2014-Heilke-MatthiasMatthias Heilke

My colleagues asked me to write a retrospective of my twelve weeks at CEHURD. Much as I am looking forward to cheese curds, CanLII, and public transit, it has been a spectacular summer. I came to Uganda hoping to learn about how law interacts with ground realities to produce good or bad outcomes. My experiences here taught me a great many things about working in law, and the issues surrounding ground realities were chief among them. The real lessons tend to be fairly specific, so this summary is slightly trite, but bear with me anyway.

Let’s start out really obvious: ground realities are shocking. I spent some time on a lawsuit against a hospital whose doctor took several hours to attend to a woman named Irene, even though she had a ruptured uterus. Irene ended her life begging for mercy while her husband watched helpless. Around a quarter of HIV-positive Ugandans do not receive public anti-retroviral treatment — yet HIV-positive mothers are sometimes forced by their families to breast-feed their children, giving them HIV in turn. I have read hundreds of pages of Ugandan health policy, and much of it is first-rate. But policy solves nothing without implementation, in which case it isn’t much comfort to Irene’s family.

People are varied and pragmatic, and Ugandans are as varied and pragmatic as anyone. At a trivial level, people’s response to a mzungu varied from cynical opportunism to kind hospitality — more of the latter, happily! Less trivially: many doctors in Uganda demand bribes from the patients, even when the patients’ conditions are life-threatening. However, there are also Ugandan doctors who travel long distances by motorcycle to deliver urgent care to patients who cannot reach the hospital. Others even pay for emergency treatments out of pocket when the patient is destitute. Health interventions tend to aim at the median of the target group — that isn’t a bad thing — but it is worth remembering that generalizations about a country of thirty million are, well, generalizations.

Gender relations and other inequalities have an enormous impact on access to health, especially as it relates to combatting HIV. Both women and men hate to get tested, and rarely tell sexual partners their HIV status — men because nobody will sleep with an HIV-positive person, and women both for that reason and because they are afraid their husbands will throw them out. Wives don’t always have a choice about whether to sleep with their husbands, which also transmits HIV. Health centres try to overcome the testing barrier by including HIV testing with regular services like antenatal care — but men see ANC as a women’s job, don’t like sitting in waiting rooms full of women, and don’t come. Then the health centres resort to discrimination to try to bring in the men. NGO’s, incidentally, make the problem worse — NGO’s usually present testing men as just another way to protect women and children, so men don’t perceive the health benefit to themselves. Poverty has comparable effects: the impoverished lack resources to protect themselves against exploitation, and yet cannot afford to be exploited. Reduce inequality, and the right to health improves.

However, the dominant issue I have seen everywhere this summer is limited capacities. I went on a field visit in June to meet with doctors. They complained of lacking surgical gloves, blades, and essential medicines. Boxes of pharmaceuticals reach health centres almost empty. Health centres never receive the beds they need. There are never any funds to repair equipment — if something breaks, it just rusts. Private health providers pop up everywhere to fill the gaps, but many people cannot afford to pay — so they die instead. Private clinics are often run by public doctors; doctors barely earn a subsistence wage, so they illicitly open private clinics and try to force patients to use their clinics instead of the health centres. Policies can ameliorate such problems: for instance, donors should always budget for training and repairs, and good lines of accountability keep corruption in check. That said, funding levels always limit services, and that in turn limits outcomes.

Limited capacities also affect the law. Good policymaking takes time and expertise, and time and expertise cost money. Uganda does not always end up with the laws, regulations, and programmes it deserves, simply because the funds are lacking to create innovative solutions. CSO’s are constrained, too — there are ideas and strategies that CEHURD would undoubtedly pursue much further if there were donors to support them. Just like doctors and patients, policymakers, lawyers and CSO’s have to make do with what they have.

However, there is reason to hope. At a grand level, Uganda’s health is improving: more people are getting vaccines, ARV’s, etc.; health facilities are slowly improving; people are living longer. At the ground level, the people I met, from elites to subsistence farmers, pay attention to health issues, are learning how to make the most of their situations, and are ready to hold the authorities accountable for upholding Ugandans’ right to health. Dear authorities, take note. People are unusually afraid of the future in Uganda — Milton Obote, Idi Amin, and Joseph Kony (among many others) have given people good reasons to think of the current peace as an aberration — but Uganda is getting wealthier, and its people increasingly want a hard look at how that wealth is spent. Health is improving, and expect it to improve a whole lot more.