Sagarika Koka -- Malaria-focused education and community health in Uganda

Sagarika Koka is a second year MPH candidate at the Drexel University School of Public Health. Sagarika spent some time in Bumwalukanim, Uganda during the summer of 2008, which was between her first and second years at the school, to do a global health-oriented practicum project. She organized malaria-focused education and community health in remote villages across the region. Sagarika recently shared her experiences and perspectives of her work in Africa in a Q&A session with the School of Public Health. (Left: Sagarika Koka with colleagues in Uganda.)

SPH: Why did you go to Africa?
Koka: I joined the Foundation for International Medical Relief of Children (FIMRC) in February 2008. FIMRC was originally going to serve as my (first-year) practicum site. I picked FIMRC specifically because I wanted to do a global health oriented practicum. During my first meeting with Alison Grace (an SPH alumni), she told me about their Uganda site after learning about my interest in Infectious Disease.

In February 2007, OXFAM International distributed three bed nets and one canister of pesticides per household in Bumwalukani, Uganda. However, the bed nets were often utilized improperly, ineffectively or often sold at the local street markets. In response to the need to better educate the community about how to use their bed nets and prevent malaria, FIMRC asked me to develop an assessment strategy. Once I developed my bed net outcome evaluation, I decided that I wanted to continue my practicum experience by travelling to Uganda to implement it.

SPH: What was your experience?
Koka: Bumwalukani is a small lush mountainous Ugandan village. I was moved by the friendliness of the community, where everyone you pass says hello and wants to shake your hand. Certain cultural and environmental barriers became apparent from the start - including language, daily rains, and a slower pace of village life. I was paired with a translator named Mike, who spoke both English and Lugisu.

The questionnaire I had developed before my arrival was intended to be a door-to-door questionnaire. Thus in the mornings, Mike and I would set out on a path with a series of malaria educational illustrations along with the Bednet Questionnaire. We would go house to house administering the questionnaires and give a short five minute presentation about how malaria is transmitted and the role bed nets play in the prevention of the disease.

One of the most memorable families invited me into their home and they continue to tell me that "We are the creators of our own problems.” They took me outside and showed me a 200 sqft area dug extremely deep into the ground, which collected rain water and provided an excellent place for mosquitoes to breed - a fact that they obviously knew. Collaborating with the local neighbors, they had dug this area to serve as the outhouse. They were trying to improve hygiene instead of using pits inside the home. However, the outhouse was never completed and now serves as a breeding ground for pests. They do not have the resources to fill in the huge hole in the ground or build the outhouse.

SPH: How did your work at the School of Public Health help you?
Koka: By going to Uganda, I was able to identify several inconsistencies in the information at FIMRC management in Philadelphia. For example, FIMRC initially thought that everyone in the community had received bed nets and one canister of insecticides to re-treat the nets. But this certainly wasn't the case. Only two villages had received nets from OXFAM because these were the villages that were severely flooded a few years age during the rainy season. These villages, moreover, included the one the clinic belongs to. There is still a great need, however, for the other adjacent villages that the health care clinic serves to receive bed nets.

Also, I was told that these villages had received insecticides to retreat the nets. But I gleaned that the people, in fact, never received them - even after being told that they would soon arrive.

As a result, many people asked when they would be getting their nets. I informed them that the nets would not need to be retreated for another four to five years. Community health and prevention course work stressed the importance of establishing and maintaining credibility and trust above all. Therefore, it would be critical to follow through on any promises that were made to the community even though it was a different NGO that made the initial clams. My public health background helped me to identify the fact that the people of Bumwalukani perceived all the Muzungus (the general Lugisu word to describe all foreigners) to be more or less the same. Therefore the failures of one Muzungu would reflect poorly on the rest.

One of the main barriers to the use of bed nets seems to be a lack of space. Indeed, I travelled into several of homes, where the families sleep in very small spaces. These cramped spaces are hard to describe -- but perhaps most significantly, between floor and ceiling there is an additional dividing floor. This creates two narrow, tight cave-like sleeping areas where all the members of the family sleep. This type of sleeping space, however, is not ideal for the use of bed nets, which were designed to be spread out over a generous amount of space.

My activities included working with local community leaders, community members and varying levels of management, allowing me to draw from many of the disciplines within public health. My duties also included the creation of an outcome evaluation following the distribution of bed nets and holding educational sessions at homes. The perception and the feedback that I was given was mostly positive. Most families have stated that they have seen a drop in malaria rates and plan to continue to use the nets.

SPH: Were there any other health-related issues raised by the people in the villages?
Koka: Yes. Another interesting experience happens to be non-malaria related and occurred during a women focus group. The group was discussing human rights and the women all sought to have a 'mazungu right,' when prompted with the question as to which rights they truly wanted to possess. They defined this as the right to NOT have children and the right to birth control. The women in the community seem to want family planning opportunities, suggesting that they would be receptive to condoms. This could be extremely beneficial for family planning and HIV/AIDs prevention.

Indeed, here proved another moment when my public health background was particularly useful. One of the principles that was taught during our first year course work was community-based participatory research where the community helps to identify and set goals. This discussion helped to ascertain a goal that could help promote safe sex while giving the women the right to birth control. In the future, FIMRC can promote AIDS prevention by stressing the role of condoms as a contraceptive method. All in all, then, community and FIMRC can work toward achieving one goal.

SPH: What did you enjoy?
Koka: I enjoyed being able to learn about a new culture and a different way of life. I absolutely admire the ways in which these people forge forward despite their difficulties. Furthermore, the time I spent living with them educated me in all sorts of ways; not least by teaching me that it is quite possible to survive without the everyday comforts that we take for granted, like plumbing and electricity.

I enjoyed the whole experience as a whole because it taught me to appreciate how hard it is for people to overcome disparities. I enjoyed the simplicity of life and my tranquil surroundings despite the fact that we did not have access to many forms of entertainment.

Most of all I enjoyed the fact that most of the people in the villages who received the bed nets now understood a lot about malaria. It validated the fact that community education is effective and bolstered the involvement of women and men in the weekly focus groups.

SPH: Are there any other particular moments that stand out?
Koka: One day I accompanied Danae (a fellow SPH student) on a trip to the hospital to see if it would be possible to use their operating room space to do some minor operations for the kids in our village. They were willing to help, which we were incredibly thankful for, because they specialize in neurosurgery and do work with kids with hydrocephalic and spinabiphta. Indeed, this hospital treats the most hydrocephalus cases in the world and is at the center of research in this field. It was inspirational to see such great work being done in spite of so many obstacles.

Another added bonuse came when another volunteer organized a talent show for the street kids (the kids who did not go to school) in the village. This gave the children something constructive to do with their time. Although the prizes were simple things like shirts, about a hundred kids participated - and we were able to enjoy a day of seeing them dance and sing and showcasing various other talents.

SPH: Any negative memories?
Koka: Some of the things I saw while I was there were clearly disturbing. The Boshika market had a stall where a person had syringes and needles and gave patrons shots of various antibiotics and pain killers. This is an extremely dangerous practice since it is unclear if the syringes are new and most of the medicine was photosensitive. This proved an alarming and unanticipated discovery.

Another problem was the fact that many patients would come to the FIMRC clinic and claim to have malaria symptoms in order to get medications. The patients liked to horde the drugs and it was unclear if they liked to keep them or if they did in fact take the drugs. This type behavior could help promote antibiotic resistance. To overcome this behavior the clinic needs to collect enough funds to expand the clinic so that the staff can start to have diagnostic equipment.

SPH: Any unanticipated lessons?
Koka: What I disliked the most, however, was the disconnect between the Uganda site and the main Philadelphia headquarters. The people that ran the NGO have never been to the Uganda site and communication between the site and headquarters were minimal. I was surprised to find so many differences between what I was told and what was in fact true on the ground. This taught me the importance of having hands-on involvement when running a grassroots NGO.

SPH: What are your career goals?
Koka: Once I have completed my MPH, I plan on going to medical school and specialize in Infectious Disease. My ultimate goal is to be able to work in underserved areas around the world as an Infectious Disease physician. I am hopeful that, with this experience and a Public Health degree, I will one day use my skills to work on improving health care systems abroad.