[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.]

                          ____________________