Adjumani is one of the districts in the North-Western region of Uganda. It is bordered by Moyo district to the West and South Sudan to the North, Arua and Yumbe to the West with River Nile in between, and Amuru District in the South and East. Adjumani District Local Government is one of the Districts in Uganda that has hosted refugees for a number of years, primarily from South Sudan.
Forty minutes outside of the center of Adjumani district, there is a health center, Dziapi Health Centre III, in Dziapi Subcounty. It is shaded by tall trees and is mostly quiet. People who have come from all over wait patiently on benches to see the doctor. Some have their children in tow.
It is here where I met Dr. Simon Endema, the Chief Medical Officer of the health center. As the RAHU team and I waited for him, we could hear a young boy crying as Dr. Endema was stitching a wound. A few minutes later, the boy walked out with a small bandage on his foot, followed by Dr. Simon, who waved goodbye to him, and then greeted us. We came into his office, and he asked us what we wanted to know.
I told him about my work in the United States, how I work in health care policy, and how I worked at a free health center when I was in graduate school. I told him I wanted to know everything to learn about how he does what he does and the conversation took off.
Dr. Endema and his colleagues see about 75 patients a week from all over this sub-county and beyond. They provide primary care and sexual and reproductive health care including an HIV clinic, midwifery services, and prenatal care. In addition to having the brick and mortar clinic, it is not uncommon for staff to do home visits. It is a robust operation, that he is clearly passionate about.
Dr. Endema talked about the unique challenges facing adolescents as they try to access health care. He said there is an incredible stigma surrounding sexual and reproductive health care, especially among youth. To assuage their fear, the clinic started an adolescent clinic day once a week. He said that many times young people will come in for STI testing, but it is difficult to get both young people in as a couple to come and receive care.
He also spoke about how his health centre is reaching out to young people who are so afraid of testing even after they know they have been exposed to HIV. There is an intervention called the ‘Assistant Partner Notification’ where if someone tests HIV positive, they are tasked to share contacts of all the people they may have put at risk of infection and health centre counsellors call them in for testing too. This is done in confidentiality and compassionately so that people cooperate.
Similarly, young people who have been exposed to HIV do come in for PEP, a medication that prevents the transmission of HIV after exposure, but they do not want to get tested beforehand due to the fear of the results. Unfortunately for them, testing before administering the drug is mandatory.
We asked the other common STI cases the health centre registers and Gonorrhoea was ranking high. This he attributed to the still existing primitive cultural beliefs that discourage condomizing especially after the influx of the refugees so their communities need more interventions.
We talked about abortion and if he has handled cases of people who unsafely tried to terminate their pregnancies and he responded in affirmative. He said it is absurd that young women take rudimentary options and then have to run to health centres for post abortion care. Considering that abortion is criminal in Uganda, we asked him what happens in these instances and he said, his job as a doctor is to save lives and so he does what he has to do and lets the police to investigate whatever they need to investigate, as long as the person first gets medical help.
Despite being an ocean away, I saw many similarities between rural health care service delivery in Uganda and health care service delivery in the American South.
In Tennessee specifically, we have the “Gateway Law” that bans any information that might entice a young person to engage in premarital sexual activity from public schools. This means that, similar to Uganda, young people receive a patchwork of sexuality education from their peers, their schools, and their families. Oftentimes this education is abstinence-only, leaving young people ill-equipped to navigate the challenges of their lives.
Stemming from a lack of sexual education and broad access to contraception, teenage pregnancy rates remain high. While the rest of the country has come out of the HIV epidemic, the South continues to experience the burden of HIV. According to the Center for Disease Control while the Southeast is only home to 37 percent of the population, yet they account for 44 percent of the people living with HIV in the United States. Dr. Endema said that although PEP is accessible, PrEP is not yet available at his health centre. This is also true of the South. One of the services that we provide at Planned Parenthood is Pep/PrEP, but we are only of few health centres to do so.
Despite the challenges, we see doctors like Dr. Endema and those around the world who choose to serve in medically underserved and under funded places. From rural Tennessee to Adjumani, we owe a debt to our providers who understand healthcare to be a human right and are willing to go even to remote places to provide it.
*This was written by Elizabeth “Lizzy” Thomas, a 2019 recipient of Planned Parenthood Global Youth Ambassador Fellowship. Based in Nashville, Tennessee, Lizzy is a Community Organizer at Planned Parenthood of Tennessee and North Mississippi, where she manages all political and advocacy work in Middle Tennessee.