Engeye Clinic - A Haven in Rural Uganda

It is two in the morning on a Monday night. Joe – a recent Union college graduate - is wrestling with sleep in his room at the Engeye clinic in rural Ddegeya, Uganda where he is volunteering. He hears his name, then a knock on his window.

“Joe,” a small voice whispers. He isn’t sure if he’s dreaming. Then he hears it again.

“Joe, are you awake?” He recognizes the voice of Immaculate, one of the Engeye scholars on staff at the clinic.

“Immaculate, is that you?”

“Yes,” she responds. Because of the language barrier, she cannot provide a reason for her visit. Joe surmises that something terrible is happening.

“I am sick,” she says, “is John home?” John Kalule is the clinic manager and longest-serving staff member.

Disoriented, Joe gets dressed and stuffs some Advil into his pocket. He heads to the front door, thinking the liquid gels should do the trick. Before volunteering in Uganda, he completed his degree in psychology and history and has almost no knowledge of medicine. When he reaches the door, he sees a woman keeled over in pain. It is not Immaculate, but a woman from Ddegeya he’s seen in passing.

“Here take these,” he says, showing her the Advil, “they will make you feel better.”

“I don’t want ingestibles,” she says, “I am pregnant.” When she stands up straight, Joe can see that she is extremely pregnant and in labor. Panicking, now fully awake, Joe runs to get John who gets the clinic’s ambulance. Soon they are all en route to the hospital.

In the ambulance the woman tells John that she needs to return home to retrieve a suitcase of her belongings. They drive a mile to her home – a mile that she walked in total darkness, in labor, just to knock on Joe’s window. Thirty minutes later they check the woman into a public clinic with a maternity ward and return back to Engeye to try and get some sleep before they have to wake up again in a few hours.

Joe wrestles with sleep again. Eyes wide open.

This occurrence is just one of the difficulties of scarce maternal healthcare for women in rural Uganda.

Nine months ago, Joe began his Minerva fellowship through Union College in Schenectady, New York. The fellowship program was established in 2008. Its goal is to send students with various undergraduate degrees to NGOs in developing countries to make them more self-sustaining, using business practices and creative thought. Joe was the eighth round of fellows that went to Engeye to “make their mark” on the village and learn what their predecessors have built.

He applied for the fellowship hoping to facilitate after-school programs for the children in the village, but when he got to Ddegeya, he quickly realized that there was so much more he could do to impact the community. Having gone to school for psychology and history, he had no experience with medicine but found that he couldn’t avoid the politics of public health in rural Uganda.

From talking to Ugandans in Ddegeya, Joe found that there is widespread distrust of the government from past and current instances of violence, corruption and embezzlement. “There are some people who see ‘ministry of health’ on ibuprofen and wont take it because of their lack of trust in the government,” he tells me, “In Uganda, people listen to the radio and what their neighbors are saying. Word of mouth is often trusted over factual information.” This is one reason why patients often consult traditional natural remedies before visiting a clinic.

Sexual Health and Education

The intersections of wealth, gender and education are crucial for those seeking quality medical care. Over the phone Joe explained to me, “when women are subsistence farming, they aren’t making enough money to send their children to school. They are dependent on their husband to bring home money. In this way, men are often used as leverage to continue having children. There is a phenomena wrapped up in economics, gender equality, and history among other factors and that can be very confusing because if a woman doesn’t want to have another child, she might be left by her husband and therefore viewed as ‘less desirable’ in her community and can no longer afford the costs of raising her children. Joe insists, “educated, wealthy women have more leverage in their career paths and the size of their family, but in poverty-stricken rural Uganda, gender equality is polarizing.”

An excerpt taken from Joe’s blog reads: “In 2015, it was reported that 48.1% of the Ugandan population was under the age of 14. So, people are having a lot of babies here. Only with time will we see the political, economic, and educational implications of this trend.”

In many cases Ugandan women choose not to have children but have them anyways. According to a ‘Contraceptive Use’ study conducted by Makerere University, Ugandan women have two more children than they desire. In this way, childrearing becomes a form of rape with many children dying before they reach the age of five because they cannot be cared for.

Religious and cultural norms also battle public health.According to a Mother Jones article, Uganda, with its large Christian population has been particularly “fertile ground” for an Evangelical Crusade. Evangelical’s preach abstinence as the only birth control method, but rural Ugandans often have many sexual partners, so abstinence from a religious point of view is not realistic. Because of limited access to birth control, HIV infects millions of people a year.

Dangerous Options for Vulnerable Women

At Masaka Regional Refferal hospital in central Uganda – a government operated health facility in a more densely populated area - women sit on the floor waiting to get tested for STDs. Attendants perform 30 to 50 deliveries a day. There are no walls separating rooms, no curtains, and women are prohibited from screaming. After they deliver, women are taught to nurse their baby, defecate in the corner of the room and then leave to give up their bed for another woman in labor.

There is no accountability for workers – hospital staff can choose not show up and still get paid by the public health facilities. This leaves the hospitals, even the largest ones, understaffed and underserved. There are many health centers but nowhere near enough, and depending on the level the care quality is very different. Engeye is a level II facility, which means they are unable to perform deliveries. Level III facilities like Masaka perform deliveries and treat STDs with money provided by the government. Otherwise, women deliver at home or deliver in a private hospital room if they can afford it (this is the most expensive option).

Private facilities offer high quality services, but they are out of reach for people who can’t afford them. Down the road at a level III facility, a Peace Corps volunteer working there tells Joe that before the medicine gets to their clinic, it goes to the pharmacy in town. The clinic will then prescribe medication and tell patients to go to the pharmacy to get the rest, essentially creating a middleman and taking advantage of their patients.

“You can’t get fired from a government job. It’s free range from there. If you want to take away medicine and sell it somewhere else, you can because you wont be held responsible by the government.” So while it made Joe angry to see how women were being treated even in the largest clinics, he understood why the understaffed and underpaid hospital couldn’t accommodate them. He also empathized with the mistrust of a government that won’t regulate or adequately subsidize its hospitals.

Engeye Clinic - Promoting Change

In a rural facility it is difficult to hire reliable employees and electricity is reduced. However, Engeye is financed by loyal donor support in various communities across America and therefore has access to important utilities, such as a ‘Doctors Without Borders’ generator to refrigerate medicine. They are also one of the few health facilities in the area that have their own ambulance. Joe reflects, “being at a resource limited location is challenging, and serving a population with varying socio-economic and educational backgrounds is nearly impossible because you are always trying to convince people that this type of medicine is helpful.”

Women often deliver at home to sidestep political boundaries and dangerous medical options. “A statistic in “Half the Sky” [by Nicholas Kristof],” Joe writes, “fully encapsulates both maternal mortality and high conception rates; 1 in 22 women living in Sub-Saharan Africa dies during childbirth. In addition to the high risk of death, home births also pose the prospect of life-threatening injuries to the mother, such as obstetric fistula. Also, by not delivering at a health center, it is less likely that that baby will be immunized.”

Engeye offers a maama kit to every pregnant woman for a discounted price. A maama kit is a home delivery package used either for home deliveries or hospitals. It costs about five or six dollars and includes all the equipment you need for delivery – gloves, plastic sheets, a blade, etc. Women use them to safely deliver at home or bring to the hospital when they give birth.

For seven of the nine consecutive years they have been operating, Engeye has empowered scholars as community leaders. They have also planted seeds with the Minerva Fellowship program which Joe was part of. In addition to offering sexual education and holistic medicine to the community, they work with patients to determine a price that is right for them. Patient fees cover almost half of Engeye’s clinical budget. Additionally, the clinic compensates all of their employees’ financial needs and provides housing for staff from all over the country. They’ve found that treating employees with respect generates great patient outcomes.

“An average of four women a month request to deliver their children there,” Joe explained, “but that care is currently not offered. [We were] sending patients to facilities that had more services but not nearly the quality that we offered. It was a tough reality to come to grips with.” Joe and Charlotte – another Minerva fellow – are pushing to expand Engeye.

“How many women and children will be suffering delivery related complications because they are waiting too long at a hospital that is understaffed and underserved?” Joe said, concerned. He told me that with more donations, the clinic could afford access to prenatal care, postnatal care, deliveries, and staff housing. Most importantly with all of those necessities they would become a level III facility, which means automatic access to HIV treatment and medication that prevents women from passing the virus to their children.

“It’s so hard to see preventable death and preventable illness,” Resty, Engeye’s pharmacist, told Joe. Engeye is the only place people want to go in Ddegeya because it is trusted and resourceful. They discourage people from going to other facilities where they are being ripped off or underserved.

Throughout his trip, Joe wondered, “Is it more important to change a few people’s lives dramatically or change everyone’s life incrementally?” Witnessing the impact of Engeye in the community, Joe decided it was better to lift one community up then give every community crutches. In this way, scholars and doctors that come to Engeye spread knowledge from all different perspectives. “A kid that was going to be a bean farmer now wants to be a doctor.” Sometimes large changes in small communities can impact the entire population because more educated children use their knowledge to become doctors and educators.

For more information on Engeye and the Minerva Fellows’ mission, click here