Neglected Voices

**IMPORTANT: This article contains mentions of pain and death. If you feel uncomfortable with these topics, please refrain from reading.

A pregnant Batwa woman hiked along the mountainside to Bufundi Hospital, a small nurse-led clinic a few hours from her village. I learnt of this woman when I spoke to her family a few days after her journey -- when asked about the medical care she received they responded in their native language,

“She survived… but her unborn child perished on her long walk to the hospital.”

On July 9, I traveled roughly 3 hours from the town of Kabale in Southern Uganda to the mountainous Bufundi Region, approximately 2400 meters above sea level. (1) My primary goal was to learn more about the culture and health needs of the indigenous Batwa community.

Some background.

The Batwa community (often described as pygmies due to their short height) have inhabited the forested region of Bwindi Impenetrable Forest and Mgahinga National Park in modern Uganda, Rwanda, Burundi, and Congo for thousands of years. Untouched by the rest of society, they maintained a traditional lifestyle, building houses in trees, hunting animals using arrows, and developing medications from forest herbs. While they have generally lived in harmony with surrounding peoples, their relationship with national and regional governments over the past several decades has become strained. For a multitude of reasons including the conservation of endangered gorillas in the forests where they dwelled, the Batwa have been pushed out of their communities into government-built settlements in the surrounding valleys.

Since government health records have included the Batwa in official metrics, a stark disparity can be seen between the outcomes of the Batwa and the rest of the Ugandan population. While the rest of Uganda has an average life expectancy of about 53 years and child mortality of 13.7%, for the Batwa, average life expectancy is 28 years and child mortality is 41%. (2)

Below is the leader of the Batwa village whom I spoke to. He and the rest of the community allowed us to take their pictures.

What are some of the issues this community faces?

The first is medical. Because the Batwa lack access to cars and other forms of transportation, they must walk to Bufundi Hospital and other lower level centers nearby. In my previous article “Similar Systems Different Results,” I discuss the various levels of healthcare centers in Uganda. Bufundi Hospital (images of which were found via Google Maps) is a Level 3 Center. The center, at the time of my visit, was operated by limited staff and led by a single nurse; patients from nearby villages waited outside on benches and on the grass to receive care. 

The second is financial - in the past, the Batwa have relied on tourism as their primary source of income. However, with COVID-19 and reduced tourism over the past few years, members of the Batwa community are receiving even less income which could be used to pay for complex medical procedures or transportation. (3) Finally, the Batwa speak a few different languages distinct from the rest of the surrounding populations; this barrier prevents Batwa from interacting with other communities and medical professionals without a translator.

A young Batwa woman lay on the side of the road in distress. Upon asking what had happened to her, the other Batwa walking with us replied calmly, “She probably drank too much.”

The physician I traveled with performed a quick examination, finding that she showed signs of malaria. While relatively common in Uganda, malaria is even more dangerous amongst the Batwa community due to a lack of prophylactic treatments. Although we assisted the young woman to the nearest clinic, what resources would be available to her at the clinic? How long would she have to wait to receive care? 

But furthermore, how can we assist the Batwa so that they might diagnose disease within their communities? 

In the future, I hope to discuss the Batwa in greater detail, focusing on how healthcare can be allocated between communities, even those that are geographically and socially isolated. However, progress is being made as we speak. 

The Ugandan Department of Health has offices in each district coordinating healthcare strategy with the national government and local clinics. A Department of Health office I visited near Bufundi Hospital is shown below.

Bufundi Hospital, at the time of my departure, was designated to become a Level 4 Health Center due to increased population in the area. This would mean the presence of at least one physician in the clinic and hopefully increased access to care for the Batwa. Additionally, local clinics have begun educating Batwa members about healthcare issues and resources hoping that they will in turn educate their communities; these clinics also send volunteer community health workers to provide health information and hygiene resources (for example, sanitation products) to individual communities. Unfortunately, providing high quality medical care to the Batwa community involves surmounting unique logistical and ethnic barriers; by integrating traditional healthcare with culturally-informed education and by reducing social determinants of health, Ugandan public health practitioners and medical providers might reduce existing healthcare disparities between the Batwa and the rest of the Ugandan population.