Scooters

 We leave the students at Ruhija in the Impenetrable Forest , heading for Bwindi near the Congo Border where our next group are posted at the Bwindi Community Hospital.  We can find no lower cost accommodation so at the driver’s suggestion that just around the corner is a good spot we head off down the road.  
Around the corner drags on and on, through a number of small towns, forty-five minutes later and it is almost dark.  The place owned by a minister has closed down.  We are directed to accommodation with a bar where the music is already blasting.  We stand around in a loose group clearly disgruntled. 
A fellow comes over and directs us to another spot in town.  The prices here are double what we wanted but it has a restaurant and it is quiet.  The double room Angella and I share has huge poster beds with about 6 inches between them but we don’t need to dance.  Andrew, the volunteer, is in a fix becase he can’t afford it so Angella offers to pay for his room and the driver takes off  agreeing to collect us at 8 am the next morning.  The staff is helpful, cutting up Angella’s pawpaw for her.  They call us when our order of chicken and chips is ready.

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They have fresh passion fruit juice for me for breakfast but power is off so there is not enough boiled water for Angella and Andrew.  But we have a 2 litre bottle of boiled water with us so we present it to them and everayone has passion fruit.  I get a delicious Spanish omelet.  Angella has not seen one before so gets scrambled eggs but decides after a bite of mine that she is going to order one next time.  Andrew is not quite so adventurous. 

It is market day in Kihihi, outside the Impenetrable Forest, where we have ended up.  The early morning streets are jammed with people coming into town, heavy loads and home-made scooters.  At first we wonder if the scooters  are used for the handicapped as one or both legs seem to be tucked up behind in them, but watching someone get down from one, we note he has use of both legs. 

Many of the scooters are operated by young boys who are moving heavy loads about town or wait outside shops.  It is the first time I have seen such scooters and the town seems to be full of them. 

Tackling Malnutrition Thru Primary School Peer Groups

John Briefs Kikunda PS Parents Meeting

John Ssenoga, the field coordinator of the Primary School Gardening Project, arranged to make his second visit to train Peer Group Educators (PGE) this week.  The project is funded through the American Academy of Pediatrics, I-Catch program for international community pediatrics. Officially the project is not with Harvest Plus, which is disseminating bio-fortified crops of high iron beans and orange sweet potato in Uganda, but because we would like OSP and high iron beans reach school age children, we are doing our bit to promote them in our school gardens. 

Parents Meeting Packed

However when John arrives at Kikuda PS, the Parents and Teachers are holding a last minute, urgent meeting.  They are very pleased to see John and ask him to tell them about the Gardening project. The parents are overwhelmingly in support  of the program.  In fact they want to be more involved!  They provide John with information about traditional farming practices, traditional weaning and pest control.  Parents living close by and the local Volunteer Health Worker (VHT), even offer to take care of the student's garden over the holiday. 

Parents Provide Farming Wisdom

“Wow”, says John when he tells me all this, “We should have involved them earlier.” 

The School teacher in charge of the Peer Group at Kikunda PS, has been very enthusiastic but  has had a number of problems with garden pests. He shows John around describing the problems in detail.  The local parents who are farmers say the problem is simple, the high iron beans and orange Sweet Potato vines provided were planted too late.  The Peer Group Trainer who has come with John, is Avictas, a 3^rd year Agriculture student at Bishop Stuart University nearby.  He concurs with the local farmers.  It seems project communications were not clear and the teacher thought he was supposed to wait for project staff to come before planting. 

The parents request that they be allowed to "take the project to their homes".  They want to grow high iron beans and orange sweet potatoes and start kitchen gardens. This is one of our hoped for outcomes.  They tell us they can help us to lobby the churches in the area for additional land for the school garden.  We have been very lucky at all the schools to have large areas set aside for the student gardens as well as generous offers of land from the nearby churches.

Peer Educators Use Puppets and Hats for HEd

At the beginning of the project, we had asked the designated teachers at each school to do things with us in a step-wise manner, but gardens of course have to be planted in season.   Another lesson for us non-farmers in the project, is that farmers till the land twice here.  Once, about a month prior to planting, land is tilled in order to turn under all the grass to let it decompose,  Then a second digging is done to turn the soil over at the time of planting.  Lots of things for us to learn in a gardening project!  
The aphids found on the beans are usually handled by sprinkling them with ash (kashenda) which causes them to die and fall off.

There isn’t time at Kikunda because of a lengthy Parent’s Meeting to teach the Peer Group Educators but John feels the contact and information has been invaluable for the project.  Planting was done on time at Bushwere PS and all their crops are doing well. 

Avitas Teaches Head & Fingers Hygiene Song

We have a huge flock of Peer Group Educators, 176 in the four primary schools.  All the schools have drawn their Peer Group Educators from the four classes from Primary 3-6 and their classes are very large.  One of the classes has 90 students.  As the schools and the project hopes to reach all the school children, the teachers have selected many PGEs.   In in the two schools in Mwizi area,  Kikunda PS has 65 PGE and Bushwere PS has 36.  
The other two primary schools are in Kibaare, quite a ways from the Mwizi Schools so are seen on another day later in the week..  At Kanyantura PS there are 40 with 36 at Kibaare PS.  It will be a real challenge to train all the PGE effectively, but the four Peer Group Trainers and our field coordinator are going to give it their best.

Snakes & Ladders on Rice Bag

Kanyantura PS had received an extra bag of OSP vines because it was thought that the vines were planted in small heaps and would not thrive.  However the 1^st crop looked surprisingly good even though the heaps were small.  The local VHT advises the teacher to have the children collect and add manure to the heaps as the potatoes continue to grow, so they are covered as they will begin to push upwards. The 2^nd crop of OSP vines have been planted on clay-like soil and were not doing so well, dry around the base with leeching .  Avitas suggests manure also be added to this soil as well and instructs the students set up composting bins nearby.  There is also time during the visits to Kibaare schools to train the PGE in Micronutrients such as is found in Vit A-enriched Orange Sweet Potato and High Iron Beans.  The sessions go well.    John, Avitas and the teacher demonstrate to the PGEs how to play Nutritional Snakes and Ladders.  The whole class gathers around on the large rice bag of the Snakes and Ladders game.  Two sets of die are given to each school but the teachers are happy we are also encouraging them to continue to use their traditional method of throwing 6 split seeds determine the count from the number in which the cotyledons land facing up.

Kids Collect Water After School

At Kibaare PS the children are doing tests so it is not possible to do a training session with them but John was able to tour the gardens and report that most are doing well.  One batch of OSP were planted in clay-like soil and are not doing well but both schools in Kibaare will have bumper crops of beans and be able to share with the parents. 

We are learning lessons as we go.  We need to meet with Parents Groups early and often and set up a Garden Advisory Committees with the teachers and parents. We need to schedule several non-training visits to each school . And we are going to have to be very creative to train so many Peer Group Educators effectively and well.  
Photos:  John Ssengo, Avitas

Harvest Plus Cooking Demonstration in Kibaare

Kibaare Balanced Meal 

Each VHT brought two community women and children to the Kibaare Cooking Demonstration.  The VHTs were all wearing their identifying T-Shirts.  They also brought along food from their own gardens.   As most mothers in this area know how to cook both beans and sweet potatoes, Angella and I used it as an opportunity for health education.  While we waited for people to arrive we had the VHTs colour in two small versions of the posters for use in one-on-one health education.

Deus with Food Wheel 

On our arrival wood for the fire was obtained.  While the community members peeled and chopped the vegetables, VHTs began colouring their health education material.  Angella made a presentation using the Harvest Plus poster.  VHTs were very reluctant to do presentations, suggesting that they have not been practicing how to do so in their training and/or do not have the confidence yet.  Finally two were coaxed to do a Health Talk, which was mostly talking and did not include questions until prompting.

VHTs Colour Food Wheels

Dovinia Colours Her Food Wheel

As we had brought with us vaccines from the Health Center III for Immunization Day a large number of mothers with young children were gathered on the Kibaare Health Center II porch, at one point numbering over 25.   VHTs were requested to go to the health center porch to do health education for the women waiting in line.  Keneth, the health worker, stepped in to assist them.

Angella Tells Stone Soup Story

Angella did a Flannel Board demonstration of Stone Soup which was watched avidly.  One of the VHTs started to do a return demonstration but when she lost her place in the story, a community member stepped in to assist. 

Community Member Does Stone Soup

For the large group of mothers with infants gathered on the porch of the Kibaare Health Center one of the male VHTs, Deus presented Stone Soup flannel board.  He is a great story-teller and did a wonderful job.

Deus Demonstrates on Clinic Porch

When the HEd pictures were coloured, they were mounted on the clinic wall with the best in each of the 5 different scenes given a small prize.   VHTs who finished two pictures put their names on them.  These will be laminated by Angella for them so they can be used in one-to-one health education.

A large amount of food was brought by the VHTs and cooked by them including many OSP which were steamed in their skins.  These were placed in an Ankole basket and distributed to some of the kids around.  There were 18 VHTs and approximately 25 mothers and children invited.

Beautifully Mended Sufuria

The bean harvest in this area appears to be bountiful.  One of the VHTs asked us what she could do with so many beans!  We suggested that if she was successful in telling her community members about the benefits of these beans, she would likely have more requests and customers for them than she could manage.  
During the day, I found myself mesmerized by the beautiful repair of the large cooking pot suitable for a community dinner. It had been mended in four distinct jobs, exquisitely, as you can see.

Cooking Demo in Nyarubungo

VHT uses Hand-Coloured Aid

Donated Food 

Angella and I arrive at Kinoni HC IV shortly after noon. The Nyarubungo Group asked for their cooking demo to start at 2 pm.  There are a couple of Volunteer Health Team members (VHTs) who begin to sort the dried high iron beans we have brought with us. The VHT coordinator arrives on his motorbike with a good variety of pumpkins, potatoes and tomatoes.  Other VHTs add to the enlarging pile.  Somehow the message that VHTs were to bring two community members was not understood so they have come alone.

 At the Orange Sweet Potato distribution a couple of weeks ago, when it appeared that seven of the VHTs from a distant village, had already supplied two community members each from their own fields, we had 7 “extra” bags of OSP vines to distribute.  Within an hour, the VHTs in the nearby parishes had brought in 14 new recipients.  
A tribute to the ubiquity of cell phones and the close connection of VHTs to their community, many of the last-minute recipients were poor, older, female farmers unable to write their names.  VHTs had been instructed to bring pregnant women and mothers with children under-five for the first distribution of OSP vines.  Most of the older female farmers of course would likely be supporting orphans and grandchildren, so we are pleased  with their choice of the VHTs.

HEd With Harvest+ Posters in Runyankole

The Nyarabungo group is eager to show their skills at group teaching using the Harvest Plus posters.  They demonstrate in pairs and play off each other, something I haven’t seen done before.  
Angella demonstrates the Stone Soup Flannel Board Story for them next.  One of the VHTs eagerly steps up to do a repeat demonstration and almost makes her presentation a dance.

Getting the Beans Started

Afterwards I say to Angella, “She made some changes to the story, didn’t she?”

Angella laughs, “She really liked the story!”

At the point in Stone Soup where greens are added to the soup by child saying his grandmother said they were ery nutritious, one of the VHTs go to the garden close to the cook shed and picks a big handful of pumpkin leaves to add to ourpile of ingredients. 

Pumpkin leaves, like all greens, although ubiquitous, are rarely included in meals here.  Like dodo and sumkumiwiki, other locally available greens, pumpkin leaves are regarded as poor people’s food.  I have heard people commenting in surprise, after trying the pumpkin leaves, how tasty they are.  One of our jobs in teaching good nutrition is to reinsert greens into the local diet. 

Flannel Board Stone Soup Captivates

The beans were started early as they will take a while to cook.  Angella is busy distributing and collecting the VHT forms for beneficiaries as we will be tracking who gets high iron beans and orange sweet potato vines after each harvest, hoping to saturate the parish within two years so that everyone has access to enough of both crops to keep their family healthy.

Hand-Coloured Aids Displayed

With the beans on the hearth, as we wait for the rest of the VHTs to arrive, we distribute nutrition pictures and coloured pencils.  A contest for the best colouring job done for each of the five posters is judged by the VHT trainer, Dennis, with pens for prizes.  We will take their coloured posters to be laminated back to back and returned to the VHTs for use in health education

Meal Preparation

I leave with Angella at 5:00 pm.  The beans are almost done but preparation of pumpkin, cassava, potatoes, sweet potatoes, OSP, tomatoes and pumpkin leaves is still underway.  Angella and I are glad we took lunch at one of the local Pork Joints in the area.  We return to Mbarara with the fridge donated to Kinoni HC for the MUST student placements more than 18 months ago.  The fridge according to the Health staff has never worked but unfortunately it was not fixed while it was still under warrant.  We plan to get it repaired at long last.  It feels rewarding  to be able to combine a number of activities on a single visit and we often can.

Harvest Plus Cooking Demonstration in Ryamiyonga

Health Education 

For three days in a row we have been out in the field doing cooking demonstrations as part of the Harvest Plus program establishing orange sweet potatoes and high iron beans in SW Uganda using Volunteer Health Teams.  The VHTs at the three sites we visited are among the best of the many Healthy Child Uganda (HCU) sites. 

VHTs and Their Community Members Gather

There are a couple of other NGOs working in the area on different issues with the rural health units.  One such group I just learned about is the USAID-funded SecuringUganda’s Resources for Essential Medicines (SURE).  The health units at Ryamiyonga HC II staffed by Nursing  Aid  Agnes and Kibaare HC II staffed by Nursing  Aid  Keneth are both sporting their prizes when I arrive. 

Agnes has a lovely bright green and blue T-shirt while Keneth has a similarly coloured cap because they won first prize among all the other rural HCs.  They proudly tell me that they are always winning the prizes because their health units are well run and managed.  I can believe it, as they both run a tight ship and I would also like to credit their training as Trainers for the VHTs at which they both excell. I tentatively suggest this and sure enough they agree with me. 

A Balanced Meal

Wednesday we are in Ryamiyonga.  Each VHT who attends has brought with them two community members, most of them mother with children under five.  The cooking demo has been slated for the same day as Immunization, so the mothers can also get their under fives’ immunized.  In addition to the invited guests the porch of the Health Center is packed with women and children, as many as 30 sit on benches. 

Shucking High Iron Beans

We have received a call from Keneth, the health worker, to pick up his vaccines at local HC IV depot.  This takes a while as they do not have a proper vaccine carrier and a box has to be outfitted with dry ice for the half hour.  Fire wood has been collected, peeling is started and the foods people have brought to produce a balanced diet are prepare.  This group has lots of OSP and organize to steam hem with their skins on.  I am not sure who we are demonstrating to because most of those attending are familiar with both beans and sweet potatoes.

Using the Harvest+ Poster

The coordinator, Angella, does a health education presentation on the Balanced Diet using the brightly coloured Harvest Plus poster she has brought.  She then asks one the VHTs to do a session on Vitamin A.  They seem reluctant, but one finally agrees.  Angella then demonstrates the flannel board story, Stone Soup, which highlights the food groups and properties of micronutrients, Vitamin A, iron and iodine.  She asks for someone to do a return demonstration and a young girl from the community steps forward, assisted by the group.  After we are finished, Agnes asks if she can get these felt pieces.  She tells me she has felt remaining  so I tell her I will make and send the patterns to her.  It is hard for VHTs to keep teaching the same health messages and new materials and new approaches are always in demand. 

Kigezi Basket with Banana Leaf Repair

This group has supplied beans and OSP from their own harvest, so time is spend shucking the beans.   They request but do not receive even token payment although beans have been provided by the project to the other groups.  It seems like penalizing those  who are most independent.  As well they have brought pumpkin, onions, potatoes, greens, Irish potatoes, small eggplant and sweet potatoes for a balanced meal.  I notice the banana bark “patch” in the bottom of the potato basket, a lovely example of thrift and the extensive use given even simple household items here.  

VHTs Sign Their HEd Songs

The VHTs sing a couple of their health education on Maternal and Child Health and their anthem about their own volunteering for the visitors, a way to remember all the details and information. So far they do not have songs about nutrition but we expect them shortly.  A group of local "raggamuffin" kids join us, listening carefully.  We hope they will at least be still around when the meal is cooked but by then they have all disappeared.  We need to find a way to get OSP to them too.

Plenty of OSP for the Community

Certainly as the OSP are washed and prepared it is obvious that there will be plenty for everyone to sample, even to consume in plenty.  While Ryamiyonga is high up on the hill and often cooler than other parts of this subdistrict, it has always been a fertile place full of hardworking farmers.
What a joyous evenT to celebrate. When we finally sit down to eat, Agnes, the health worker who supervises the VHTs in this area has finally finished her clinic and is able to join us.

HMEF Student Project Prize Winners, 2013

1st Prize, Rukunya

Saturday morning, November 23 at 8:00 am, student groups are already busily moving about the classroom mounting their posters on the walls.  Some have as many as 20 full manila sheets Often it is hard to find the name of their site on the posters.  Their places have been assigned randomly in advance by Moses Ntaro, the assistant coordinator of the Community Based Education Program at MUST 
It seems the examiners are going to be the ones who have to move.   This will not be easy as the classroom chairs are welded together in sets of four.  Nonetheless there is a sense of excitement in the room, among examiners and students.  I make a mental note that we are going to have to limit the number of posters in future.  It is going to be hard to hear seven groups go thru the Challenge model, one after the other. 

2nd Prize, Kisoro Hospital

The six student groups selected by faculty examiners as the best in their group  are from: Kisoro Hosp, Rukunyu, Ruhoko, Kabuyanda, Bugoye B, and Rubanda PHC.  Our job is to select the top three to receive the Hillman Medical Education Fund prizes.  The prizes will allow them to present their project at scientific gatherings outside of th university.  This is the second year the prizes have been offered.  The first year, not all groups were aware of the prizes, but this year, the visibility of  last year’s winners have helped to spread the word and the competition has intensified. 
I missed the assessments done earlier this year but it is clear that there is more polish to the presentations this year.

3rd Prize, Kabuyanda

The community projects we will be evaluating have been done by groups of multidisciplinary students drawn from medicine, lab, pharmacy and nursing.  The students spent 5 weeks in rural field placements throughout the South West of Uganda.  They were attached to Health Center III or IVs. 
We are interested in learning if and how they connected with the community-based health workers at the site, whether they engaged the community in the project, how they dealt with any setbacks and their sense of commitment to the community.  Many of the projects have to do with sanitation and construction of Tippy Taps and latrine covers this year.

Best Diagrams

All group members are involved in their presentations.  Transitions move smoothly between them, each having an active role.  They are dressed up and professional in their presentations.  I am most engaged by their answers during the short question period.  One group is superb, as they tackle each question adroitly, we examiners find a more difficult one for them. Our questions just seem to bring out their best.  What magnificent skill!   The ability to anticipate and handle questions is an important part of research and we are going to have to give it more weight in future.  Also a couple of the diagrams and maps are excellent, vivid representations that deserve recognition

Quality Map

 A week or two prior to this event, two student groups, the Kabuyanda Group and the group from Bukoko, wrote up and presented their projects as scientific papers at the Mbarara University of Science and Technology (MUST)Research Symposium.  They were the only undergraduates who presented and both did a spectacular job.  To do this takes a fair amount of time and commitment by their supervisor and one of the dynamic supervisors, Dr. Wilfred  Arubaker, assisted both groups. 

Latrine covers

At the same Symposium, I heard a well-presented paper on interocular pressure presented by former MUST student, now an Ophthalmologist, Dr. Simon Arunga.  Simon along with Dennis Mala facilitated a Cholera Workshop developed from their rural student placement a couple of years ago at the Towards Unity for Global Health (TUFH) International Conference when it was held in Kampala.  More than 30 people attended their workshop and they received rave reviews.  It’s a great reminder to me about how important student presentations are in developing skills that support us in our future careers.

Challenge Model

It is hard in such a group to pick winners, however when the scores of the examiners are tallied  1^st prize goes to the Rukunya group; 2^nd prize goes to Kisoro Hospital group and 3^rd prize to Kabuyanda group.

The Kisoro group also a winner was last year.  Their faculty supervisor, Simon Rugera from Laboratory Medicine is justly proud of his groups.  It's a great day for celebrating the students, their supervisors and MUST University.

Delivering Vines II

OSP vines Below Kibare HC II 

A day later we head off to 2 more communities with a supply of vines for the community. A truck is used this time but as it will not wait for us once the vines are delivered, we travel in a special hire.  We are barely startd e with a new driver when he turns on the radio.  Angella talks to him briefly in Lunyankole and he turns it off.

“What did you say,” I ask.

“I told him we like to talk and plan on the way so we don’t have the radio on,” she tells me. 

OSP bags under tree at Kinoni

We definitely do review our planning and program and even begin to write up our notes in the car.  I often quiz her about what has been going on in my absence but I don’t actually recall ever mentioning to her about the radio.  I am thrilled that she has picked it up and recognizes its importance.  We have decided this visit that I am going to work with her on report writing.

We stop first on the highway at Kinoni Health Center IV at 10:00 am where the Volunteer Health Team members (VHTs) from Nyarubungo parish will bring their community members.  The health worker, Dennis, is located in the record room where he works.  He tells us the VHTs have arranged to come at 2:00 pm so we pile the bags of vines in the shade under a tree on the compound.  A late pickup means few of the vines will be planted today, not the best as the vines are getting drier with each passing day.  We are unable to reach the VHT coordinator so VHTs can be alerted to come earlier.  Later we learn he has replaced his cellphone.  The bags are counted and left.  We hope they will be picked up by the time we return.

Primary School Children Get Worm Tx

We head off into the hills for our second stop in Kibare HC.  Kibare has some of our best OSP farmers mentioned earlier.  Although the cell phone network does not reach here, we find our VHT OSP coordinator, Dovina, at Mulago  Primary School with her big smile and her eleven enthusiastic VHTs under the mango tree in the center of the compound.  
This parish is very extensive, so in order to decrease the distance community members have to transport their bags on foot, the group has arranged for two drop off sites.   The eleven VHTs are set up in preparation for distribution of de-worming medicine at the Primary School as well.  The VHTs assist the health worker, who has gone to town to try to get some Vit A capsules.  We off load 11 bags of OSP vines under the tree and Dovina is instructed on filling in the community members details on the forms.   We will pick up the forms on our return. 

Boy Collects His Mom's OSP Vines

Our next stop is at Kanyantura Primary School where the rest of the bags of vines are unloaded.  One of the male VHTs gets up on the truck and the others collect the bags as he off loads them.  I count as they come off the truck and then the truck leaves us.  We have a couple more bags than VHTs.  As I didn’t count the number put on the truck, I am confused but figure we must have received more bags than planned.  

One young boy has come as his mother is sick.  He is wearing a man’s shirt that is way too large for him and I wonder where his dad is.  But the VHT coordinator acknowledges him and he collects his ½ bag.  We have one bag for the Primary School teacher who is part of our School Garden project.  He arranges to have the children plant the vines right after school. A couple of teachers from the Secondary School come by asking for a bag as well.  At first we turn them away but when it appears we have a couple of extra bags we have them sign for and explain they will need to share vines with four community members when they get their harvest.

Signing Proceeds

We leave the VHT OSP coordinator to finish distributing the remaining bags and head back to Kinoni to pick up their completed forms.  Unfortunately the process has not even started when we arrive, so Angella and I start to record the names of those who are there.  As there is no photocopy or carbon, I make a second copy so we can leave it with the OSP coordinator so he can gather any signatures that we have not obtained.  We try to get as many signatures as we can.    

Boy  play with Tire

The signing process takes a long time.  Many of the "signatures" are actually the printed names of people.  Then I notice someone signing a second time and ask her why.  She says she is signing for someone else who cannot write.  I have the person put an X down which the VHT can witness.  We have to show her what an X looks like, most come out more like an +, a much more familiar symbol here.  Angella writes an X on her palm to show her how to do it.  It turns out there are many more who cannot write their names in this group.  Either that or I was not noticing it earlier.   I explain to Angella that they can also sign with a thumb print if it is witnessed, that it is legal, but someone else signing for you is not.

The VHT coordinator for this parish turns up half way through.  He tells us that 7 VHTs from several distant villages sent word that they have produced enough OSP vines that they are able to share with two community members each so will not need Harvest Plus vines.  He has communicated this to some of the VHTs that live near by who have quickly identified local farmers, many of them illiterate who seem very poor.  This, I think to myself, is the beauty of having an agriculture project with the health workers. They know who works hard and has little in their community and can ensure we reach them.