A Call for Sex Education in Uganda

Originally published April 1, 2019. Received 2nd Place in the Women’s Issues Essay Contest hosted by the National Society of the Daughters of the American Revolution.

This past fall I was given the unique opportunity by a client to accompany her to Uganda as she works to treat women in Africa, affected by pre-cancerous cervical cells. What I discovered is the important of women’s healthcare education to both men and women, and the domino effect when both sexes are not equally taught the basics of sex education.

The official purpose of my trip was simply to photograph and document the interactions of my client’s non-profit, as she trained with doctors and nurses in Uganda on various cervical cancer prevention tools, and to photograph scenes of her and the staff interacting with the Ugandan patients.

I spent a few days in Kampala attending meetings with various NGO’s, healthcare colleagues, and contacts in Uganda—all striving to improve healthcare and accessibility for the country’s rural communities.

I accompanied my client as she spoke to groups about the importance of pap smears, screening and vaccinations for HPV—the most common cause of cervical cancer—and the importance of using protection to prevent HPV and sexually transmitted diseases. I had the privilege of twice meeting with the Minister of Trade, Industry and Cooperatives—Amelia Kyambadde—a woman dedicated to improving healthcare for women in her country and one of the few women serving in Parliament.

After Kampala, I drove southwest to Mbarara, which lies 90 miles east of the border from the Democratic Republic of the Congo. I spent the week at the Mbarara University Hospital as my client trained on two cervical cancer treatment methods—the Thermocoagulator and Cryotherapy—collaborating and learning from the nurses and midwives leading the Cervical Cancer Screening Clinic.

I arrived the first day at the clinic at 8 am to find a room full of women in colorful layered fabric dresses, patiently waiting for the nurses to arrive and the clinic to open. Appointments were given on a first-come, first-serve basis. There were no pre-scheduled appointments for convenience, or reception desks to greet patients.

When nurses arrived each morning, sometimes as late at 11 am, one would step into the waiting room to explain to the patients what to expect in her appointment. My presence at that time was glaring as both an American and the only Caucasian in the clinic. Despite the nurses never explaining my official appearance in the clinic, the women were kind and cooperative during my visit.

At times I pretended to wander aimlessly around the waiting room, looking out windows so the women lined up on wooden benches in the cold, broken tiled waiting room could familiarize themselves with me and the large camera I held. On one occasion, an older lady staggered up to me, pulled out a flip phone and took a picture of my face. Her curiosity and innocence erupted into laughter among us all.

Each morning the women sat calm and composed, almost like statues, rarely venturing away for the restroom or food. One by one, they were called back to one of two exam rooms. Each brought with them a black trash bag, serving as her personal liner on the exam table, and a faded-light blue book used to record her medical history. Everything is recorded with paper and pencil. Everyday clinic necessities are sparse with each nurse serving as a sort of medical engineer, improvising as she can. Lubricant is non-existent, and on one occasion I watched as a nurse rolled a condom onto a speculum to grease the device, for ease of entry for one particular patient.

Privacy is something left to be desired. In the middle of one exam, a nurse brought back a second patient—a young woman of about 25 years old who had found a lump in her breast. A sheer, hunter green curtain barely divided the patient on the exam table from the young woman undergoing the breast exam.

And yet, a third patient wandered back with a midwife and sat at a table, next to where the young woman stood topless as her nurse massaged and examined her right breast. All the while, the first woman continued to lay on the exam table, knees in the air with her feet wedged under her bottom—she would need Cryotherapy to remove some pre-cancerous cervical cancer cells.

At first I decided the women I photographed were easygoing enough not to be disturbed by my presence, or having to share an exam room with multiple other patients and strangers. In the states, I couldn’t help but imagine the dozens of tantrums that might have erupted. The truth I discovered, is that there are no expectations as there are very few resources—which I found evident in the improvisations made by the nurses, midwives and hospital staff.

Though I had official clearance from the hospital to be on the grounds and for me to photograph the campus and patients, access to most buildings would have been attainable regardless. Families of patients sat lined up on the grounds, often washing clothes together as many families traveled over a week to seek treatment at the hospital—whether it be for an illness, birth or fractured leg.

In Uganda, medical treatment is elective—at least when it comes to women's health. No one is required to have a pap smear or HPV vaccine. The women visiting the Cervical Cancer Screening Clinic do so because of a reason—they are experiencing pain.

One midwife in particular explained in detail, that most of the women are in pain or experiencing an issue that requires treatment—usually due to aggressive intercourse, she explained—common among the polygamous, male-dominated culture most of the rural women occupy—or because she has cervical cancer or similar symptoms.

Empowering women in Uganda to make healthcare a priority requires a cultural shift.

During one Cryotheraphy treatment a slender, younger patient laid still, unflinching, as the nurses held the cold probe up to her cervix while freezing off pre-cancerous cells. My client was amazed and pointed out how awesome it was that the woman was so stoic, laying there without complaint.

I pointed out she was a “mosquito girl” (aka a prostitute as they are called in many African countries, particularly Uganda)—that her expression was not stoic, but rather one of distance. The look of someone who is used to pain—pain that comes when your body no longer belongs to you. She wasn’t stoic, but rather emotionless. This was confirmed by the hospital nurses.

Ms. Amelia Kyambadde, the Ugandan Minister of Trade, once asked me if the United States has the same issues with screening and protection use. She explained that Ugandans are aware of AIDS and HIV and use protection predominately only for that purpose, and nothing more. Few know of HPV and even fewer know of the HPV vaccine she explained—or have access to it.

If the mosquito girl, I explained to the Minister, had the resources to avoid infection (i.e. sanitary pads, aspirin, etc.), but also allow her body to heal before resuming work—she would recover. More likely than not—as the Cervical Cancer Screening Clinic’s primary midwife confirmed—she would be back at work a week later, with a body left unhealed and exposed to other diseases and infection.

During my visit, my client and I visited a variety of non-profit organizations and community groups. We met with children from the Winterland Primary School where my client spoke about the importance of hope—having hope beyond the circumstances in which you are born. Later, the male classmates were dismissed while we engaged in a more intimate conversation with the female students, explaining the importance of proper feminine hygiene, the importance of staying in school, and the need to rely on reusable feminine products (donated to us by several US-based non-profits) to ensure monthly mensuration does not deter the young children from continuing their education—a common side-effect for those in countries with little access to the primary needs of mensuration, which often causes young girls to drop out of school and pursue prostitution due to the inability to complete their basic education requirements.

We met with a church group to speak on HPV and the importance of preventive care and the use of condoms. It was in this particular meeting that I realized the true value of health education for all, for the questions asked by the male participants—while enthusiastically shared—also reflected a lack of awareness on the basics of sexually transmitted diseases, the importance of condoms, and even the general healthcare needs of both sexes. For instance, one eager young gentleman asked questions related to why condoms are important if you have more than one sexual partner, how doctors test for HPV, why the testing of HPV cannot be done as a blood test or simply through his partner, and how HPV is transmitted.

During one of my several meeting with the Minister, I raised the issue of condom usage. In rural areas she explained, the men are rarely polygamous. For those who are single she continued, and frequent the mosquito girls, if they are not HIV positive there is often little reason to use protection. I brought to her attention the discussions we had with the several co-ed groups during our lectures with my client—that surprisingly, both men and women are equally unaware of the importune of protection, but also the cycle it creates in the country.

I explained to the Minister, that across all nations we have to empower women to take back our health as part of taking back our bodies. At times and depending on the country and its culture, the shift needs to be one of reverse psychology. To empower women, a society must empower men to care—to learn and to feel compelled to stay educated on both their own health and also the health of women.

My time in Uganda opened my eyes to the importance of education, because it is the foundation for health. All sexually active adults should know the risks of intercourse, including that HPV can lead to cervical cancer for both men and women, those who are HIV positive are more at risk for HPV and cervical cancer, and that all of these problems begin with unprotected sex. When men and women know how their health is affected by unprotected sex, they feel personally compelled to practice safe sex—and more importantly, to support one another in prioritizing health.