by Alan Weisman
And that, Gladys had guessed, was the source of the trouble that had pulled her across the country from Uganda Wildlife Authority headquarters in Kampala, the capital, where she’d just begun as the UWA’s first full-time veterinarian. A distress call had come from the Bwindi park rangers: gorillas were losing their hair, leaving patches of scaly white bare skin, big enough to be noticed by tourists. The whole reason for the national park was that Europeans and Americans would pay $500 apiece for a chance to glimpse these creatures. The park’s boundaries had been gazetted, Batwa pygmies had been expelled, and teams of biologists had trudged through Bwindi’s dense lianas and hardwoods, counting gorillas by measuring the different sizes of dung left in their night nests. Then they’d focused on acclimating two of the thirty-eight separate gorilla bands to human presence, creeping a few meters nearer each visit, not retreating when the silverback charged, hoping he remembered that he was a vegetarian.
After two years, they could get within seven meters without the silverback threatening or the other gorillas fleeing, and they began to bring in tourists. As gorillas and humans share about 98 percent of their DNA, they kept people and these lucrative primates a full seven meters apart: a bad measles outbreak among mountain gorillas in Rwanda a few years before had probably come from humans. It had taken more than ten years after the ouster of macabre dictator Idi Amin, who exterminated hundreds of thousands of his citizens during the 1970s, to finally convince tourists to return to Uganda, and they couldn’t risk something else going amiss.
Before the ten-hour trip over unpaved roads to Bwindi, Gladys called a doctor in Kampala. “What’s the most common skin disease in people?”
“Scabies.”
Gladys had done her veterinary studies in London; her mother was a Uganda parliamentarian who entered politics after Gladys’s father, a government minister, was among the first that Idi Amin killed after his 1971 coup. In England, people hardly ever got scabies. But hygiene was wretched in rural Uganda, and from what the rangers described, the gorillas might well have human scabies.
Now she would see. The rangers were used to viewing gorillas, but not to taking skin scrapings and blood samples from them. A six-year-old with a half-bald back was in the worst shape, but if Gladys approached him, the silverback was sure to charge. The rangers would be no help, she saw, and the Kenyan vet looked terrified: Kenya might have lions, but not 500-pound gorillas. Sighing, Gladys stood, all of five foot four, faced the silverback, and started clapping and shouting. During Rwanda’s measles outbreak, she had seen vets do this with gorillas habituated to humans a lot longer than these. She hoped it would work. The massive creature moved a few meters away, clearly upset, but kept his distance as she advanced and fired her air gun into the juvenile’s thigh.
Ten minutes later, she had taken samples from the sorry creature, so afflicted that he kept scratching under anesthesia. As he began to stir, to the rangers’ amazement the young veterinarian lifted the fifty-pound youngster in her arms and carried him back to the silverback. A few days later, the scabies diagnosis was confirmed—a relief, because ringworm would have been much harder to treat. The following morning, Gladys returned to the forest with enough darts and ivermectin to cure the entire gorilla band with a single dose.
She had a hunch how they’d been infected. Once, the fields and land beneath local wattle-and-daub huts and tourist lodges were part of their range. Habituated gorillas, having lost their fear of humans, ignored park boundaries more than ever, especially since farmers were growing bananas, whose succulent stems and leaves they savored. One reason people here had big families, Gladys learned, was because they needed kids to shoo gorillas from their crops.
But children couldn’t throw rocks and bang on pots day and night, so they’d make scarecrows, dressed in discarded clothing. Every one Gladys tested was crawling with the same scabies species. More curious than frightened, apes were examining the clothes and picking up mites.
In her report, Gladys wrote that people needed to learn basic hygiene for their own good and for the sake of wildlife that brought income to their communities. That wouldn’t be easy: nobody had toilets or piped water, and most couldn’t afford soap. The Uganda Wildlife Authority and the International Gorilla Conservation Programme asked her to design an education program for the Bwindi region. With a conservation ranger, she arranged workshops in eight villages for more than a thousand people. She came armed with flip charts. “Gorillas can get our parasites, our measles, dysentery, pneumonia, and tuberculosis,” she explained. Uganda had one of the world’s highest rates of TB. A quarter of the chronic coughers in communities surrounding the park tested positive, as did 5 percent of Bwindi’s park staff.
She was about to flip to a list of solutions, such as using charcoal to wash when there was no soap, when the ranger touched her arm. “Let them suggest solutions,” he said.
A city girl who’d studied abroad, she’d assumed that uneducated people were ignorant. They actually knew their own situation best, once they understood the problem. Gladys listened. They wanted closer health services. They wanted safe water. They needed more and better pit latrines, and covered trash heaps.
They discussed what they could do themselves and what required government assistance. They needed help scaring the gorillas from their fields, so that they weren’t putting their children at risk. That eventually resulted in “HUGOs”—human-gorilla conflict resolution patrol teams, paid with gum boots and rain slickers from a gorilla conservation NGO, cornmeal rations from park headquarters, and the respect of the community: a commodity that Gladys learned was especially prized.
After two years as veterinarian to the Uganda Wildlife Service and two more getting a master’s in public health in the United States and marrying a Ugandan telecommunications specialist, Gladys made a decision. To really safeguard mountain gorillas, she needed her own NGO: There was another human health issue to confront for wildlife conservation to stand a chance, and no one in Uganda’s government was doing it.
ii. Alphabet Soup
July 2010: Dr. Amy Voedisch puts down her ring forceps and speculum, removes her exam gloves, thanks the nurses for a good day’s work, and walks out of the Bwindi Community Hospital’s maternity ward into afternoon sunlight. In the courtyard, women in flowered cottons sit in the shade of the plastered walls. Most walked for hours to stay at the hospital’s hostel for mothers waiting to give birth. Amy saw four of them today. For the Uganda shilling equivalent of US$1.50, a woman can buy a voucher to cover prenatal care, her stay in the hostel, delivery, and postnatal care. The vouchers are subsidized by Marie Stopes International, Britain’s analog of America’s International Planned Parenthood Federation,1 although the program is running out, and they have yet to find a new sponsor.
The Bwindi hospital literally began under a tree. When the park was founded, about a hundred Batwa pygmy families had been evicted and left to fend for themselves on the bare margins of an already marginal setting. Landless, considered subhuman by the Bantu, their hunting skills and their uncanny ability to smell honey now useless because they couldn’t forage in their former forest home, they were among the poorest of Africa’s poor. Most Batwa children died, and life expectancy was twenty-eight years. In 2003, an American missionary doctor named Scott Kellermann held an impromptu outdoor clinic for the Batwa. But as he learned, beyond some drugstores, the hundred thousand Bantu in villages ringing the national park had no more medical care than the dispossessed pygmies. He ended up starting a foundation to raise money for a hospital.
By the time Amy, an OB-GYN from California in her early thirties, arrived, Bwindi Community Hospital comprised four reinforced concrete buildings. They included a maternity ward recently expanded to forty beds through a Japanese Embassy donation. Even as it was inaugurated, however, the Kellermann Foundation was already seeking bunk beds to double those numbers. In a country with one of the world’s highest fertility rates, where many men have multiple wives—the 33 million Ugandans
will more than triple by 2050—Bwindi is on the high side of the national median, with families of eight children or more common.
A breeze rustles the flame trees as Amy follows a footpath from the hospital, past a billboard proclaiming that “Smaller Families Are Richer Families” and through a thicket where sunbirds dart at peach-colored hibiscus blossoms. It leads to a road filled with barefoot women clutching plastic jerry cans of water and balancing baskets of fruit on their heads. They are headed home from the dusty market at the center of Buhoma, the village at the entrance to Bwindi Impenetrable National Park, two kilometers from the Congo border. Amy’s destination, just across the road, is marked by a small white wooden sign protruding from the foliage. It reads, “CTPH—Conservation Through Public Health: Field Clinic for Mountain Gorillas and Other Species,” the NGO that Dr. Gladys Kalema-Zikusoka and her husband, Lawrence, founded.
A voice calls out. Amy doesn’t speak Rukiga, the local Bantu dialect, but she turns. A skinny woman who looks around sixty, walking with a stick between two banana-laden companions, is hobbling toward her, smiling toothlessly, arms widespread to embrace her. The day before, Amy delivered this woman’s tenth child, a daughter. Afterward, through a nurse-interpreter, Amy asked if she wanted any more.
The woman, who is actually thirty, had burst into tears. “Lord, no!” she whispered. She was HIV-positive, and already had suffered one stroke. “I’m too weak to go through this again.” Her husband, however, had other ideas. So Amy had explained that she could put something in her uterus that would keep her from conceiving for the next twelve years. “Right now, if you want.”
She wanted.
Her dark blond hair tied back in a ponytail, Amy stands before fourteen women and twelve men seated in wicker chairs under a thatched roof on CTPH’s patio. These are family-planning peer counselors recruited in surrounding villages, who are paid with soap and goats. Their job is to educate their neighbors about the availability and comparative advantages of condoms, daily birth control pills, Depo-Provera injections that last three months, and hormonal upper arm implants that last five years.
Gladys Kalema-Zikusoka and five of her staff are also present. There was no way, Gladys had concluded while getting her master’s, that she was going to save any gorillas if she didn’t deal with western Uganda’s double bind. Like so many of the world’s biological hot spots, for the same fertile reason that animals abound here, so do humans. Even with no city for hundreds of miles, nearly a third of Ugandans live in their country’s southwest quadrant around Bwindi, one of Africa’s most densely populated rural regions. More than half were under fifteen years old, and farms already had been subdivided so many times that most were now under a hectare.2 Eventually, Gladys knew, hungry people would convince park officials by bribes or threats to let them keep chipping at the boundaries.
To keep animals healthy, she had to keep people healthy. But the healthier people were, the more they survived, and the longer they lived. So many were already pressing up against the Bwindi forest that its gorilla habitat was imperiled, and with better health care, there would be even more. The logical thing was to limit the amount of healthy people, by providing them incentives, and the means, to limit themselves. Having earned the public’s trust in campaigns against scabies and tuberculosis, CTPH now added family planning. Managing the number of humans was the gorillas’ only chance.
A factor in Gladys’s favor was the importance of gorilla tourism to the area: 20 percent of park fees were shared with surrounding communities. Nobody wanted to jeopardize that. Everyone remembered the day in 1999 when a Hutu death squad that had fled into the Congo jungle after the Tutsis won in Rwanda crossed into Uganda, entered Bwindi Impenetrable National Park, and captured fourteen tourists and a park warden. Their targets were British and Americans, whose governments had supported their overthrow. The Hutus let German and French tourists go free, including a deputy French ambassador. The two Americans, four British, and two New Zealanders who got lumped in with the other English speakers they hacked to death with machetes. A warden who tried to stop them was bound and burned alive. It took three years for tourism to recover, while the entire region reeled.
“If we have too many babies and keep growing bigger,” Gladys explained, “people will cut more forest to grow more crops, we’ll lose the gorillas, and tourists will never come back.” Women needed little convincing. The local tradition of respect accruing from having many offspring was rooted only in men. Women simply accrued each other’s commiseration as their broods grew.
The concept of family planning doesn’t exist in Rukiga, so women soon learned to say it in English. But willingness to have fewer was useless without access to the means. One obstacle was Uganda’s president, Yoweri Museveni, a popular leader who had restored calm after years of bloody chaos under Idi Amin. Now in his second quarter-century in office, President Museveni believed that the surging economies of China and India were due in direct proportion to their vast populations—so the more Ugandans, he reasoned, the better off Uganda would be.
He saw the fact that the country’s population had doubled in just seventeen years as a window of opportunity to leap through: Population growth meant more people earning more money to buy more domestic goods, and paying more taxes to fund more education to teach even more people, and so forth. His government didn’t prohibit contraception: the health ministry even offered it. But its meager budget depended on foreign donations, and didn’t reach half the country’s fertile women. In 2008, only 6.4 percent of it was actually spent, much of it on handheld abacuses that the president’s wife advocated for calculating ovulation days. Known as Moon Beads, this variation on the rhythm method resembled prayer beads, and was about as effective in averting pregnancy.
“Yebare munonga,” says Amy, exhausting most of her Rukiga vocabulary as she thanks her audience of community-conservation health workers, as they call themselves. In English, she explains that she is a women’s doctor who came to share an important family-planning tool, one that lasts much longer than ones they already have. She pauses as one of Gladys’s colleagues translates. Like Amy, he wears a gray T-shirt with the CTPH logo: a mama and baby gorilla with a human couple.
Amy holds up a ParaGard T-380A, the American-made intrauterine device she has been inserting since her arrival earlier in the week. She passes the T-shaped IUD around. It is an inch long, made of milky polyethylene, with two nylon monofilaments dangling from the end. Fine copper coils circle the stem and the arms of the T, which are about 1/32 inch in breadth. Its cost here, courtesy of Population Services International, a U.S. NGO, is under a dollar.
The women heft it: it is practically weightless.
“How does it work?” one asks.
“The copper,” Amy explains, “releases ions that block sperm from reaching the egg.” A lengthy translation ensues.
“How long does it keep working?”
“Twelve years. You can put a new one in when the old one is removed.”
“What about side effects?” This was always the biggest concern. Many birth control myths, often traceable to men, circulated in Uganda, such as women on Depo-Provera retaining so much menstrual blood that their uteruses rot.
“An IUD has none of the side effects of hormonal methods, like headaches or weight gain or mood changes,” Amy replies. “In some women it does make menstruation heavier.”
Groans follow the translation. “But that usually normalizes after a few months. In my experience, very few women are unhappy with it. If heavy bleeding persists, it’s easily removed by these cords that hang into the vagina.”
“Can the man feel them?”
“The strings are clipped, and they curl up where he can’t reach them. They’re invisible.”
From a bag she produces an oversized leather model of a uterus, Caucasian-flesh pink. Everyone titters. Using an instrument resembling a small forceps with a loop at one end, Amy demonstrates how easily the IUD is inserted and removed.
&nb
sp; “It doesn’t move around inside you?”
Amy shakes her head. The advantage, she explains, is that this is a long-term method that’s completely reversible. No need for another Depo shot every three months, no trek to the clinic for a new implant. A young woman might insert one until she’s ready to have a baby. After giving birth, she can replace it, then remove it when she wants to have another. An older woman with enough children could put one in and leave it for the next dozen years, at which point she wouldn’t need contraception anymore.
“And,” Amy adds, “one of the easiest times to insert an IUD is in the forty-eight hours after giving birth, when you’re already in the hospital anyway.”
She pauses to let this sink in. “And the husband wouldn’t have to know?” asks a woman swaddled in orange.
“Not,” Amy replies, “unless his wife tells him.”
Everybody grins.
Several peer counselors here have been trained to give Depo injections in their villages. None is qualified to insert an intrauterine device, but they can refer women to the hospital, which will offer postpartum IUDs for free. They scoot their chairs into groups of three to role-play referrals. Amy gives each a scenario. In one, a twenty-seven-year-old woman with tuberculosis wants long-term birth control. The proper response is to counsel her to get an IUD, because there are no hormonal side effects to complicate her illness or conflict with other medications. A twenty-year-old woman, eight months pregnant, wants space between her first child and subsequent births—what kind of family planning should she use? In this case, all methods from condoms to chemicals to intrauterine devices should be explained, so she can decide which fits her circumstances best. But it’s a good idea to mention that, other than requiring a hospital visit to remove it, a postpartum IUD is the least worrisome. Once out, she can get pregnant the next time she ovulates.
