I asked the very uncomfortable question to Mukasa, a trusted Family Health Educator (FHE) and now colleague, that has been working in the villages for over 18 years: Why do these women keep having more children if they are unable to feed the children that they have? It was a burning question within me, and I ensured I only asked it at the appropriate time.
Mukasa’s answer was simple “God has a plan for all my children, God will feed my children. This is what the people believe.”
How do you argue with that?? The under 5 mortality rate here is so high at 69 deaths per 1000 births compared in the UK of 5 deaths per 1000 births that they perhaps expect one of their children to die, so they continue to have them. Sierra Leone has the highest mortality rate of 182 per 1000 live births (World Bank 2012).
Things are not helped by the fact that the people who are meant to be educating the locals are often plagued with false beliefs such as if you use family planning methods then you will get cancer or become infertile and so they discourage women from using them. This leaves many women, one of whom I saw yesterday, with a child of 9 months of age and already 7 months pregnant with her second! She will have 2 children under the age of 1! Breast milk becomes more dilute and less nutritious with ongoing pregnancy so she brought her first child to the health clinic with symptoms of severe malnourishment. Abortion is illegal in Uganda and therefore education at ANY and EVERY opportunity is the only way things will improve.
There also seems to be strong undertones of male dominance. Women often do come for family planning methods, usually the depot injection and most don’t tell their husbands. There are huge cultural differences here compared with the UK. From what we are being told, men don’t really get involved with pregnancy or the delivery of the baby and certainly not in the day to day care of the child feeling that it is the ‘woman’s job’. These attitudes and beliefs are what FHE’s are working very hard to change, trying to engage with the men to encourage them to help their wives with looking after the children. Male FHE’s are pivotal to this as if they are seen to be receptive to change then others will follow.
When a child does get sick, it is seen as the woman’s problem. They are sometimes cautious of seeking help from health centres and hospitals for multiple reasons; distance, expense, childcare, and in some cases a mistrust of Western medicine, believing it to be witchcraft. Only yesterday at the Children’s Hospital, a father frustrated at the poor response to treatment and the minimal recovery his child was making from a Tetanus infection, made the decision to carry his child out of the hospital grounds and seek advice from his village doctor fearing we had been using witchcraft on his son.
Trust is a big thing here, trusting the Muzungu (foreigner) can be understandably challenging for the locals. Often it works best when Ugandans are educating and empowering Ugandans and the Muzungus work in the background. From my short time in Jinja that it feels that Non-Government Organisations (NGOs), missionary projects and individual inspiring people like Dr Debbie who we are working with, seem to prop up the government initiatives which don’t seem to have much enforcement. People do feel that the government is trying to make improvements, but actions, especially money, seem to get lost somewhere in the middle.
As I settle in to life in Jinja, I am slowly trying to unpick the subtleties of the Ugandan Health Service. What is clear, even at this early stage, and what my new young friend Michael told me, is that ‘knowledge is power’. Michael was a street kid that has been sponsored by one of the NGO’s working in Jinja. From speaking to him an you can truly see first hand that education is the single most powerful tool we can use to change things here.