A forty-year walk with Ebola – it hasn’t been a 'walk in the park'

By Esther Nakkazi

40 Years ago, around September, the first Ebola blood samples were carried by a Congolese woman in her handbag from Zaire to Belgium on Sabena airlines. Yes, you read that correctly.

Currently, with an Ebola outbreak anywhere, travelers not even remotely near the source have to fill in forms, temperatures have to be taken, suspects quizzed and isolated or even denied access to places. It is the drill.

The fascinating 40-year history of Ebola since the first outbreak in Yambuku, a small village in the DRC, was told at the 8th international symposium on filoviruses in Antwerp, Belgium.

Nothing is the same anymore. Zaire is now the Democratic Republic of Congo, Sabena airlines - then the national carrier for Belgium - closed in 2001, its succeeded by Brussels Airlines.

As you know, this last Ebola outbreak was vastly different from all the ones before. Ebola has become a household name now, 40 years after Yambuku.

Forty years ago, though, Ebola was unknown.

In 1976, in Yambuku, a small village in Mongala Province in northern DR Congo, a young doctor Jean-Jacques Muyembe was ordered by the minister of health to make investigations about a disease that had killed some people.

Muyembe arrived with a medical assistant. The health workers suspected typhoid or yellow fever. Muyembe examined some sick people and collected blood samples without gloves. His hands and fingers were stained with blood but he just washed it off with water and soap. In addition, he collected liver samples from 3 nurses who had died.

When a nurse who he knew was vaccinated from typhoid and yellow fever said she had a fever the alarm bells started to ring. The trio (Muyembe, the medical assistant, and nurse) flew to Kisansha to further investigate the samples.

The disease was nothing they knew. Sadly, the nurse and medical assistant died in the next few days but Muyembe was saved - not by the ‘moon suit’ but by washing his hands with water and soap.

A Congolese woman who was traveling to Belgium on Sabena airlines was asked to drop the samples off at the Institute of Tropical Medicine (ITM) in Antwerp, where Muyembe’s friend was working.

The Ebola samples arrived in Belgium in September 1976. Dr. Guido van der Groen picked them up on his bicycle. They were packed in used containers. He took them for proper storage at ITM.

Here the team tried to identify the virus and found that it was close to the Marburg virus isolated from monkeys in Uganda by the Germans, but clearly, it was not the same. Muyembe was informed about it and warned that it concerned a very dangerous new virus. They then tried to give the new virus a name.

At first, they opted for Yambuku where the index case was discovered but they soon realized that if you use the name of a town it will cause too much stigma. Then they looked for any landmark near Yambuku and found the Ebola river which is why Ebola is now named after a river near Yambuku.

The Ebola forty-year journey has seen 25 outbreaks by now, 30,900 cumulative cases and 12,800 deaths. A new book ‘on the trail of Ebola’ by Dr. Guido van der Groen details this history.

Frontline health workers have been most affected by Ebola over the years, but right now it is a serious public health threat. Many ongoing efforts in terms of policy, diagnostics, and research are being discussed at this symposium.

Clearly, the Ebola journey hasn’t been a ‘walk in the park’.

ends.

Uganda off WHO list of yellow fever risk countries

By Esther Nakkazi

After a month of no evidence of active transmission, Uganda has now been declared yellow fever free.

The ministry of Health says between the 1st to the 30th of June 2016 there were no cases of active transmission in the country. A vaccination coverage of 94 percent, which is above the World Health Organisation (WHO) recommended coverage of 90 percent was achieved in the three affected districts of Masaka, Rukungiri and Kalangala.

Following the successful yellow fever vaccination campaign in the affected districts, no new cases have been confirmed, said Professor Anthony Mbonye, the acting director of general health services, Ministry of Health.

A total of 627,706 residents (aged six months and above) were vaccinated including 273,447 in Masaka district and 304,605, 49,654 in Rukungiri and Kalangala districts respectively.

Thereafter, the Public Health Emergencies Operations Centre Network (PHEOC) coordinated a one month enhanced Yellow Fever surveillance in 17 districts surrounding the three districts with no confirmed cases.

However, disease surveillance to detect any other possible outbreak and heightened efforts to prevent the risk of transmission through international travel is still ongoing, said Prof. Mbonye.

It is mandatory that individuals travelling from yellow fever high risk countries into Uganda are fully vaccinated against it before entry into Uganda. Unvaccinated travellers from Uganda are also advised to access the yellow fever vaccine from accredited centres.

On 7th April 2016, yellow fever was confirmed by Uganda Virus Research Institute (UVRI) on 3 samples from Masaka by serology. This diagnosis was re-confirmed on 21st April 2016 by CDC Fort Collins (WHO Collaborative Centre for Yellow Fever)

Intensification of yellow fever Surveillance activities also confirmed yellow fever in Rukungiri and Kalangala districts on 13th April 2016 and 4th May 2016 respectively.

From 24th March to 4th May 2016, a total of 65 suspected yellow fever cases were reported from districts in the greater Masaka region and 7 cases were confirmed from Masaka (5), Rukungiri (1) and Kalangala (1). Three of confirmed cases died.

With support from World Health Organization (WHO), the CDC, ICG, GAVI, UNICEF and other partners, the Ministry of Health conducted a reactive yellow fever vaccination in the three districts that had confirmed outbreaks.

The vaccination campaign was implemented from 19th May 2016 to 22nd May 2016 in Masaka and Rukungiri districts and from 4th June 2016 to 7th June 2016 in Kalangala district.

ends

Sex education in Uganda schools was a bad move?

By Esther Nakkazi

It was at the celebrations of the 2016 World population day held in Isingiro district that I first heard President Yoweri Museveni talk about the unessential need for Uganda to have sex education in schools.

The theme was ‘invest in teen girls’ and in his speech, Museveni juxtaposed high teenage pregnancy with teaching sex education in schools.

“I want to discuss with all stakeholders about sex education in schools. There is a time for everything,” he said meaning he actually wanted to fix what he started.

Sex education started being taught in primary and secondary schools in 2001 when Uganda was preaching abstinence-only. It was an official program of President Museveni under the Presidential Initiative on AIDS Strategy for Communication to Youth (PIASCY).

PIASCY was launched by President Museveni in 2002 to promote abstinence and life skills education among school children. It was funded by the US lead government agency USAID and the Centres for Disease Control and Prevention (CDC). It was later bounced to the U.S. President's Emergency Plan for AIDS Relief (PEPFAR). 

The main aim of PIASCY was to empower young people to delay their sexual relations until marriage through abstinence. Thus, materials of instruction were made and distributed in primary and secondary schools and at youth rallies.

For kids aged 5-12 years the message was mainly abstinence and its benefits and as they grew older the subsequent message was correct condom application and uses. For kids 13-18 years it was upgraded to also include age sensitive subjects like masturbation, abortion, homosexuality but there was also some misleading and inaccurate information on condoms and HIV prevention.

Fifteen years down the line, after pumping kids with comprehensive sex education in schools, this is the scenario.

Uganda teen pregnancy incidence rates are sky high compared to its neighbors, HIV rates among adolescents are growing, teens spend happy moments exchanging porn and according to Parliamentarians the God-fearing Nation- read Uganda- is getting ‘more gay’.

Of course, there are positive contributions that sex education has made to Uganda's teens but the policymakers are adamant about them. All that is cited are these bad stats.

Latest stats from United Nations Population Fund (UNFPA) say 140 per 1,000 teenage girls get pregnant annually in Uganda compared to 41, 101 and 128 in Rwanda, Kenya, and Tanzania respectively.

The Ministry of Health reports that 25 percent of Uganda teenagers become pregnant by 19 years and face four times the risk of maternal death compared to women older than 20 years plus their rates of neonatal death are about 50% higher.

According to the 2011 Uganda Demographic Health Survey (UDHS), many of the pregnancies in female adolescents aged 15-19 years are neither desired nor planned and those who had a child five years prior to the survey did not want to have it at that time.

Abortion is illegal in Uganda except under exceptional circumstances that include saving the life of the woman or preserving her physical and mental health. Studies show unplanned pregnancies in adolescents coupled with high teen pregnancy rates contribute to the high incidence of abortion and its related deaths.

A study done at the national referral hospital, Mulago, showed that almost 50% of the women who died from abortion complications were adolescents. But these also tend to seek an abortion later than others and are more likely to use unskilled providers.

In mid-August, a month after President Museveni who signed onto this program complained, the Uganda parliament debated the motion to withdraw sex education in schools.

Lucy Akello, a Member of Parliament, Amuru district moved a motion, which appreciated that ‘comprehensive sexuality education lacks defined approaches to guide children at their tender age and to uphold Uganda with its morals, virtues of an Africa setting and a God fearing Nation.

It was agreed that the ministry of education halts dissemination of comprehensive sexuality education training materials and conduct of such programs in any schools in Uganda until a policy has been laid out in Parliament. 

Also, the National Curriculum Development Center in conjunction with relevant stakeholders would develop a comprehensive sexuality education curriculum in line with Uganda’s cultural values and practices.

During the debate, every member who spoke supported the motion. They blamed sex education in schools for the widespread 'immorality' inclusive but not limited to early sex, abortions, homosexuality and teen disobedience.

Of course, there should be other things to blame like the increasing exposure to porn and ‘raw and uncensored material’ on the Internet but in the meantime according to our legislators adopting this motion will fix everything.

Here is another scenario from a highly educated Ugandan.

So last year, I was attending the Makerere University Walter Reed Project (MUWRP) stakeholders meeting in Kampala thematized ‘Mitigating disease threats of Public Health Importance: 13 years of MUWRP in Uganda’.

Prof Vinand Nantulya, the Chairman of the Uganda Aids Commission (UAC) was the key speaker. He juxtaposed Uganda’s HIV new infections increase to the vulnerability of young women who are increasingly getting lured into sexual activities. He said it is worse.

UNAIDS estimates that 380 new HIV infections occur in Uganda making it the third leading contributor to new HIV infections in Africa after Nigeria and South Africa.

Prof Nantulya said one of the ways this would be fixed was to have more education about HIV in schools, which is also part of the comprehensive sexuality education package. He said more funds needed to be provided for PIASCY.

“PIASCY, which was good and helpful to educate the youth is not as good as it used to be. I want PIASCY back,” he said.

So its either that Uganda children and adolescents do not need sex education at all or that the PIASCY project got it wrong. Whatever it is we are not going back to the era when Uganda’s children got sex education from their grandparents, parents or relatives as Museveni suggested. No one has that time anymore. It is easier done in schools with the right messages and at an appropriate age. So since it cannot just be blown away, fix it.

Is a malaria free Africa by 2030 possible?

By Esther Nakkazi
Is a malaria free Africa by 2030 possible? The glass is half full.

Forty-seven World Health Organisation member states in the African Region unanimously adopted a new malaria framework with specific actions to reach ‘an African Region free of malaria’ by 2030.

In a meeting held in Addis Ababa on 21st August, they came up with a framework to guide member countries towards attaining targets of the Global Technical Strategy (GTS) for malaria (2016-2030) within a given time frame.

The GTS was founded in May 2015 at the 68th World Health Assembly on the vision of a world free of malaria and consists of four goals and related targets to be achieved by 2020, 2025 and ultimately by 2030.

It for instance aims to reduce malaria mortality rates and case incidence by at least 90% by 2030 as well to eliminate malaria from at least 20 malaria endemic countries. It also aims to prevent re-establishment of malaria in all Member States that are malaria-free.

A press release from WHO AFRO says this framework's priority interventions and actions have been organized according to programme epidemiological strata in order to engender evidence-based targeted interventions.

The GTS has guiding principles like country ownership and leadership with involvement and participation of communities within a multisectoral context. It also encourages mobilizing and working with other sectors in malaria control and elimination.

To an extent some of these goals are achievable.  Some projects have demonstrated it. Six countries; Algeria, Botswana, Cape Verde, Comoros, South Africa, Swaziland have the potential according to the WHO to eliminate local transmission of malaria by 2020.

Meanwhile, two countries, the Democratic Republic of the Congo (DRC) and Nigeria alone account for more than 35% of the global estimated malaria deaths so if efforts are concentrated here that would give a lot of mileage I suppose.

But how possible is it that the Africa region can be malaria free by 2030?

Well, there is some impressive progress so far in controlling it. Since 2000, malaria death rates have plunged by 66%, translating into 6.2 million lives saved, most of them children. Between 2000 and 2015, the number of malaria cases and deaths within the African Region declined by 42% and 66%, respectively says the WHO.

In addition, more people with suspected malaria get tested before treatment and many more are sleeping under insecticide-treated mosquito nets. In 2014, 65% of the suspected malaria cases got tested before treatment compared to only 41% in 2010. In 2015, two in three households in Africa had their own insecticide-treated mosquito net, compared to only 2% back in 2000.

And like Dr Matshidiso Moeti, the WHO Regional Director for Africa said, “Malaria is no longer the leading cause of death among children in sub-Saharan Africa. More and more children get to sleep under a net.”

Malaria is also still on top of the global and regional agenda and so it remains a priority, identified in target 3.3 of the Sustainable Development Goals (SDGs) which commits to end it by 2030. The WHO also reaffirms to end it by then.

However, despite the significant progress made, malaria continues to be a major health and development problem in the Africa Region as it still bears the biggest malaria burden with about 190 million cases (89% of the global total) and 400 000 deaths (91% of the global total) in 2015 alone.

We cannot talk about a malaria free Africa without talking funding which the World Malaria report 2005 says increased substantially by 410% between 2005 and 2013 for programme financing. Overall, international financing for malaria control increased from US$ 100 million to US$ 1,640 million in 2013.

But the report also shows that even with these increases the annual investment per person at risk remained low at US$ 2 in the year 2013 and this funding situation is further threatened by low domestic financing.

So in the period 2005-2013, the proportion of total malaria funding contributed by national governments in Africa stagnated at less than 10% and these rely on external funding.

Meanwhile, based on GTS cost estimates and at a fixed 2013 population at risk of malaria in Africa of about 830 million, the total cost of malaria elimination in Africa by 2030 is US$ 66 billion.

There is thus a funding gap which is not new because most health projects are suffering from low aid.

Furthermore, implementation of the GTS will necessitate addressing some key challenges like weak health systems (which were tested during the Ebola outbreak).

As well there is the threat of resistance to the medicines combined to a lack of a vaccine and the adverse effects of climate variability and change.

One of the reasons for reversing the malaria deaths as mentioned earlier was as said by Dr Moeti; ‘more children slept under a net but there is need to continue to invest in changing people’s behaviours.’ She also said more people with suspected malaria got tested before treatment.

It is only if people in the region change their behaviour and sleep under treated nets and also seek treatment within 24 hours after testing. These are some of the sustainable ways to keep the gains achieved and also move forward.

Otherwise, the glass really remains half full as the balance for the gains and the challenges for implementing the GTS remains glaringly odd.

ends

Anne Merriman Hospice Africa Foundation launched

By Esther Nakkazi

The 2014 Nobel Peace Prize nominee Professor Dr. Anne Merriman's efforts to improve palliative care for Africans are starting to pay off. She is also an advocate of a good death, which is a basic human right.

While in 1993 only three African countries had palliative care now 35 have support care and 20 have affordable oral morphine based on Merriman’s formula which she developed in 1980. Hospice Africa Uganda (HAU) the model she founded for Africa is also producing enough oral liquid morphine for all in need in Uganda, with the support of the Ugandan government.

Since its founding, Hospice Africa Uganda has cared for more than 27,000 patients. It currently provides family centred care for up to 2,000 patients across its three centres in Kampala, Mbarara and Hoima. 

 “An Africa where Palliative Care reaches whoever needs it is a very big vision. This vision can only be achieved if impeccable clinical services, like the ones offered at Hospice Africa Uganda, are spread all over the continent and are integrated into the health service delivery system of every country, said Dr. Eddie Mwebesa, the Chief Executive Director of HAU.

Also recognising the shortage of morphine prescribing doctors,  Merriman’s work has changed the law in Uganda to allow specially trained nurses to also prescribe morphine. 

So Uganda is the only country in the world where nurses can prescribe morphine, hence it was in 2015 ranked by the Economist, Quality of death Index as the second country in Africa (35th worldwide) for the highest quality of death.

It is estimated that 50 percent of people in Africa will not access a health worker in their lifetime, and less than 5 percent reach chemotherapy or radiotherapy.

On Wednesday, 17 August the Anne Merriman Hospice Africa Foundation was launched in Kampala by Dr. Jane Aceng,  the Uganda minister of health during the 5th International African Palliative Care Association Conference. 

“Every human being on the planet no matter their colour, creed or social background should expect a pain free, peaceful, end of life. Unfortunately in Africa this is not the case for most," said Merriman.

"I have worked with dedicated teams for the last 23 years to change this and now that I am 81-years-of age, our loyal supporters and I, want to ensure that this work continues, until the vision is a reality. Together we have achieved a lot - but so much more needs to be done.”

She appealed to world leaders and policy makers to take note and to do all in their power to ensure that people in Africa experience a good death. “We need strong and powerful advocates to support this cause.”

“We are here because we want to move the ethos of care: compassionate, team oriented, and patient centred, forward together. It's for this purpose that the Anne Merriman Hospice Africa Foundation will thrive in its vision," said Mrs Shelley Enarson, a founding advisor to the Foundation, at the launch.

"The AMHA Foundation will promote the spirit of keeping the patient at the center of our care, and ensuring that the ethos of organisational partnerships are encouraged” said Dr. Mwebesa.

ends.

Refugees a Blessing to Uganda says Museveni

By Esther Nakkazi

Since 17th July 2016, the total number of South Sudanese refugees that have arrived in Uganda is 37,890 according to UNHCR. 73 percent of all refugee new arrivals are children.

Two days ago at the joint political leadership of the NRM that included the central executive committee, cabinet and permanent secretaries President Museveni said Uganda caring for African refugees brought by adversity, is not just charity. It is also good strategy.

He elaborated how the Banyarwanda comrades were supported when they stayed in Uganda as refugees for 34 years (1960-1994). When they gained ascendance in Rwanda, they opened it up for interaction, including trade, with East Africa. Today Uganda exports US$263 million worth of goods and services to Rwanda. Rwanda, in turn, is exporting US$78 million worth of goods to Uganda.

And through Rwanda Airlines, Uganda is currently contributing about US$ 24.1 million to the prosperity of the people of Rwanda. South Sudan, before the outbreak of the conflict in 2013, was contributing US$ 700 million per annum (exports and remittances) to the prosperity of the people of Uganda.

Recently, about 40,000 Ugandans came back from South Sudan on account of the present conflict there. They were there apparently looking for prosperity.

Therefore, Ugandans should know that unity within Uganda and Pan-Africanism in the whole of Africa are not mere acts of solidarity but are also investments to create a better framework for the prosperity of all Africans said Museveni.

“I, therefore, salute Ugandans for welcoming our brothers and sisters, the African refugees as well as other African business persons. It is the cumulative, Pan-Africanist efforts of as many Africans as are enlightened on this point that will guarantee the prosperity of the African people,” he concluded.

Uganda rural based doctors play God

By Esther Nakkazi

Only two years into medical practise, the youthful doctor Gamukama Tuhaise is the in-charge of Rwekubo health centre IV, where a new born baby dies almost every day. With limited resources and a small workforce tough choices make him play God.

On the eve of Uganda's 2016 World Population day celebrations, commemorated world over on the 11th of July, I travelled to Isingiro the land of highland bananas (Matooke) and the venue for Uganda’s big event celebrated and attended by President Museveni and non profits like UNFPA-Uganda.

As the road snaked into the hilly, ridged terrain of Isingiro, you would think all the Matooke eaten in east Africa is grown here as almost the entire vegetation was of Matooke and the many lorries on the road from this Uganda-Tanzania border district were all loaded with them with just a few carrying milk cans.

At least 20 lorries of Matooke leave Isingiro for Kampala everyday and 700,000 litres of milk are produced per month. For the thousands of guests who attended the World Population day  celebrations in Isingiro, refreshments served to us were between a choice of water or milk. I am certain if lunch was served too, it would be a mountain of Matooke on our plates.

The 2016 theme, ‘investing in teenage girls’ was timely and relevant to especially Uganda, which tops the East African region in teenage pregnancy. Everyday over 20, 000 girls under age 18 give birth in developing countries according to UNFPA.

In Uganda, 140 per 1,000 teenage girls get pregnant annually compared to 41, 101 and 128 in Rwanda, Kenya and Tanzania respectively according to UNFPA.

Stillbirths and death in the first week of life are 50 percent higher among babies born to mothers younger than 20 years than among babies born to mothers 20–29 years old, says the WHO.

Furthermore, deaths during the first month of life are 50–100 percent more frequent if the mother is an adolescent versus older, and the younger the mother, the higher the risk.

The rates of preterm birth, low birth weight and asphyxia are higher among the children of adolescents, all of which increase the chance of death and of future health problems for the baby.

The statistics for Isingironian pregnant teens are not available but when I interviewed some of them most were impregnated by fellow teen boys and I am not sure I got an explanation to pin this to. Later when I visited Rwekubo health centre IV and also talked to some teen mothers and their youthful mothers ( now grandmothers) my heart sunk.

A teenage mother with her son Austin in Isingiro district

Seventeen year old Rosemary Kukiriza lay on the bed staring blankly at the ceiling her face showing no particular emotion, not exactly sad, eyes darting from her mother who was standing by her bedside to other teen mothers like her holding their new borns.

She was only 3 hours out of theatre and had lost her first born baby, another statistic at Rwekubo health centre IV where at least a new born dies everyday.

Isingiro has about half a million people. Its located in western Uganda, on the Uganda-Tanzania border, a newly established young district with no referral hospital with Rwekubo health centre IV as one of two biggest and busiest health providers.

Kukiriza’s 36 year old mother was making all the noise, seemingly restless and talking in undertones with an elderly woman attending to a patient on the left bed next to Kukiriza’s. It was her first grandchild afterall who had passed on and she told me she had given birth to Kukiriza at 14 years so why did fate have to follow her daughter and not any other?

She narrated ‘the story’ from when they had arrived at Rwekubo health centre in the night at about 4pm to when they got her daughter in theatre at 10am in the morning, occasionally opening her eyes wide or clasping her hands or slapping one finger into the palm of her left hand to emphasise a point - the whole system was full of delays- she said.

“Why didn’t they take Kukiriza to be operated upon as soon as we arrived? That nurse really delayed. They only took her to the theatre this morning at about 10 o’clock,” she said with near anger or regret in her voice.

Doctor Gamukama dressed in a faded, dark green, cotton health workers uniform and half listening to our conversation explained the circumstances under which Kukiriza had been admitted.

She was in distress, pain and before taking her to theatre certain practical things had to be done; blood type established, vitals taken, the theatre cleaned and prepared, fuel for the generator bought and the lone anaesthetist called in.

The health centre has one oxygen point; no running water - every week a water truck delivers water; it has a few health workers - this happens everywhere as few health workers want to be based in rural areas like Rwekubo health centre IV,  it is powered by a generator-sometimes this jams; and Rwekubo almost serves an entire district of half a million people.

“We have only one anaesthetist will he stay here day and night without doing anything else? Preparation of theatre takes about 40 minutes. The generator has to be fuelled and the theatre powered,” if an operation is to happen said Gamukama.

Kukiriza’s baby was born alive but died a few hours afterwards. It was tired. Efforts to resuscitate it did not help something partly blamed on herbs. “Many women take herbs which thicken the fluids so it becomes difficult when you try to resuscitate the baby,” said Gamukama. Asked which particular herb was responsible for this outcome he said he did not know.

His advise is for women to stop taking herbs when pregnant although in Africa, herbal knowledge for pregnancy is passed on across generations and herbs are preferred to antenatal visits. So outlawed traditional birth attendants still remain women’s preferred choice when giving birth and for nursing pregnancy sickness.

“If you resuscitate a baby for an hour and there is no response you take a decision,” said Gamukama. The oxygen has to be turned off. It is only rational.  It could also be playing God?

He explains; if only there was another doctor-led team in the theatre to handle the baby it would be easier but he has to handle both mother and baby concurrently. Usually, the preference is to save the mother.

Understanding doctor Gamukama’s perspective of the theme in terms of teen mums and saving new borns was real important afterall he is the star of the Isingironian film.

Of the 70 maternal related operations that take place in a month at Rwekubo health centre IV, most of them done by him, 20 percent are of teenage mothers aged 16-19 years and their babies often die. Looking at the centre’s records from 1st July almost a baby had died a day most of them born to teen mums.

“It does not affect them much. After one year they will be back here. They are usually pregnant within the next three months after losing a baby,” said Gamukama with certainty.

Some want to fill the void immediately while others want to stop the scorn and stigma by village communities ‘as the daughter of so and so who has failed to bear a child for our son’.

But there is also prestige in switching names to ‘mama boy’ or whatever name the first born child bears and merely just to prove themselves.

Seventeen year old Ainembabazi Brenda is also camped at the Rwekubo health centre for the last one month and 2 weeks. She has no complications yet in her third trimester of the pregnancy but being a teen and at the advise of the health worker she has stayed.

“When the teen mothers stay here it reduces the risk of losing the baby and it keeps us health workers updated on every step,” said Gamukama. However, its expensive on both the health centre which has limited space and resources and on the family that has to ferry daily meals to the otherwise not sick pregnant woman. Not forgetting the overall confounding factor- poverty.

But its worth it. For instance, in doctor Gamukama’s opinion if Kukiriza had come in at least 24 hours before the onset of her symptoms her baby would be alive. For all those reasons, ‘you cannot stop babies from dying,’ he says. As well, poverty cannot let teen pregnancies stop, he concludes.

As we drive out of Rwekubo health centre's gates, Kukiriza's mother is holding a box wrapped in Africa fabric cloth bearing the body of her grandchild. She waves back to us limply and we wish her well.

Hopefully, her next grandchild born born by teenage Kukiriza will live to see another day and drink of Isingiro's thousands of litres of milk and eat of its mountains of matooke.
ends-

This trip was facilitated by UNFPA-Uganda