Interviewed by Julia Royall August 23, 2006
Mulago Hospital, Uganda.
Transcribed by Alison Oppenheim October, 2006
Faculty Member Dr. Ian Munabi
Students: William Lubeya, Nelson Igaba, Nixon Niyonzima
Field Testing: Challenges and Rewards
WL: When you get into the communities you get to understand what the people out there in the communities, what do they think about disease. Not what Hippocrates thinks about disease, but what this lay man who has probably never seen a medical book. What is their perspective of their disease, what do they understand?
NI: We are very privileged in Uganda to have a community of people who can listen if they are informed.
NN: In Uganda, whenever you have health workers going in to the community trying to do something, people are always interested, and they will always be willing to do something. And it’s a little different because not many Ugandans have had actual contact with health workers.
WL: The area of about 50,000 people has only one doctor.
NL: People ask us about ordinary questions which we think are easy, but which concern them. And we tend to explain them in much more scientific way and they don’t really understand what we say.
WL: Something about our cultural heritage is a lot, people value their languages, people value their cultures and beliefs. So understanding the cultures and beliefs in the different communities and translating this product in their local languages (list of English words and Luganda translations) will help us reach out to those people.
NI: But when we develop these tools, these simple tools, in their languages people will understand them better than us explaining in our medical languages.
WL: When medical students go out there and tell them about malaria they feel like somebody cares about them, the health workers care about them.
Tackling Community Beliefs
NI: When we go out to villages, we face very many challenges.
NN: The beauty of this program is that it talks about what is actually in the community, tries to talk what is there on the ground.
NI: Someone constructs a house and in the next 2 meters is the whole shamba, the whole plantation of maize. So during this season, when the maize has just grown, the mosquitoes will accumulate and they will just be flying from the plantation through the windows of the houses, so this person will think that because of the maize, that is why we are getting malaria.
NN: In medical school, they won’t teach to that people think that mangoes cause malaria.
NI: They say, don’t eat ripe mangoes. You can eat raw mangoes but don’t eat ripe mangoes because they cause malaria. These mangoes, when they ripe up, they drop ( drawing of ripe mangoes in a red bowl). And when they drop, remember it is the rainy season, they rot. And when they rot when it is raining, these rotten mangoes are a breeding area for mosquitoes. You will just see insects flying out of the dirty rotten mango.
NN: The biggest surprise was when I asked a lady what causes malaria and she told me, she doesn’t know but she thinks that it is witch craft.
WL: Some of the illnesses, the very severe illnesses they are best attributed to witchcraft.
NN: If you go into a community and can get their ideas, their beliefs, it is the beliefs of the people in the community that you try to work upon.
WL: We had to interact with them to understand their perspective. Why did they think that mangoes cause malaria? Why did they think that maize caused malaria? And through this we are also able to educate them as we are collecting information to make this product.
The Value of Visual Imagery.
WL: Pictures are crowd pullers. Once somebody sees a picture they are interested, what does that picture say? And so they will join there and they will read whatever literature is there.
NI: Pictorial display of information in Uganda is much better than only words, in that (drawing of mangoes) we have people who are too illiterate and they can only pick a word but after seeing that a baby is holding a cup of water (portrayed) and is taking water, then you can explain better that taking a lot of fluids can help in the case of diarrhea. Than just explaining by words. When you see the pictures they will pull much attention of these people than just giving a lecture.
WL: Even if somebody doesn’t know the local language then they will look at the picture and they will get the message because the tool has been developed in Uganda and they can identify with it.
NI: And you will turn a page and you show the coffin, people get shocked a little bit (drawing of pregnant African woman and a coffin) then, when you explain further, you say that this is the effect of malaria, it will ring a bell in their mind. By seeing a coffin, they will know that malaria kills.
WL: There was a picture of people gathering under a tree, (shown) which is basically typical of our African culture. Mostly village meetings are conducted under the trees, under temporary shelter, it is something that somebody would identify with. So if somebody looks at that they feel like it is part of them, they feel like the pictures were gotten right out of their community and placed there.
NI: We met an old lady she was I think in her 60s, who we tried to explain that mosquitoes do cause malaria. But this lady believed that malaria is caused by maize. So she asked this small insect can cause malaria? How come? It really took some good time to convince this lady that malaria is caused by mosquitoes. But at the end of the day we convinced her and I am proud to say that I will declare the project a success in that the next days we were going into the communities, we were getting masses listening to us because they felt that they were benefiting.
WL: Most people don’t really finish their medication. As long as somebody takes their medication and their headaches have been alleviated, they stop taking their medicine. But they need to be constantly reminded that they need to finish their doses. (Drawing of man taking his medicine) They don’t know that.
Then another problem that you have is sharing drugs. Let’s say I am feeling a bit better, and then following then, my kid is sick, then definitely I would share my medicine with my kid because I am feeling much better. So that way, people develop resistant strains. This way the fact that people have got this knowledge about malaria. They know malaria kills, but they need to be constantly reminded with visuals. Somebody has to get out there in the community and constantly remind them that this is their problem and this is how we have to solve it.
NI: When we went to a home and we found that the person didn’t have a cover to the toilet, and we told him that the toilet, when flies enter the toilet, and they don’t have a cover, they can easily go and contaminate food or any item in the house. Then the person still had a very bushy compound.
NN: To convince them that the bushes are a factor in malaria is a bit difficult. It takes a lot of time to change the beliefs of the people. But eventually with time and with simplified tools, (drawing of houses with few bushes around) and examples, it comes around easier.
NI: It was to our surprise and excitement to find that the next time we went there, we found a very cleared bush, the toilet had already a cover and the family was very happy that they had benefited from our knowledge. In the clinics or in the health centers in the villages we have out patient departments which are flooded. The outpatients in the health centers are full. They are getting 1,000 patients, or less than 1,000 patients per day. Now you find when they are waiting for their turn to see the doctor, you take the advantage of the people are seated very well to wait for their turn to see the doctor. You take the advantage of those people and you explain to them it becomes like it is good because you get a very big number and these people will listen to you. They have come to the health center and you are giving them a health talk. These tools will simplify our language.
Empowering Communities to Help Themselves.
WL: This program first of all should be integrated into our curriculum, because with our curriculum people are going out into these communities every year. Every year as students go out into the communities, they can share this knowledge with these people. And that would help in cutting down malaria.
NN: The idea of empowering the community themselves to teach the rest of the community to prevent malaria. People who live in the community are better informed about how the community is, the community beliefs, what you have is only a sample of what the community believes.
NI: So if this information could be dissipated to all these communities, then the next time you go there you would be just implementing the ideas that your friends left there.
WL: The Ministry of Health may not be necessarily able to facilitate community extension workers to go into these communities and teach the general public about malaria. But when these medial students go into these communities they can always carry with them that information that to tackle some of the cultural beliefs.
NN: It is much cheaper on the side of manpower because the people are there in the community, you can bring them from their own communities, so it is much easier to change their local community. They know their beliefs because they have the same beliefs so they can work with the beliefs of the rest of the community better than we can.
WL: Some of these diseases they are preventable, and yet we spend lots of money treating these diseases. There are simple solutions to these big problems. Like for example removing those empty cans, trying to get rid of the stagnant water. They are simple solutions. But here in Africa we spend lots of money on treatment and lots of people die. These are simple solutions to the big problems we face.
Agents of Change
NI: I think of this project as some tool which will change the society.
Dr. IM: This is actually one of the aims of the COBS (??) curriculum. We wanted to make students who are actually agents of change on a community level.
NN: If every student who goes for COBS (??) is empowered to do something I think we can make a big contribution to changing the state of malaria in Uganda.
WL: A big part of this project was what I could do to contribute to the betterment of this society.
NI: I was very much excited, I felt I can change a society.