[MUSIC] Welcome. Today we'll talk to Professor Susan White here at the University of Copenhagen. Which for many years conducted ethnographic research in Uganda with her husband Michael White, and colleagues from Uganda. Maybe you can briefly introduce us to the research you have done for many years in Uganda. >> Yes, thank you Fleming. It's a pleasure to have a chance to talk to you about a long story of research in Uganda. I started, together with my husband who's also an anthropologist, I started field work in eastern Uganda in 1969. My particular focus in that first field work was how people interpret and manage misfortune. Misfortune can be many things. But it turned out that most of the difficulties that people were confronting had to do with health. >> In those early days, what were the kind of health problems you would see people would consult the biomedical or the health service in general? >> They were infectious diseases. But when we first came, there was really no national vaccination program. So immunization wasn't there. I remember one of the very first days that we were living in this rural community. We heard that a family in the neighborhood had lost four children. Four children had died within the space of a couple of days. And people were shaking their heads, wondering how it could happen. In retrospect, I suppose it was measles. There was lots of measles and there was no measles immunization at that time, so infectious diseases were very common. Lots and lots of malaria was there. Children got lung infections. And those were the kinds of things that people were struggling with. We had one of the two cars in the whole county. So we learned about these things because people came day and night with emergencies asking us to please carry their sick person to the local health center which was 14, 15 kilometers away. So we got involved the anthropologists must do by participating, trying to help people who are struggling with problems of health. So after we left in 1971, came a period of political instability in Uganda with General Idi Amin, and later with other dictators, and periods of political violence, disturbance. So that we weren't able to come back and do more research in Uganda until the end of the 1980's. When I started going back to do research in the same part of Uganda, it was after a period of great instability. Where the government health facilities had been neglected, health workers weren't getting their salaries, or they were very late and they were totally insufficient. Medicines were lacking. So, there had been a real breakdown, you could say. Not a total disappearance, but a real deterioration of the government health facilities. And people had responded in a creative way. Because the health workers tried to access medicines where they could. And they set up lots of small drug shops in the trading centers, and near the local hospital and near the local health centers where there. In the meantime, there had been construction of some new health units. And among other things, twenty two rural hospitals had been built in that period in Uganda. So the infrastructure, somehow, the buildings were there. But it was functioning very poorly, and lots of times the health workers weren't at their posts because they were doing other things, trying to make money. And as one commented, they pretend to pay us and we pretend to work. So there was a new kind of healthcare that was becoming evident. I experienced when I went back in the late 1980s, that local people, often not well-educated at all, maybe having not ever finished primary school, knew more names of medicines than I did. So this was a very important development. But when new programs came in, as they did when the donors started to come back after this period of political instability, all the focus was on traditional birth attendants or training community health workers. And the real community health workers who were those who were selling the pharmaceuticals were ignored. Because it was felt that they were they were doing something illegal by selling medicines that were supposed to be on prescription only. >> In the late 80s, how did the primary health care approach in the primary health care programs evolved in Uganda? >> In 1986, after the long period of instability, a new government came into power, the National Resistance Movement with President Yoweri Museveni who's still the President of Uganda. And when he came in, he turned over a new page. Primary healthcare programs definitely came in. And there were things like community distributors of antimalarials. Training of traditional birth attendants was popular. And all kinds of the immunization program was developed and strengthened. So things that really did make a difference. But then, what happened also when the new government came to power in 1986, was that the first cases of a mysterious disease began to appear. And some of the very first international scientific recognition of AIDS actually came from studies in Uganda in the late 1980s. What made Uganda unique at that time was that the new president was extremely open about AIDS as a national problem. He had defeated his political enemies and then he took on a biological enemy which was this new epidemic. And so he was open, he said we must confront this, we must not hide it. And he welcomed donors to come to support the fight against AIDS, when other African countries were denying it. They didn't want to scare away tourists or they didn't want to become unpopular with their own people by admitting that there was a very huge threat in the country. But Museveni must be praised for his visionary leadership in the beginning of the AIDS epidemic. But what it also meant was that even more donors came in and began to play a crucial role in biomedical healthcare in Uganda. To the extent, in fact, that by the, when was it, the 2008 I think, the figures show that the Ugandan government was only covering 7% of the cost of fighting AIDS. And 93% came from donors. So that is an incredible dependence on external funding. It was an interesting time when people were both yes, accepting that AIDS was there, and listening to and I think taking, appropriating really, the messages about how you could avoid infection. But at the same time, using herbal medicines and to some extent also turning to new enthusiastic forms of Christianity in trying to deal with those who are already sick. It wasn't until 2004, 2005 That antiretroviral treatment became available for free on a wide scale. Before that, the elite, those who had money could buy the treatment. From the late 1990's actually, you could buy treatment for For HIV in Uganda. But it was very few people who could afford it. It was way too expensive. But then when the big programs came online in 2004, 2005, many people came forward to test. There was a enthusiastic, I would say, embrace of the possibility of getting on treatment, and a lot of support. I think in many ways because Uganda had been so open about the epidemic from the beginning, that the transition to actually testing and using treatment was also smoother there than it was in other African countries. >> And has the increased focus on treatments, has that taken away some of the focus on primary prevention in HIV/AIDS? >> Yeah, that's the big worry now, because what one can see in Uganda was that first of all there was a very dramatic decline in prevalence and incidence. But now from about something like some people say 30% of adults being HIV infected, it went down to Something around 6%. Which was a great success story at a time when the world needed a success story because the AIDS epidemic was so terrifying. But what we've seen in the last, three, four, five years in Uganda is again an increase in both prevalence and incidence. You would expect an increase in prevalence because people are not dying, they're living with the virus. So the virus has become a life sentence not a death sentence, as they say. But also there's an increase in incidence. That's to say that more people are contracting the virus. And this is a very big worry for the Ministry of Health and well, for everybody. >> And what are the most recent developments you see in Uganda? >> As I was saying, I think that the provision of treatment, chronic treatment for HIV was a revolution in Uganda healthcare. I think it's not fully appreciated how important it was that people who used to shop around, get some medicine from the health center, then maybe it doesn't help. So you go to a drug shop and you buy another kind of medicine. Then maybe you try some herbal medicine. People shopped around. But with the coming of these clinics for HIV, people had to join a program. And they became, as they call them in Uganda now, they became clients, not patients, but clients of a clinic. And they were registered there. Their files stayed there, they had records there. They were given appointments to come back. And in a sense they belonged. They got to know the health workers. They learned a lot about their condition and its treatment, so they joined. And I think it really Increased people's confidence in biomedicine generally. That first of all, there were these miraculous returns to health. People who were literally reduced to skin, and bones and rashes in a few months had gained weight, and looked healthy and fine. And they got a second chance to live, and biomedicine did that. So some people are even saying that all over Africa, that successful AIDS programs have increased expectations about what biomedicine can do. So it was a very big step. So what happens now? The WHO has been calling for much greater attention to noncommunicable diseases which are increasing all over the world, but also in Africa. Even though there are still lots of infectious diseases, but as people are living longer they are living with chronic problems like cardiovascular conditions, diabetes. Cancer is becoming more and more recognized as a problem. So, and epilepsy, mental health which have long been there but which have never had adequate what I call chronic treatment programs of the kind that are provided for HIV patients. Now the question is will these other diseases, some of which are increasing, will they be subjected to this revolutionary move In healthcare where you have chronic treatment for chronic conditions? It could be done. But I think, in Uganda, at least, the problem is that the healthcare system is so dependent on donors, and the donors are so interested in AIDS. That whether an investment, an adequate investment will be made in other chronic conditions is a big question. It's something that policy makers, and activists, and researchers like us should be consumed with. >> Thank you so much. [MUSIC]
