yoked: Has Globalization Dealt Africa a Bad Hand?” Yale Global Online. On-line at http://yaleglobal.yale.edu/article.print?id=2721 13. Kaiser Family Foundation. 2008. “Fact Sheet: The HIV/AIDS Epidemic in Sub-Saharan Africa.” On- line at http://www.kff.org/hivaids/upload/7391-071.pdf 14. Westerhaus, Michael, Finnegan, Amy, and Mukherjee, Joia. 2007. “Entangled Realities: Framing the HIV Prevention Discourse to Encompass the Complexities of War.” American Journal of Public Health 97:1184-1186. 15. Westerhaus, Michael. 2007. “Linking Anthropological Analysis and Epidemiologic Evidence: Formulating a Narrative of HIV Transmission in northern Uganda.” Journal of the Social Aspects of HIV/AIDS 4 (2): 590-605. 16. Spiegel, P, Bennedsen, A, Claass, J, Bruns, L, Patterson, N, Yiweza, D, and Schilperoord, M. 2007. “Prevalence of HIV infection in conflict-affected and displaced people in seven sub-Saharan African countries: a systematic review.” Lancet 369 (9580): 2187-2195. 17. Garfield, Richard and Neugut, Alfred. 2000. “The Human Consequences of War.” In: Levy, Barry and Sidel, Victor (eds.) War and Public Health. Washington, DC: American Journal of Public Health, pp. 27-38. 18. Vaughan, Megan. 1991. Curing Their Ills: Colonial Power and African Illnes. Stanford University Press

II. GLOBAL HEALTH INTERVENTIONS: PARADIGMS OF CHARITY, HUMANITARIANISM, AND STRUCTURAL CHANGE

Films: 1. National Geographic films about Médecins Sans Frontières in Africa 2. Catch a Fire/ other Uganda-created film 3. Invisible Children

Readings: 1. Kleinman, Arthur and Kleinman, Joan. 1996. “The Appeal of Experience; The Dismay of Images: Cultural Appropriations of Suffering in Our Times.” Daedulus 125(1): 1-23. 2. Panosian, C and Coates TJ. 2006. “The New Medical ‘Missionaries’ – Grooming the Next Generation of Global Health Workers.” New England Journal of Medicine 354: 1771-1773. 3. Bruderlein, Claude and Leaning, Jennifer. 1999. “New Challenges for Humanitarian Protection.” British Medical Journal 319(7207): 430-5. 4. Duffield, Mark. 2001. “The New Humanitarianism.” In: Global Governance and the New Wars: The Merging of Development and Security. Zed Books. 5. Iweala, Uzodinma. July 15, 2007. “Stop Trying to ‘Save’ Africa.” Washington Post. On-line at: http://www.washingtonpost.com/wp-dyn/content/article/2007/07/13/AR2007071301714.html

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6. Easterly, William. July 6, 2007. “What Bono Doesn’t Say About Africa.” Los Angeles Times. On- line at: http://www.latimes.com/news/opinion/la-oe-easterly6jul06,0,6188154.story?coll=la-opinion- rightrail 7. Easterly, William. 2006. The White Man’s Burdern: Why the West’s Efforts to Aid the Rest Have Done So Much Ill and So Little Good. Penguin Group. 8. Rieff, David. 2003. “The Humanitarian Paradox” and “The Hazards of Charity” in A Bed for the Night. Simon and Schuster, pp: 31-90. 9. Pandolfi, Mariella. 2003. “Contract of Mutual (In)Difference: Governance and the Humanitarian Apparatus in Contemporary Albania and Kosovo.” Indiana Journal of Global Legal Studies 10(1): 369-381. 10. Farmer, Paul. 1995. “Medicine and Social Justice.” America 173(2):13-17. 11. Médecins Sans Frontières. 2007. “MSF Activity Report 2007.” On-line at: http://www.msf.org/source/actrep/2008/IAR-2008_complete.pdf 12. The AIDS Service Organization (TASO). Selections from website: http://www.tasouganda.org/index.php?option=com_content&view=article&id=51&Itemid=61 13. Physicians for Human Rights. “Annual Report: 2007-2008.” On-line at: http://physiciansforhumanrights.org/about/annual-report/ 14. Partners in Health. “2008 Annual Report.” On-line at: http://pih.org/inforesources/annual.html 15. World Health Organization. “The WHO Agenda,” “The role of WHO in public health,” “History of WHO.” On-line at: http://www.who.int/about/en/

III. SOCIAL JUSTICE IN HEALTH INTERVENTIONS: MODELS OF COMMUNITY-BASED HEALTHCARE

Films: 1. Partners in Health Video (overview of work) 2. A Closer Walk 3. A Walk To Beautiful (NOVA) – free online http://www.pbs.org/wgbh/nova/beautiful/program.html

Readings: 1. Gutiérrez, Gustavo. A Theology of Liberation: History, Politics, and Salvation. Selections from introduction that explain notion of the ‘preferential option for the poor.’ 2. Partners in Health. 2006. PIH Guide to Community-Based Treatment of HIV in Resource-Poor Settings. Boston: Partners in Health, pp 1-16. 3. Farmer, P, Léandre, F, Mukherjee, J, Claude, M, Nevil, P, Smith-Fawzi, M, Koenig, S, Castro, A, Becerra, M, Sachs, J, Attaran, A, and Kim, J. 2002. “Community-based approaches to HIV treatment in resource-poor settings.” Lancet 358(9279): 404-9. 4. Behforouz, Heidi, Farmer, Paul, and Mukherjee, Joia. 2004. “From Directly Observed Therapy to Accompagnateurs: Enhancing AIDS Treatment Outcomes in Haiti and Boston.” Clinical Infectious Disease 38 (Suppl 5): S429-36. 5. Selection chosen by Professor Daniel Komakech of Gulu University. 6. Kleinman, Arthur, Das, Veena, and Lock, Margaret. “Introduction.” In: Social Suffering. Berkeley: University of California Press, pp. ix-xxvii. 7. Morgan, Lynn. 2006. Chapter from Community Participation in Health: The Politics of Primary Care in Costa Rica. Cambridge University Press.

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IV. HEALTH AND HUMAN RIGHTS: HEALTHCARE WORKERS AS ADVOCATES

Readings: 1. United Nations. 1948. “UN Declaration of Human Rights” On-line at: http://www.un.org/Overview/rights.html 2. Physicians for Human Rights. 2008. “The Right to Health and Health Workforce Planning: A Guide for Government Officials, NGOs, Health Workers, and Development Partners.” On-line at: http://physiciansforhumanrights.org/library/news-2008-08-04-haa.html 3. Physicians for Human Rights. 2004. “An Action Plan to Prevent Brain Drain: Building Equitable Health Systems in Africa.” On-line at: http://physiciansforhumanrights.org/library/report-2004- july.html 4. Action Group for Health, Human Rights, and HIV/AIDS Uganda. 2006. “A Promise Unmet: A Survey Report on Access to Essential Medicines in Uganda.” On-line at: http://physiciansforhumanrights.org/library/report-2007-10-01.html 5. Physician for Human Rights. 2003. “The Right to Equal Treatment: An Action Plan to End Racial and Ethnic Disparities in Clinical Diagnosis and Treatment in the United States.” On-line at: http://physiciansforhumanrights.org/library/report-equaltreatment-2003.html 6. Physicians for Human Rights. 2008. “Health Professionals’ World AIDS Day Letter to Obama Administration.” On-line at: http://physiciansforhumanrights.org/library/health-professionals- letter.html

V. TOOLS FOR EFFECTIVE APPLICATION OF THE GLOBAL HEALTH EXPERIENCE: WRITING, PHOTOGRAPHY, RESEARCH, AND POLITICAL ENGAGEMENT

Films: 1. Sudden Flowers Film (www.suddenflowers.org) 2. Treatment Action Campaign: State of Denial 3. Constant Gardener

Readings 1. Kleinman, Arthur. “The Personal and Social Meanings of Illness.” In: Illness Narratives. Basic Books, pp. 31-55. 2. Roberts, Maya. 2006. “Duffle Bag Medicine.” JAMA 295: 1491-1492. 3. Hurt, Avery. 2007. “Hidden Ethics of Overseas Electives.” The New Physician 56(9). On-line at: http://www.amsa.org/tnp/articles/article.cfx?id=407. 4. Epstein, Helen. 2007. “The Invisible Cure.” In: The Invisible Cure: Africa, The West, and The Fight Against AIDS. New York: Farra, Straus, and Giroux, pp. 155-171. 5. Wawer, Maria J., Nelson K. Sewankambo, David Serwadda, Thomas C. Quinn, Lynn A. Paxton, Noah Kiwanuka, Fred Wabwire-Mangen, Chuanjun Li, Thomas Lutalo, Fred Nalugoda, Charlotte A. Gaydos, Lawrence H. Moulton, Mary O. Meehan, Saifuddin Ahmed, the Rakai Project Study Group, and Ronald H. Gray. 1999. “Control of sexually transmitted diseases for AIDS prevention in Uganda: a randomised community trial.” The Lancet 353:525-535. 6. Altman, Lawrence. February 24, 2005. “Study Challenges Abstinence as Crucial to AIDS Strategy.” New York Times. On-line at: http://www.nytimes.com/2005/02/24/national/24aids.html?_r=1 7. National Public Radio (audiofile). 2005. “Study: Uganda AIDS Prevention Primarily Due to Condoms.” On-line at: http://www.npr.org/templates/rundowns/rundown.php?prgId=3&prgDate=2-24- Page 31 of 36 Engeye Volunteer Manual – Revised Jan 2014

2005 8. Green, Edward, Halperin, Daniel, Nantulya, and Hogle, Janice. 2006. “Uganda’s HIV Prevention Success: The Role of Sexual Behavior Change and the National Response.” AIDS and Behavior. 10(4): 335-346. 9. Crump, J, and Sugarman, J. 2008. “Ethical Considerations for Short-term Experiences by Trainees in Global Health.” JAMA 300 (12): 1456-8. 10. Bleiker, Roland and Kay, Amy. 2007. “Representing HIV/AIDS in Africa: Pluralist Photography and Local Empowerment.” International Studies Quarterly 51(4): 1003-1006. 11. Power, Samantha. May 19, 2003. “The AIDS Rebel.” The New Yorker (reprinted by PBS). On-line at: http://www.pbs.org/pov/pov2003/stateofdenial/special_rebel.html 12. De Waal, Alex. 2006. “AIDS Activists: Reformers and Revolutionaries.” AIDS and Power: Why There is Not Political Crisis - Yet. London, New York: Zed Books, pp. 34-65.

Providence employees recommend the film:

Bela Fleck’s Throw Down Your Heart, a documentary about traditional music in East and West Africa with a lovely section on the music of southwestern rural Uganda.

UGANDAN CULTURAL CONTEXT

“Uganda is a fairy-tale. You climb up a railway instead of a beanstalk, and at the end there is a wonderful new world,” wrote Sir Winston Churchill, who visited the country during its years under British rule and who called it “the pearl of Africa.”

Most of Uganda is situated on a plateau, a large expanse that drops gently from about 5,000 feet in the south to approximately 3,000 feet in the north. Uganda’s Lake Victoria, in the southeastern part of the country, is the world’s second largest inland freshwater lake by size after Lake Superior.

Uganda obtained formal independence on Oct. 9, 1962. Its borders, drawn in an artificial and arbitrary manner in the late 19th century, encompassed two essentially different types of society: the relatively centralized Bantu kingdoms of the south and the more decentralized Nilotic and Sudanic peoples to the north. The country’s sad record of political conflict since then, coupled with environmental problems and the ravages of the countrywide AIDS epidemic, hindered progress and growth for many years.

Although Uganda is inhabited by a large variety of ethnic groups, a division is usually made between the “Nilotic North” and the “Bantu South.” Bantu speakers are the largest portion of Uganda’s population. Of these, the Ganda remain the largest single ethnic group, constituting almost one-fifth of the total national population. There are at least 32 languages spoken in Uganda, but English, Swahili, and Luganda are the most commonly used.

Under British colonial rule, economic power and education were concentrated in the south. As a result, the Bantu came to dominate modern Uganda, occupying most of the high academic, judicial, bureaucratic, and religious positions and a whole range of other prestigious roles. However, the British recruited overwhelmingly from the north for the armed forces, police, and paramilitary forces. This

Page 32 of 36 Engeye Volunteer Manual – Revised Jan 2014 meant that while economic power lay in the south, military power was concentrated in the north, and this imbalance has to a large extent shaped the political events of postcolonial Uganda.

Uganda’s religious heritage is tripartite: indigenous religions, Islam, and Christianity. About four- fifths of the population is Christian, primarily divided between Roman Catholics and Protestants (mostly Anglicans). Other Christian denominations include the Seventh-day Adventists, Baptists, Greek Orthodoxy, Jehovah’s Witnesses, Latter-day Saints (Mormons), and Presbyterians. About one-tenth of the population is Muslim, and, of the remainder, most practice traditional religions. As in other parts of Africa, Islam and Christianity have been combined with indigenous religions to form various syncretic religious trends. A small number of Jews live in communities in eastern Uganda.

Uganda’s population remains rural (about 85-90%), and a third of all city dwellers live in Kampala. The economy is largely agricultural; four-fifths of the working population are involved in agriculture. Small-scale mixed farming predominates, with largely rudimentary technology. Farmers rely heavily on the hand hoe and associated tools and have minimal access to and use of fertilizers and herbicides. Two important cash crops for export are coffee and cotton. Tea and horticultural products (including fresh-cut flowers) are also grown for export. Food crops include corn (maize), millet, beans, sorghum, cassava, sweet potatoes, plantains, peanuts (groundnuts), soybeans, and such vegetables as cabbages, greens, carrots, onions, tomatoes, and numerous peppers.

The staple diet in most of the south is a kind of plantain called matooke, which is cooked in stews and curries. (A Buganda legend relates that one of the first acts of the first man on earth, Kintu, was to plant a matoke tree for his descendants to enjoy.) Sweet potatoes, ugali (maize meal), chapatti, Irish potatoes, and cassava are consumed along with a variety of vegetables. Most people eat little meat, usually mutton, goat, and sometimes beef.

Only about half of the population has access to medical facilities. Malaria, measles, anemia, acute respiratory infections and pneumonia, gastrointestinal diseases, sleeping sickness, venereal diseases, schistosomiasis, guinea worm (dracunculiasis), tuberculosis, chicken pox, and typhoid are all serious problems in Uganda. At the root of many of these diseases is a lack of clean water.

AIDS, known locally as “slim” because of its debilitating effects, spread widely in the early 1980s. However, there has been a vigorous campaign to educate and inform the public about AIDS and sexually transmitted diseases, and in 1998 Uganda became the first country in sub-Saharan Africa to report a significant decrease in the rate of HIV infection.

Primary education begins at six years of age and continues for seven years. Secondary education begins at 13 years of age and consists of a four-year segment followed by a two-year segment. In early 1997 Uganda revolutionized education policy by introducing an initiative called Universal Primary Education, under which the government would pay tuition fees for all orphans and for up to four children per family. The policy, aimed at rapidly expanding literacy throughout the population, resulted in an increase in school attendance. Many of the oldest schools in Uganda were established by Christian missionaries from Europe.

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In the countryside, the year is filled with a variety of festivals and ritual celebrations, including marriage “introductions,” weddings, births, christenings, and other familial gatherings. As in other places, the agricultural year is marked by a number of important events that require social gatherings.

The Ugandan population has grown rapidly since independence, when it was approximately seven million, to now total more than four times that number. Like many other African countries, the population is predominantly young, with roughly half under 15 years of age. Uganda’s birth rate is about twice that of the world average, and the death rate is also higher than the world average. Life expectancy in Uganda is about 50 years.

(Adapted from Encyclopedia Britannica)

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SECTION 13

PROVIDENCE MEDICAL MISSION GROUPS:

Read the packet carefully and follow the packing list. Check with your group leader regarding medicines, supplies and medical equipment such as BP cuffs, as much of this is now available at the clinic.

1) Get a valid passport with an expiration date after you are planning to leave Uganda.

2) You need a visa and can get it by mail several weeks in advance or when you land in Uganda. You need two extra passport photos for your visa. Follow instructions in this packet for a visa by mail. If you are getting it when you land, you need a $50 bill as well as photos. Print out from this packet the information required to fill out the visa.

3) Transport, food and lodging are provided for the group, along with interpreters. This includes tips as long as you are with the group. Plan to exchange $50 at the airport. Carry at least $300 with you in cash to give to the support staff as needed. This needs to be in $50 and $100 bills, in the newest bills you can find. (This will take a little searching; crisp, recent bills fetch a higher exchange rate). Travelers’ checks will not be useful. You can use a credit card in some areas to get more cash, and sometimes ATM cards work. Be sure you know the pin. Bring more cash if you plan to do any extra traveling. There is usually enough money and time that everyone can enjoy a side trip to see wildlife as well. You will need to give $100 in advance to the support person in the group for transport and hotel.

4) Call employee health and get a copy of your immunization history. See this packet for immunizations required. You can get all these and a prescription for malaria medication at the Providence Travel Clinic. Immunizations and prophylactic medications are expensive and generally not covered by travel insurance. You must have a yellow fever card and immunization history in your passport to travel. Plan to get shots about 6 weeks ahead of the trip for immunity.

5) Travel insurance is highly recommended. Volcanoes have erupted during these trips. Carry proof and contact information with you. Be sure insurance covers medical evacuation and trip delay.

6) Carry your own emergency contact information with you. Carry Ugandan contact information for local staff as well as United States contacts for Engeye. There are cell phones and internet available at the clinic, although sometimes this is slow.

7) Providence provides mission grants for most employees. The amount is usually $500-750 per person. You can apply for the grant after you have bought a plane ticket and have approved PTO. Go to the intranet site System Support Services > Departments > Mission Leadership > Providence Health International and click on the link for “Volunteer Guidelines and Grant Application.” It takes several weeks to process the grant. There are requirements attached for writing a report after the trip and sharing your experience with fellow employees.

8) Bring a copy of the diagnostic and treatment algorithms with you. They are also available in the clinic, as are multiple medical texts.

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9) The group will meet several times before the trip, to get to know each other and share information and experience. See you there!

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