“If I die, I just die:” Health, Structural Violence and Neocolonialism in Eastern Uganda (Part I)

“If I die, I just die,” she said, “feeding is a problem, buying tablets [medicine] for my children … I won’t be able to go to Mbale” – Ugandan woman

I felt my head get heavy. Tears, as they always do in this work, swelled in my eyes and I fought to push them back. I stared at my computer trying to capture the information our translator, Francis*, was sharing with us. You see, this woman’s sentiments are most likely not isolated. She, like hundreds of other women, was expecting free health care for her illnesses and answers to the painful symptoms she was experiencing. A local clinic hosted a screening for women in the community and they’d found “something” during hers and she was referred to the main hospital in Mbale. However, she could not afford a biopsy or even money for transport. She was impoverished and resigned. If she died from not seeking treatment then that was her fate. She could do nothing.

This woman and many other women were looking for a comprehensive health care screening organized for women from the nearest sub-counties, but what did they receive? A hyper-political event that left many of them disappointed, confused and disempowered.

This post is part one of a two part reflection on this health event in Eastern Uganda, but also social commentary on the implications of mass social experiments on vulnerable and marginalized groups. Although this is my personal interpretation of the event, there is evidence (structured interviews, participant and complete observations) that we collected that support these findings.

I arrived in Uganda June 13th for a research training program sponsored by a U.S. university. Our program broadly focuses on health, health disparities, biomedical care, traditional health care practices and the relational gap between the community and public/private health care providers. The research is community-based, but we are here under invitation from a local clinic. They commissioned us to conduct a study and provide a report, and any recommendations, that could bridge the gap between them and the community in an attempt to improve health care and outreach to surrounding populations. Our site locations are in Eastern and Northern Uganda. However, our team this year is mainly focused on a district in Eastern Uganda, in one of the, if not the, poorest regions in the country.

It should come as no surprise, thus, that we are not the only muzungus, or the Swahili word for “white people/foreigners,” doing work here. In our location we met a group of Canadian nurses helping at The Clinic and a group of less than two dozen American service and mission oriented volunteers. The American group was led by a woman who worked and traveled to this region before to assist The Clinic. Although well-intentioned, John Crump and Jeremy Sugarman warned of this type of “help” in their article Ethical Consideration for Short-Term Experiences by Trainees in Global Health:

“In many settings that involve the education and training of clinicians, there can be benefits and burdens for patients’ well-being. On one hand, having students simply paying close attention to these patients may be beneficial. On the other hand, those in training may lack experience in recognizing serious or unfamiliar conditions and skills in performing particular procedures. In resource constrained health care settings, trainees from resource-replete environments may have inflated ideas about the value of their skills and yet may be unfamiliar with syndromic approaches to patient treatment that are common in setting with limited laboratory capacity. These challenges may be compounded by language barriers impending communication, cultural barriers to understanding the meaning of patients’ statements or actions, lack of mutual understanding of training and experience, and the possibility that inexperienced or ill-equipped short-term trainees are given responsibilities beyond their capability. Each of these factors may further compromise patient safety and limit the benefit of service efforts by trainees outside of clinical settings”

It is too soon to truly know if the foreigners working and volunteering at The Clinic have employed these destructive practices, but what we do know is that they did take steps not to allow their volunteers to perform any procedures they were not trained to handle. In instances like this, one feels a sigh of relief. But their presence is still an ethical concern in itself. One volunteer could not even describe why she was there. She had heard about Uganda from her friend’s sister and decided to come. She said they were there to help The Clinic, go to a few schools and do outreach, but that is was mission-oriented and all of this was done through spreading the love of Jesus Christ.

If anyone knows anything about colonialism in Africa, you know the saying, “the bible came before the gun.” This is exactly what happened just a couple weeks after the volunteers arrived with their bibles. History repeats itself terribly well. The gun came in the form of the local MP (the equivalent of a mayor) organizing a cervical cancer screening for the woman in the region (the "health event” I referred to above). Well-intentioned volunteers in this scenario exacerbated the structural violence already associated with the screening.

If anyone would take the time to think about colonialism in Africa and the fierceness in which it destroyed traditions, whole populations, customs, forests, wildlife, and emotionally and psychologically imprinted its devastating ethnocentric and racist ideology on the people, one would think twice about “spreading the love of Jesus Christ.” It has literally been used as a tool of oppression on the continent for the past 500 years. If you are not convinced, please read Curing Their Ills: Colonial Power and African Illness by Megan Vaughn which discusses in length “missionary medicine” and its horrific consequences on African peoples and traditions.

But like I said, it is too soon to tell the true effect these volunteers have had on The Clinic. What we do know is that many people from the community do not come to the clinic unless “the white people” are there. This is not only detrimental to their health, but undermines the local staff working there year-round under challenging conditions. Actually, it is even too soon to tell the true effect our team has had on The Clinic. We’ve taken precautionary steps to minimize harm and maximize the positive outcomes of our research not only for The Clinic, but for the community members we’ve come into contact with. We do not come with hidden agendas; we recognize that Uganda is an 80% Christian nation, but that religious syncretism is a relevant and complicated part of people’s lives. We do not come to proselytize, to heal, to save or to continue the culture of dependency normalized under neo-colonial policies and humanitarian intervention.

But we are here. And our presence means something. I am just not sure of the long-term effects. As it stands with the current political and governance authoritarian democracy model in Uganda, not only on the national level, but also on the local level the light at the end of the tunnel is so faint, that it may be a figment of my idealist heart.

So the stage it set dear readers: You have us, health research team, the other muzungus, American and Canadian volunteers, and a poor, rural community that has not had a new public health care center built in the region since the current president came into power in 1986 (more about why later). You have an already over-worked local clinic staff, and then various community leaders along with the MP. The Clinic we are conducting research for is a private one that was started by the MP who is a member of the ruling party in Uganda: The National Resistance Movement (the president’s party). And lastly, you have a three-day cervical cancer screening organized unbeknownst to the American and Canadian volunteers who were basically corralled into supervising it.

Intense and historical power relations are in place for a screening meant for 400 women, in which more show up. But I shall continue this post in my next blog. Just keep in mind, that in a country where the average life span of a woman is around 52, diseases such as HIV, TB, Pelvic Inflammatory Disease and Malaria will affect and kill more people than cervical cancer, if they live long enough to develop cancer. So why have this particular screening in the first place?

Imagine what this screening really means. Imagine its political significance for the MP. Imagine its harm on the women and their community. Imagine its harm on the clinic. Imagine and keep that question in your mind.

*to protect the confidentially of the community and our informants, all names and place-locations have either been omitted or changed