Shot@Life Uganda Trip Blog: "The 4 F's" for World Pneumonia Day

Four boys at Railway Primary School in Kampala, Uganda enact a dramatic 

dialogue about sanitation using very emphatic hand gestures

"My friends, do you know about the four F's?" That was the opening line of a performance by four boys at a Ugandan school in the midst of the slums of Kampala. These were among the first words I ever heard African children say. One of the young men you see in the picture had eagerly volunteered and suggested he wanted to preform their "dialogue" for their American visitors. The rest of the script went something like this:

"No, we don't know about the four F's."
"What do you MEAN you don't know? Don't you know they are the ways that you can get sick?"
"No, tell me what they are."
"They are Feces, Flies, Food, and Fingers"
...and so on.

Here is a video of group of kids doing a recitation of the Four F's. You can hear my uncertain, nervous laughter at the end of the skit when they ask how the Four F's affect their lives and a child collapses to the ground. We weren't sure if the skit was done or not. It was unlike any school performance we'd ever seen to have it end with a child falling down to indicate death. But, ultimately, I love it. This is the intersection of global health and global education. (Wait a few seconds for them to speak in unison and the sound will be clearer)

The Four F's are an easy way that children (and adults!) can remember the most common ways that diseases - like pneumonia - are transmitted. Food that is cooked on dirty cookstoves and cookpots, flies that bite many hosts, feces holding germs that cling to unwashed hands, and fingers that touch eyes and mouths and noses and friends...these can all be deadly in communities of extreme poverty. I heard this theme over and over again as we toured classrooms and heard songs about good sanitation practices.

The songs are very fun and cute - some might even think them quaint - but they aren't just schoolyard games. The Four F's are talked about by fancy grown ups like pathology experts at universities and global health organizations. This is serious stuff. I saw another skit with a girl in the role of a mother with a cook pot being admonished for not cleaning because unclean food can carry disease, make her children sick, and maybe even cause them to die. You see children coming to their mother hungry. As she prepares to cook from a dirty pot, three others appear to tell her that she has not cleaned it properly or washed her hands while the hungry children literally bend their ears to listen in.

Who else talks about sanitation and pneumonia? How about U.S. Secretary of State Hilary Clinton and internationally-known actress Julia Roberts (a.k.a the Global Ambassador for the Alliance for Clean Cookstoves) on Huffington Post? Ms. Roberts said on World Pneumonia Day 2011, "Of the 2 million people killed each year from diseases caused by toxic smoke from dirty stoves and open cooking fires, about half are young children who die from acute lower respiratory infections, most commonly pneumonia." One year later, this is still of critical importance as pneumonia is the top killer disease of children under 5 years of age in Uganda and in the world. 

If you're like me - loving numbers, but not loving to read long paragraphs full of numbers - this infographic on pneumonia is my World Pneumonia Day gift to you.

I found it posted on the ACTION blog...where not-so-coincidentally you can find an ACTION blog from me about vaccinations in Uganda reaching hard-to-reach kids and the need for the pneumococcal virus vaccine there. 

So, now, my friends, you know about the four F's, too! I leave you with the cast of the cookpot skit mugging for the camera as all good primary school thespians do.

This piece originally appeared in on www.action.org on November 9, 2012 in the lead up to World Pneumonia Day on November 12, 2012.

Vaccinating Hard-to-Reach Children in Uganda

Posted by Cindy Levin on Nov 09, 2012

Two weeks ago, I watched something remarkable: children receiving vaccines. This may seem ordinary, but I was attending a Family Health Day in rural Mubende, a district in central Uganda, where health services are hard to reach. Family Health Days are a targeted effort to bring life-saving immunizations to the country’s poorest and most remote children.

As a champion for the UN Foundation’s Shot@Life campaign, I traveled with UNICEF to strategic sites where their target population gathers regularly: mosques and churches. While there aren’t enough health clinics convenient for the rural population travelling on foot, many people can be reached by sending health providers to houses of worship where families attend together.

Uganda's vaccine campaigns are working wonders in the districts where they have been introduced. We found high awareness among mothers we interviewed. They were either eager to receive vaccines for their kids or happy their family was already immunized. In coming years, Family Health Days will be rolled out to all districts.

To put the need for these programs in context, this child mortality graph for Uganda from http://www.apromiserenewed.org/Dashboard.html shows a remarkably consistent downward trend for 20 years. However, Uganda will need to make considerable progress to reach the MDG4 goal (dotted line).

To continue improvement, Uganda must now focus on the hardest to reach kids and expand to include new types of vaccines. I saw infants receiving immunizations for polio and measles, diseases thankfully under control through the expansion of vaccination campaigns. Yet the children I played with were not protected with vaccines against the leading causes of pneumonia. This is troubling since pneumonia is the top killer disease of children under 5 years of age in Uganda and in the world.

Here is great news for World Pneumonia Day: Uganda has been approved by GAVI for pneumococcal vaccine roll out in 2013. If introduced, these immunizations will save 10,800 children’s lives and prevent 94,000 cases of pneumonia every year in Uganda.[1]

To read more about children unreached by immunizations and healthcare, read ACTION and Save the Children-UK’s report “Finding the Final Fifth: Inequalities in Immunization” and stay tuned for a follow-up report to be launched in December.

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[1] Tate, et al. Projected health benefits and costs of pneumococcal and rotavirus vaccination in Uganda. Vaccine. Volume 29, Issue 17, 12 April 2011, Pages 3329–3334.

Shot@Life Trip Blog: Uganda Innovations with Cell Phones

Many reading this blog know me as an anti-poverty advocate and a mom. Some, but not lots, know that my background is actually in engineering. Let's just say I have a fondness for data and for people who use data wisely. 

I was delighted to discover we were visiting a country where the UNICEF crew is on the forefront of poverty-fighting innovations. They were, with good reason, especially proud of the tech innovations they've started with cell phone technology. Not smart phones like most of us Shot@Life moms were carrying, but regular ol' cell phones with SMS text capability. Since many Ugandans carry this kind of low-tech phone, the opportunity to reach people all over the country instantaneously is unprecedented. There are two programs I want to tell you about: Mtrac and U-report. They make my geeky heart go pitter-pat!

U-report: Ureport is a free SMS-based system that allows Ugandans to speak out on what's happening in communities across the country, and work together with other community leaders for positive change. (You can look at it yourself by clicking here even though some of it isn't in English) Along with with the government, UNICEF is publicizing heavily to let Ugandans know anyone with a mobile phone can participate for free. Ureport sends weekly opinion polls, health alerts, and health notifications to help support programs already in place. Let's look at how this can work using the example of Family Health Days that we were there to observe.

The first round of Family Health Days took place this past July in particularly vulnerable districts, including Kabarole and Mubende, two of the districts we visited. Ureport was used to send texts to let people know the dates and locations to increase attendance. The districts later were polled by Ureport with a simple text question: "Did you or your family take part in Family Health Days? Please tell us why?" The information is summed up in this graphic pulled from their website:

Radio and newspapers publicize the results of polls on this and many other topics. U-reporters can send in their own comments, too, not related to the prescribed questions and members of Parliament receive monthly reports concerning issues raised by constituents.

There’s 154,434 members of Ureport right at this very moment, and hundreds more join each week. The average age of a Ureporter is 24, and over half are female. Poll response rates are steadily growing. As a volunteer with RESULTS, which is all about citizen empowerment in the U.S., this is truly exciting to see young Ugandans using their voices in their democracy.

MTrac: This is an SMS-based disease surveillance and medicine tracking system for all health facilities & 8,000 medicine-distributing village health workers. It provides Ugandans with timely and accurate data for response, while monitoring performance of health programs. It lets everyday citizens report things like drug outages. That may sound kind of dry and boring, but let's think about what that might mean for tuberculosis control. (Still too uninteresting? TB is the airborne disease that causes coughing up of blood and death if untreated. Got your attention now?) If you're living in a remote area of Uganda and can't get your allotment of meds, you can send a free text to the proper authorities saying "We have not received TB drugs here in a week and we need them for treatment" And then the bigger part of it is to have it acted upon. This would be critical interaction for the Ministry of Health to have with citizens because the treatment of simple TB costs only US$30. Without proper treatment, multi-drug resistant TB costs US$3000 and loss of life of many if not treated at all. For more info on Mtrac, see an article in Time magazine about it here. It also uses citizen feedback through U-report and an anonymous hotline to integrate strong governance and accountability. It has been rolled out in 28 out of 112 districts and will be scaling to national coverage in 2013. Whee!

There are a number of other cool programs like Mother Reminder (text reminders about prenatal visits and health tips), Edutrac (school monitoring to report violence in schools or teacher absenteeism), Birth Registration (what it sounds like), and many others. In fact, there is currently a moratorium on the starting up of new programs just because the government and UNICEF have a keen desire to make sure all these programs are integrated and work well together. But the initial successes and potential of these programs makes me happy that there are such strategic and forward-thinking people at the helm. Seeing the level of thought and excitement in the UNICEF offices make me very, very hopeful for the future of the country and for all of Africa.