[Congressional Record Volume 143, Number 48 (Tuesday, April 22, 1997)]
[Senate]
[Pages S3460-S3462]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]
HEALTH VOLUNTEERS OVERSEAS--UGANDA WAR VICTIMS PROJECT
Mr. LEAHY. Mr. President, we hear people complain about how
foreign aid is a waste of money, and there are certainly examples of
it. The United States poured countless millions of dollars into the
pockets of President Mobutu, and one need only observe the chaos and
suffering in Zaire today to understand what a terrible mistake that
was. Many of us said so at the time, but we were ignored. During that
same period, the United States propped up General Noriega in Panama,
until he was no longer useful to us.
But you do not hear very much about the good uses of foreign aid, and
how it makes a difference between life and death, or hope and misery,
for millions of people around the world. In fact, there are far more
examples of those good uses, than of the scandals that attract the
attention of the media.
One example is the War Victims Fund project in Uganda. This project
began in 1989, and it is now coming to an end. I think Members of
Congress and the public should know about it, because it is a
remarkable example of what the U.S. Government, a private voluntary
organization, the good will and hard work of American volunteers, and
the support of the Government of Uganda, have done for the benefit of
thousands of wounded and severely disabled people in that country.
Uganda, a once productive country that boasted the finest medical
school in sub-Saharan Africa, was virtually destroyed by the disastrous
Idi Amin and Obote regimes. The medical school was destroyed, its
faculty members killed or run out of the country. Years of civil war
left thousands of casualties, including many victims of landmines.
In 1989, the year the Leahy War Victims Fund was established, USAID
began a project in Uganda. It was implemented by Health Volunteers
Overseas, a Washington, DC-based organization that sends volunteer
doctors, nurses, and other medical professionals to train people in
poor countries.
Health Volunteers Overseas did an extraordinary job in Uganda during
the 7-year life of this project. There were tremendous achievements,
and one terrible tragedy when Dr. Rodney Belcher, the Virginia
orthopedic surgeon without whom the project would not have accomplished
nearly so much, was gunned down in a robbery. His loss was felt
throughout Uganda, because so many people knew of his selflessness, and
that he had literally given his life for them and future generations in
that country. His legacy is the scores of Ugandan health professionals
he trained who are carrying on his work today.
Mr. President, HVO's final report on the Uganda project should be
read by all. Its staff and volunteers deserve our sincere thanks, and
our continued support. USAID, and President Museveni and his Health
Ministry, also deserve credit. I ask that excerpts of the report be
printed in the Record.
The excerpts of the report follow:
Excerpts of Final Report--Uganda Orthopaedics and Physical Therapy for
the Disabled Project
introduction
In August of 1989, Health Volunteers Overseas (HVO) entered
into a three year grant agreement with the U.S. Agency for
International Development (USAID) Mission in
[[Page S3461]]
Uganda to ``improve the provision of orthopaedic, prosthetic,
orthotic and physical therapy services for Uganda's thousands
of children and adults who have lost upper and lower limbs,
been crippled through the paralytic residual of poliomyelitis
or otherwise become immobilized, especially those persons
whose disabilities resulted from civil strife''.
This grant concluded on December 31, 1996.
* * * * *
accomplishments
Facilities
HVO renovated and furnished the Polio Clinic at Old Mulago
Hospital to serve as the site for the Department of
Orthopaedics. The renovated building included space for
departmental offices, weekly clinics, library, storage,
seminar/classroom, and the HVO offices.
HVO renovated and equipped the operating room suite at Ward
7 at Old Mulago, creating two ``clean'' theaters for non-
septic cases. These rooms were opened in March of 1991 and
according to a report dated January 31, 1995, ``the well
trained nursing and theater staff [are] working smoothly to
assist the surgical teams in performing an average of 20
surgical operations weekly for conditions including polio,
trauma, fractures, spinal and hip injuries, tuberculosis,
cerebral palsy, bone tumors, club feet and a variety of
severe and late burns of hands and limbs''.
HVO rebuilt and equipped the Mbale Workshop which had been
destroyed in a fire in March of 1990.
HVO renovated and furnished a guest house on the hospital
grounds to serve as housing for volunteers.
HVO built a new, larger sterile store room adjacent to the
OR suite in the fall of 1996. This was funded by a private
donation to HVO, not with grant monies.
Training and Education
HVO established a M.Med. (Orthopaedics) postgraduate degree
at Makerere University and Mulago Hospital. The goal of this
program is to train a corps of Ugandan orthopaedic surgeons
who will be qualified to continue the teaching program in
orthopaedic surgery and trauma management after the end of
this grant. The curriculum for this four year degree was
approved by the University Senate and accepted by the School
of Postgraduate Studies in 1995. The authors of the
curriculum included Drs. Belcher and Lawrence Gordon. In the
fall of 1995, three young Ugandan physicians were formally
enrolled in the program as the first residents.
Over the life of this grant, various cadres of personnel
were taught the principles of orthopaedic surgery and trauma
management. According to a summary provided by Dr. Belcher
in 1995, over 450 medical students, 45 physicians and
surgeons, 36 orthopaedic assistant paramedical officers,
16 physical therapists and 40 nurses had been exposed to
training and education related to orthopaedic surgery.
Considerable effort was also devoted to training the OR
personnel and surgical nursing staff in operating theater
sterile techniques and surgical procedures. When the
operating theaters at Ward 6 were nearing completion, HVO
sent an experienced OR nurse, Theresa McInerney, to Kampala
for a 6 month tour. Her job was to get the newly renovated OR
suite functioning. This included organizing donations
received from the United States, determining what additional
items needed to be procured from the United States or could
be made locally, and developing procedures to ensure that
sterile technique was maintained. She also initiated a series
of classes for the OR personnel in OR technique with a
special emphasis on asepsis and the importance of
productivity.
This training continued under the direction of another OR
nurse, Wilma Ostrander, who served several tours in Uganda.
She focused her efforts on improving the efficiency and
effectiveness of the OR nursing and paramedical staff through
a series of lectures and demonstrations. She also
participated in the development of infection control programs
designed to improve the safety of the environment in the
operating rooms resulting in lower post-operative infections
and complications.
On return visits, she also assisted the department in the
development of a computerized inventory system to track the
utilization of supplies and equipment. This has facilitated
the development of a departmental system to reorder supplies
as needed, a critical function for the department. As part of
this process, she has introduced the utilization of patient
records and patient supply lists so that there is a record
available tracing the items used and to facilitate stock
orders.
As the OR became functional, it also became clear that
there was not an adequate number of trained technicians at
the hospital who could handle the maintenance and servicing
of the medical equipment needed for surgery. This was
particularly evident in the lengthy process required for the
commissioning of the autoclave purchased for the Ward 7 OR
suite. Once commissioned, Dr. Belcher learned that there was
no one on the staff of the hospital who could maintain this
autoclave, despite the fact that it was similar to others at
New Mulago Hospital.
As a result, HVO entered into a collaborative relationship
with the American Medical Resources Foundation (AMRF), a
Boston-based NGO, to design and deliver a series of workshops
to teach Ugandan technicians at both Old and New Mulago
Hospitals how to repair, maintain and service medical
equipment. A total of three workshops were held in 1996
focusing on the repair of cardiology, radiology, anesthesia,
respiratory and OR equipment. The first workshop was attended
by 30 hospital engineers and technicians from Mulago, Mengo,
Rubago and Nsambya Hospitals. Although there was significant
interest in the other two workshops, HVO and AMRF decided to
limit the number of participants to 15 in order to ensure
adequate time for hands-on work in diagnosing and repairing
equipment.
HVO also sent a resident to Hong Kong for 2.5 months of
post-graduate training at the University of Hong Kong under
the direction of Professor John C.Y. Leong. This training not
only served as an opportunity to see how services are
delivered in another country, but also fostered the
development of professional contacts outside of Uganda.
Extension of Services
The scope of this project was national. HVO, under the
direction of Dr. Belcher, focused considerable effort on
expanding the delivery of services to hospitals outside
Kampala and developing an effective orthopaedic referral
system for the up-country regions of Uganda.
For the first three years of the project, regular visits to
various up-country facilities were undertaken by members of
the Department of Orthopaedics, usually accompanied by a
volunteer. Patients would be examined and the difficult cases
referred to Mulago for surgery. Others would be measured and
fitted with calipers or, if feasible, taken into surgery.
These visits ceased when travel funds for department
personnel were no longer forthcoming from the Ministry of
Health. However, Dr. Belcher planned an ambitious program of
up-country visits starting again in 1996.
* * * * *
The goal of these trips outside of Kampala was to increase
the visibility of the services available for the disabled, to
identify patients in need of services and to successfully
enroll them in treatment programs.
With the end of the grant, this aspect of the project is
perhaps the least likely to continue, although the need for
this type of outreach is critical. Funds are needed for
transportation, as well as food and housing for the team
members. It is unlikely that the Ministry of Health will be
able to fund as many trips as originally planned on an annual
basis.
Other Accomplishments
HVO was able, with funds from the grant, to identify and
procure essential educational materials, including books,
journals, slide sets, and videos. HVO also purchased items
necessary for the viewing and development of educational
materials. For example, HVO procured overhead and slide
projectors, a television and video machine, computers with
CD-ROM capabilities, and a photocopier. Access to this
equipment is essential as members of the department or
volunteers seek to organize lectures and teaching materials
for students.
More than 5,000 books and journals were shipped to Uganda
under the auspices of this grant. Most of these were donated
by members of HVO. HVO, based on input and recommendations of
the senior members of the Department of Orthopaedics, also
procured a set of current reference texts in medicine,
rehabilitation, and orthopaedics for the departmental
library. This order filled many gaps that existed in the
library and will serve the educational needs of the
department for many years to come.
One of HVO's educational objectives at the Medical School
and Mulago Hospital was to develop better interaction and
communication between the various departments involved in
patient services and teaching. This was accomplished through
the development of a weekly joint conference with the
Radiology Department where orthopaedic surgeons and
radiologists reviewed patient x-rays and learn from one
another. Similar conferences were established with a joint
pathology, radiology, orthopaedic, and oncology conference
held monthly. Other joint conferences were established with
the Neurosurgical and Pediatric Departments.
In addition, HVO, with the assistance of Dr. Belcher, was
able to develop links with other departments. HVO initiated
volunteer-staffed teaching programs with the departments of
anesthesia, medicine and pediatrics. Strengthening the
capacity of these departments to treat patients and to teach
future generations of Ugandan medical providers is critical
to the overall improvement of health care in Uganda.
When it became evident that HVO volunteers would not be
able to have an active role assisting AVSI in the School for
Physical Therapists, HVO recruited several PT volunteers to
work primarily with the Departments of Physical Therapy.
Donna Tinsley, a PT who spent 6 months in Kampala with the
project, taught PT students during bedside ward rounds on
Ward 7 as well as in the amputee, cerebral palsy and polio
clinics.
problems encountered
Some of the problems encountered in the course of
implementing this project are inherent in the way
international assistance is designed. The original grant was
for a period of three years, an extremely short period of
time in which to ``improve the provision of orthopaedic,
prosthetic, orthotic and physical therapy services . . .''
for a country such as Uganda. Extensions were forthcoming but
only for 12 to 18 months at a time. This
[[Page S3462]]
short-term focus prevented HVO from developing longer range
plans that might have been more effective.
The logistical problems involved in renovating and
equipping the departmental offices and OR suites on Ward 7
were, at times, monumental. Dealing with local contractors
was very difficult. Materials were often delayed or ``went
missing''. Workers might not show up on time or even at all.
These problems contributed to a substantial delay in the
project which was compensated for by a one-year extension.
Communications between the field office and HVO's
Washington office were hampered by frequent power outages and
missing faxes. This situation, however, improved over the
life of the project, especially with the introduction of e-
mail.
As was mentioned above, there were recurring problems with
the maintenance of equipment, including, but not limited to,
medical equipment. Due to power surges, office equipment
frequently was damaged, often beyond repair. The problems
associated with the commissioning of the autoclave might well
serve as a case study in the difficulties in merging a highly
sophisticated piece of equipment into a facility which cannot
provide adequate supplies of water and electricity. Despite
considerable research and investigation as to which autoclave
would be best suited to the department's needs and
building's capacity, this autoclave was inoperable for
several years. When finally commissioned, its maintenance
was a recurring problem.
project sustainability
The death on March 11, 1996, of Dr. Rodney Belcher was a
tremendous loss for all involved in this project. Dr. Belcher
was murdered in front of the HVO office on the hospital
grounds in the course of a carjacking attempt that was
ultimately unsuccessful.
* * * * *
Given the unexpected and tragic turn of events in 1996,
what are the chances that activities undertaken to date will
continue and that the impact of these many years of hard work
will be sustained over time?
On a positive note, the senior members of the department
immediately took charge upon Dr. Belcher's death and
appropriately divided the departmental workload. The
department has continued to function with weekly clinics,
twice weekly operating schedules, ward rounds, seminars, etc.
Through the end of 1996, thanks to funding available from
HVO, up-country outreach clinics were conducted. Dr. Naddumba
has been elected Head of the Department and has earned high
marks for his administrative and political skills.
Health Volunteers Overseas will continue to send volunteers
to share their technical expertise with members of the
Department of Orthopaedics. HVO will also send volunteers to
work with faculty and students in the Departments of
Medicine, Pediatrics, and Anesthesia.
In addition, Dr. Norgrove Penny, a Canadian orthopaedic
surgeon and member of Orthopaedics Overseas, accepted a four
year contract in Kampala with the Christoffel Blindenmission
(CBM) beginning in August of 1996. He is working in
conjunction with the Uganda Society for Disabled Children and
the Leonard Cheshire Homes of Uganda, both British based
charities working in community based projects. His job
includes developing services to up-country district hospitals
who at present have no orthopaedic services.
There have been discussions between members of the
Department of Orthopaedics at Mulago Hospital and Dr. Penny
regarding the possibility of working together. There
certainly appears to be an overlap of mutual interests and
HVO/Washington has strongly supported this possibility.
However, * * * without a certain level of ongoing financial
support there will be some serious problems ahead for the
department and for the delivery of orthopaedic and
rehabilitation services to the population at large in Uganda.
* * * * *
summary
This project began in the fall of 1989 in the midst of
great anticipation and hope. Uganda was recovering from a
long period of intense civil strife marked by intense
fighting, brutality and bloodshed. HVO had an opportunity to
participate in a program that would help rehabilitate the
lives of thousands touched in one way or another by the
breakdown of society during this period.
Now, seven years later, we can say that this project has
done much to ``improve the provision of orthopaedic,
prosthetic, orthotic and physical therapy services for
Uganda's thousands of children and adults who have lost upper
and lower limbs, been crippled through the paralytic residual
of poliomyelitis or otherwise become immobilized, especially
those persons whose disabilities resulted from civil
strife''.
The death of Dr. Rodney Belcher was a devastating even. His
death, however, serves as a beacon for members of the
department and HVO who are determined not to allow this event
to diminish the accomplishments of his many years of
dedication and hard work.
[At the request of Mr. Reid, the following statement was ordered to
be printed in the Record.]
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