GULU UNIVERSITY MEDICAL JOURNAL

Gulu University Medical Students’ Association Passion for life 

Gulu University Medical Students’ Association Passion for life 

www.gumsa.ac.ug 

www.gumsa.ac.ugGulu 

University Medical Students’ Association 

Passion for life 

Passion for life 54 

GULU UNIVERSITY 

GULU UNIVERSITY 

MEDICAL JOURNAL 

Vol 5 2009/2010 

MEDICAL JOURNAL 

Vol 5 2009/2010 

Vol 5 2009/2010 

- Malnutrition 

Malnutrition 

and 

and 

Child 

Child 

Morbidity 

Morbidity & 

Mortality 

Mortality 

- Nutricam: 

Nutricam: 

The 

The 

food 

food 

that 

that 

saves 

saves 

- A social social Medicine Approach to Malnutrition 

- Potential Factors in Neurocognitive Developement in the unborn & young infants 

in Northern Uganda 

- Effects of IDP Resettlement Programm on the Management of HIV/AIDS in in Gulu 

District, Northern Uganda 

Theme: "Promoting Maternal and Child Health: 

Prevention of Maternal and Child Morbidity and 

Mortality in Uganda" 

Review Articles 

Malnutrition and Child Morbidity & Mortality 

A Social Medicine Approach To Malnutrition 

Potential Factors in Neurocognitive Development in the Unborn and Young 

Infants in Northern Uganda 

Original Articles 

Nutricam: the food that saves! 

Effects of IDP Resettlement Programme on the Management of HIV/AIDS in 

Gulu District, Northern Uganda 

Abstracts 

Helminth Infection in Gulu Municipality 

Annual 

Annual Annual 

publication 

publication of Gulu 

of University 

Gulu University Medical Students’ 

Medical 

Association 

Students’ 

(GUMSA), 

Association Association 

www.gumsa.ac.ug 

(GUMSA) (GUMSA)

GULU UNIVERSITY MEDICAL 

JOURNAL (GUMJ) 

Vol 5 2009/2010 

Theme: “Promoting Maternal and Child Health: Prevention of Maternal and Child 

Morbidity and Mortality in Uganda.” 

Disclaimer: The author’s views expressed in this publication do not necessarily reflect the views 

of the United States Agency for International Development or the United States Government or 

those of the Italian Cooperation.

Gulu University Medical Journal (GUMJ) 2009/2010 Vol 5. 

CONTENTS 

Editor’s word 

President’s word 

Malnutrition and Child morbdity and mortality 

Malnutrition a main cause of children’s death! 

Nutricam; the food that saves! 

A social medicine approach to malnutriton 

Social Medicine 2010: Studying the 

social determinants of health 

Effects of IDP resettlement programme on 

the management of HIV/AIDS In Gulu 

district, Northern Uganda 

PMTCT of HIV: A review of service delivery 

and challenges 

Potential factors in Neurocognitive development 

in the unborn and young infants in Uganda 

HIV/AIDS stigmatization amongst the youth 

in Gulu, Northern Uganda 

Dealing with traditional fracture splint 

Abstract 

Patience always pays: What a climax it was 

Pictorial 

It wasnt my Choice 

Hope: Man’s best strength 

GUMJ Quiz 

GUMJ Puzzle 

Guidelines 

Quiz Answers 

Puzzle Answers 

EDITORIAL BOARD: 

Editor In Chief 

Kigonya Victor 

Deputy Editor in Chief 

Nsubuga Mushin 

Secretary to the Board 

Owomugisha Gloria 

Treasurer 

Aol Pamella 

Marketing 

Buhingiro Treasure 

Production 

Kidega Robert 

Year 1 Representative 

Priscilla 

EDITORIAL CONSULTANTS: 

Dr Mshilla Maghanga Department of Pharmacology 

Associate Prof. Odongo Aginya Department of Microbiology 

Dr Kaducu Felix Department of Public Health 

Dr Oyat Freddie Department of Public Health 

Gulu University Medical Students’ Association (GUMSA) Passion for life 

7 

9 

12 

14 

18 

26 

27 

30 

36 

41 

43 

48 

50 

52 

54 

56 

58 

59 

61 

62 

64 

66 

GUMSA EXECUTIVES 2009/2010 

H.E Ssebwami Leonald President 

Hon. Opiro Keneth General sec./Vice President 

Hon. Opira Patrick Organizing Secretary 

Hon. Kasekende Ronald Sec. Justice and Constitution 

Hon. Ajambo Miriam Academic Secretary 

Hon. Sekyanzi Simon Sec. For welfare 

Hon. Oryokot Boniface Sec. for International Affairs 

Hon. Herbert Butana Class President Year V 

Hon. Clara Odhiambo Deputy Class President year V 

Hon. Ociti Moris Class President Year IV 

Hon. Mbaako Beatrice Deputy Class President year IV 

Hon. Alinaitwe Moses Class President Year III 

Hon. Alobo Jackie Deputy Class President year III 

Hon. Zzimbe Richard Class President Year II 

Hon. Wachira Grace Deputy Class President year II 

Hon. Mahulo Nelson Class President Year I 

Hon. Abanaitwe Saviour Deputy Class President Year I


Gulu University Medical Students’ Association (GUMSA) Passion for life 5


Dear readers, I am glad that yet 

another edition of the GUMJ 

is before you. I once overheard 

a conversation guided by a 

medical professional who 

said “if a health unit has no 

maternity and children’s 

wards, not much is being 

done for the community.” 

The significance of such a 

statement could not obviously 

be estimated but rather, the imprint it made in my 

mind was hard to ignore. It is evident that women 

and children make up the most vulnerable groups 

in our communities considering that in Uganda, 

the maternal mortality rate stands at 435/100,000 

while 6,000 women die every year due to pregnancy 

related problems or child birth. No doubt most health 

facilities in the developing world offer free obstetric 

services. To alleviate the evil, numerous strategies have 

been undertaken locally, nationally and internationally. 

The most significant of all is the fact that the world’s 

top unity body United Nations (UN) in collaboration 

with relevant stakeholders came up with the eight 

Millennium Development Goals (MDGS) whose 

target year is 2015. Of these, MDGs 4 and 5 aim 

at reducing infant mortality by 50% and improving 

maternal health respectively. Under the same umbrella 

is United Nations International Children’s Emergency 

Fund (UNICEF) a branch concerned specifically with 

health, social and emotional wellbeing of children and 

women. To supplement the international efforts, as the 

saying goes “charity begins at home” national health in 

many countries has been tailored to prioritize women 

and children health issues. In Uganda, the annual 

health budget addresses this. 

Many health issues pose a threat to the lives of 

women and children. For example, high prevalence 

of diarrhoeal diseases, strong rooted cultural beliefs, 

pregnancy related complications and marginalization 

of women and children. No doubt maternal and child 

health, family planning and immunization against 

infectious diseases are elements of Primary Health 

Care in many developing countries. However, with for 

example about 0.5 million women dying of pregnancy 

related complications each year with a 300% chance of 

Editor’s Word 

being African women according to the 2010 UNICEF 

report, the gap between the ideal and actual situation 

remains big. Though still, an issue with such attention 

and yet has no significant achievements to write home 

about leaves one pondering. A number of challenges 

have cut out the intended targets of making lives of 

the homemakers of this nation and their little ones 

safer and better. I cited a few like insufficient awareness 

about basic health practices, corruption, cultural beliefs 

including gender discrimination and poverty above 

all which puts the country in a vulnerable position of 

donor dependence. 

This edition of the GUMJ has come in handy because 

it is evident that a lot of attention has been put on 

maternal and child health on the African continent in 

the year 2010. 

This year has embraced instances of projected hope, 

interest and concern from various health stake holders 

all over the world. Emphasis has been clearly put on 

the delicate subject. For instance, on 28th June, 2010 

the Group of 8(G8) summit held in Toronto, Canada 

came to a close, leaving behind a cocktail of feelings 

with some outstanding aspects. In this summit, the 

traditional health issues on the African continent had 

maintained their stance with the big guns turning 

their pledging nozzles towards maternal and child 

health in Africa with a goal of reducing the suffering 

among women and their children in developing 

countries. However, of interest as skeptics noticed was 

failure of G8 nations to fulfill their US$50b promise 

by 2010 having run short of this pledge byUS$18b! 

In Africa and in Uganda in particular, the first ever 

African Youth Forum (AYF) in Entebbe held on 17th 

-19th July, 2010 deliberated on how best to achieve 

maternal and child health goals in Africa. This was 

followed by the annual heads of state AU Summit 

meeting in Kampala from 19th-27th/07/2010 where 

the theme for this 15th summit was “Maternal, Infant 

and Child health and development in Africa”. All these 

international events taking place within a space of just 

about 2 months, raises a lot of interest. Emphasis has 

been on involving leaders and policy makers in the 

battle against poor mother and child health care, and 

this seems to be a good sign and hope that success may 



soon be realized. 

Falling short of the US$18b by the G8 seems to have 

had somewhat a clear explanation, that is, the famous 

global financial crisis. How sure are we of what the 

future holds? How many more billions are we to wait 

for and not see? There is no better way for me to 

answer questions as these than to believe that it all lies 

in the hands of the policy makers and implementers 

of the affected countries. In a low resource nation 

like Uganda, maximum efficiency with the limited 

available resources should be paramount. Synonymous 

to my thinking, a population expert was once asked 

how best Uganda could curb early pregnancies and 

their consequences and his answer was, “Just keep the 

girls in school, and you will have solved one third of 

the problem”. In relation to that, family planning is 

thought to have the capacity of reducing pregnancy 

related causes and maternal deaths by 30-35%. So 

the question thus far is who makes sure the girls are 

and kept in school and who ensures maximum family 

planning use? With a population growth of 3.2% (2nd 

largest in Africa), a fertility rate of 6-7 children over a 

lifetime and a low contraceptive use the Pearl of Africa, 

Uganda, would be a better place to live if we turn 

words into action. 

As you critically flip through the pages of this piece 

of work you will discover some strategies for example 

how mothers can prevent and treat malnutrition 

in their children with cheap and locally available 

solutions. Included are articles about factors affecting 

PMTCT service delivery, potential factors affecting 

neurocognitive development in unborn and new born 

infants and HIV/AIDS stigmatization among the 

youth in Gulu. 

A pictorial and a report of what transpired on 

27/01/2010 as the Faculty of Medicine wrote history 

have been included for you to have a feel of the 

excitement because the Faculty of Medicine at Gulu 

University is practically part of this campaign of 

safe motherhood and childhood through delivering 

knowledge equipped ambassadors. 

I would like to thank Italian Cooperation and Northern 

Uganda Malaria AIDS Tuberculosis (NUMAT) for the 

financial and technical support. I also take the same 

opportunity to thank the University and Faculty 

administration the Editorial Board and GUMSA 

executives and the GUMSA community at large for 

their special support. 

Enjoy this Edition. 

God Bless You. 



President’s Message 2009/2010 

Dear readers. 

I salute you all 

on behalf of 

Gulu University 

Medical Students 

A s s o c i a t i o n 

(GUMSA). 

Once again 

GUMSA is proud 

to release the 

fifth volume of 

Gulu University 

Medical Journal 

GUMJ with 

the theme, “Reducing Maternal & Infant Mortality 

and Morbidity in Uganda” which is in line with the 

Millennium Development Goals number 4 and 5 

related to reducing child mortality and improving 

maternal health respectively. 

It is in the interest of GUMSA that the information 

in this issue be used to improve maternal and Child 

health. 

This volume comes shortly after the recently concluded 

15th African Union summit which took place in 

Kampala stressing the need to scale up health services 

in order to achieve safe motherhood and health of the 

African child. 

I also would like to take this precious moment to 

highlight some of the achievements of the GUMSA 

Government2009/2010. 

First and foremost is the production of this Volume of 

GUMJ. 

In conjunction with Transcultural Psychosocial 

Organization (TPO-Uganda), a health education 

seminar was organized addressing risky behaviors 

among the youth. The seminar was held at Gulu 

University Main Campus and was a success. 

Together with Makerere University Medical Students’ 

Association (MUMSA), Mbarara University Medical 

Students’ Association (MBUMSA), and the Medical 

students’ Association of Kampala International 

University, the Federation of Uganda Medical 

Students’ Association (FUMSA) in December 2009 

which is a joint advocacy body for all medical students 

in Uganda. 

GUMSA has established a strong working 

relationship with Continental and International 

medical students’ Associations including the Federation 

Of African Medical Students’ Association (FAMSA), 

the International Federation Of Medical Students’ 

Association (IFMSA).These associations provide 

exchange programmes for medical students. 

Under FUMSA, I represented Ugandan medical 

students at the 25th march 2010 General Assembly 

of the IFMSA in Thailand Bangkok .The Assembly 

focused on use of complementary and alternative 

Medicines plus discussing challenges faced by Medical 

students Word wide. On the same event, FUMSA 

applied for the IFMSA membership. 

In a special way, I would like to say Bravo to the 

men and women of GUMSA, GUMSA Government 

Officials 2009/2010, Prof.Emilio Ovuga (GUMSA 

patron and Dean Faculty Of Medicine), Dr.Mshilla 

Maghanga (GUMSA Financial Advisor 2009/2010)and 

the entire University administration for the support 

rendered to regime 2009/2010. 

In conclusion, I acknowledge the entire GUMSA 

fraternity, GUMSA Government Officials 2009/2010, 

University administration, NUMAT and ITALIAN 

COOPERATION for the support towards the 

production of this volume. Enjoy your reading. 

FOR COMMUNITY TRANSFORMATION 

HE.SSEBWAMI LEONALD TAMUSANGE, GUMSA 

PRESIDENT 2009/2010 

FAMSA CHIEF LIAISON OFFICER FOR EAST & 

CENTRAL AFRICA 2009/201 



Innovation Is Needed to Promote Maternal and Child 

Health 

While Uganda has made 

remarkable strides in reducing 

maternal and infant mortality 

from 506 to 437 per 100,000 

and from 109 to 76 per 1,000 

live births respectively, these 

figures are still far in excess 

of what the country should 

aim to attain. The problem 

of maternal and infant mortality is multi-factorial and 

requires the concerted efforts of every stakeholder. 

While government might be expected to provide for 

the health of its citizens, particularly the health of 

its mothers and infants, every citizen has an equally 

important contribution to make toward reducing 

maternal and infant mortality. Prominent areas of 

maternal and child health that need the contribution of 

every citizen are child spacing, antenatal care practices, 

child rearing practices, health seeking behavior, and 

behavior related to human sexuality. Important factors 

in each of these areas are the availability of reproductive 

health services and information that individuals require 

to make informed decisions on their reproductive 

behavior. 

The students of the Faculty of Medicine of Gulu 

University have conducted research on creating 

awareness on depression that aims to provide health 

care information for communities. Every semester 

our medical students conduct community-based 

learning activities during which maternal and child 

health services form a major learning component. 

Innovation using print information for communities 

on reproductive and child health is feasible targeting 

approaches that can be integrated in curricula activities 

of the Faculty of Medicine. 

For instance, communities need practical information 

on how to and why they should space pregnancies 

using culturally acceptable methods; information on 

safe days might be a useful method for most individuals 

that are opposed to the use of contraceptive devices. 

Provision of information that targets drives for sex 

and or cultural demands for children might meet 

Patron’s Foreword 

with the approval of partners when this information 

comes from communities rather than from health 

professionals. Practical information on pregnancyrelated 

health risks delivered using culturally 

appropriate terminologies might promote maternal 

and child health, thereby reducing maternal morbidity 

and mortality. Appropriate information on sex and 

nutrition during pregnancy and in early pueperium 

might provide additional health promotive value. 

I suggest that students of the Faculty of Medicine 

conduct a maternal and child health awareness campaign 

to supplement the work of health care providers. The 

medical students would conduct qualitative research 

to document lay information and concepts of maternal 

and child health. Subsequent strategies involved might 

include the production of artwork by school children 

to document their understanding of reproductive 

and child health problems and how these should 

be tackled. The advantage in using school children 

is the fact that they will be more inclined to use 

strategies and reasons that they will have suggested 

for population control and the promotion of maternal 

and child health in the future. Health experts would 

review and select drawings that bring out optimal 

information, strategies and outcomes for maternal 

and child health. The next phase would involve the 

production of scripts that best describe the messages 

that the selected drawings stand for. A pilot booklet 

developed out of these activities would be distributed 

to adults of both sexes to determine their responses, 

critiques, and suggestions. A parallel pre- and posttest 

survey would further bring out the usefulness of 

the booklets on the promotion of maternal and child 

health. Additional information from the outcome of 

the evaluations might strengthen this approach. 

Any assistance to the students of the Faculty of 

Medicine to support this project is appreciated. 



Gulu University Medical Students’ Association (GUMSA) Passion for life 

10


Malnutrition and Child Morbidity and Mortality 

Ronald Wanyama, 

Biochemistry Department, Faculty of Medicine, Gulu University 

E-mail: wanyamar@yahoo.com. Tel: +256-77/71-2330638 

Nutrition during pregnancy and infancy is crucial 

for growth and development and also for subsequent 

adult health. As much as child nutritional status is 

a powerful determinant of child survival along with 

other factors (Pelletier & Frongillo 2003), it is always 

given less attention especially in Sub-Saharan Africa 

(SSA). For example, in the report of the G8 Meeting 

in Gleneagles, UK, in 2005, the chapter dealing with 

education and health prioritizes basic health systems, 

HIV/AIDS, malaria and tuberculosis. In contrast, 

nutrition is given less than half a page and reduced 

to parasite control and micronutrient support. Indeed 

malnutrition is now seen as a neglected epidemic since 

the scale of the problem has not changed since 1990. 

Although malnutrition is prevalent in developing 

countries, it is rarely cited as being among the leading 

causes of death. This is due in part to the conventional 

way that cause of death data are reported and analyzed. 

In many countries, mortality statistics are compiled 

from records in which a single proximate cause of death 

has been reported. 

One of the Millennium Development Goals (MDGs) 

is to reduce child mortality by 50% by 2015 but 

since the time the goal was set the absolute number 

and proportion of undernourished children have 

increased in SSA. This makes SSA the only region in 

the world where the absolute number and proportion 

of undernourished children have increased in the last 

decade. Eastern Africa is the sub-region experiencing 

the largest increases in numbers of underweight 

children – projected to have increased by 36% from 

1990 to 2005. Findings for stunting and wasting are 

similar (Global Nutrition Report, 2004). SSA is also 

the only region of the world where the number of child 

deaths is rising. With such trend and slow progress 

(FAO, 2005) towards the Millennium Development 

Goal target on child mortality, it has been pointed out 

that if current trends continue; SSA will achieve the 

MDG for child mortality around 2115 – one century 

after the target date. 

Malnutrition is one of the most important factors 

contributing to child mortality and a leading cause of 

the global burden of disease in developing countries 

(UNICEF, 1998; Ezzati et al., 2002). The magnitude of 

the health loss associated with childhood malnutrition 

worldwide is such that every three seconds, a 

child under the age of five dies (more than 26,000 

children everyday) mostly from preventable causes 

(WHO, 2008). The majority of these deaths occur 

in developing countries. Malnutrition (as measured 

by child anthropometry) contributes to more than 

half of child deaths worldwide. 56% of deaths among 

children under five (Pelletier, 1994; Black et al., 2003) 

in the developing world are due to the underlying 

effects of malnutrition on disease. Several other studies 

have documented that severely malnourished children 

are at a much greater risk of dying than are healthy 

children (Bull WHO, 1996). Research also indicates 

that malnutrition multiplies the number of deaths 

caused by infectious diseases rather than following an 

additive model. It is not a cause of death on its own 

but magnifies the role of infectious diseases in causing 

mortality. 

The substantial contribution to child mortality of 

all degrees of malnutrition is now widely recognized 

(Schroeder & Brown, 1994; Pelletier et al., 1995). 

‘Under-nutrition steals a child’s strength and makes 

illnesses that the body might otherwise fight off far 

more dangerous’. Malnourished children are up to 

12 times more likely to die from easily preventable 

and treatable diseases (like measles, pneumonia, and 

diarrhea) than are well-nourished children. On average, 

a child who is severely underweight is 8.4 times more 

likely to die from infectious diseases than a wellnourished 

child (Pelletier et al., 1994). Children who 

are moderately underweight and mildly underweight 

are 4.6 and 2.5 times respectively more likely to die 

than well-nourished children. 83% of all malnutrition 

related deaths worldwide occur in children who are 

mildly and moderately underweight. 



Although disease centered treatment and prevention programs can positively affect nutritional status, preventing 

malnutrition in children is essential to reduce significantly child mortality. Thus the first step in preventing child 

death is to make sure that every child is well nourished 

References 

Black RE, Morris SS & Bryice J, (2003). Where and Why are 10 million children dying every year? Lancet 361:2226- 

2234 

Ezzati M, Lopez AD, Rodgers A, Vander HS & Murray CJ (2002). The Comparative Risk Assessment Collaborating 

Group: Selected major risk factors and global and regional burden of disease. Lancet 360: 1347-1360 

Food and Agricultural Organization (2005). The State of Food Insecurity in the World: Eradicating world hunger 

key to achieving the Millennium Development Goals. Rome, Italy 

Pelletier DL, (1994). The relationship between child anthropometry and mortality in developing countries: 

implications for policy, programs and future research. Journal of Nutrition; 124: 2047S–2081S. 

Pelletier DL et al., (1995). The effects of malnutrition on child mortality in developing countries. Bulletin of the 

World Health Organization, 73: 443–448 

Pelletier DL, Frongillo EA Jr., Habicht JP, (1994). A methodology for estimating the contribution of malnutrition to 

child mortality in developing countries, The Journal of Nutrition, Supplement, 124 (10S): 2106S-2122S, 

Pelletier DL & Frongillo EA, (2003). Changes in Child Survival are Strongly Associated with Changes in Malnutrition 

in Developing Countries. Journal of Nutrition 133:107-119. 

Schofield C & Ashworth A, (1996). Why have mortality rates for severe malnutrition remained so high? Bulletin of 

the World Health Organization, 74: 223–229. 

Schroeder DG & Brown KH, (1994). Nutritional status as a predictor of child survival: summarizing the association 

and quantifying its global impact. Bulletin of the World Health Organization, 72: 569–579. 

UNICEF (1998). The State of the World’s Children 1998. New York: Oxford University Press. 

United Nations (UN) Administrative Committee on Coordination, SCN. The 5th Global Nutrition Report. Geneva: 

UN System Standing Committee for Nutrition, 2004. 

World Health Organization, 2008. The state of the world’s children 2008: Child survival. Geneva, WHO 



Malnutrition: A main cause of children’s death! 

Luigi Greco, M.Sc. (MCH), M.D., D.C.H., PhD (Hon) 

Department of Pediatrics, University of Naples Federico II and European Laboratory for Food Induced Disease 

Valentina Fiorito, M.D. Department of Pediatrics, University of Naples Federico II 

Malnutrition is one of the greatest public health 

problems facing the world today because of the number 

of children affected and the long-term consequences. 

The World Health Organization (WHO) estimates 

that malnutrition contributes to 53% of child mortality 

worldwide (1-2). There is a strong association between 

malnutrition and mortality in developing countries 

because even mild degrees of malnutrition double the 

risk of mortality for other diseases such as respiratory 

tract infection, diarrhoea, pneumonia, malaria and 

measles (3-4) (Figure 1). 

Table I shows how WHO defines a patient’s nutritional 

status. 

Mild Acute Malnutrition benefits of health counselling 

and community mobilization. 

Moderate Acute Malnutrition is still manageable 

in community setting but needs a specific program: 

Supplementary Feeding Program (SFP). This program 

is based on Supplementary Feeding Centres (SFC) that 

monitor every week the patient and provide antibiotics, 

antihelminthics, vitamin A and high energy fortified 

supplementary food like Ready–to-Use Therapeutic 

Food (RUFT). 

Severely malnourished children and infants less then 

6 months old with specific features (Wt < 4Kg, Wt/ 

Length< 85% and not able to suckle/not fed on 

breast-milk, mother died or mother has no or little 

milk or presence of oedema) have to be admitted in 

a Therapeutic Feeding Centre (TFC). In this centre 

they are managed, according to a specific Therapeutic 

Feeding Program (TFP). 

Almost all severely malnourished children have 

infections, impaired liver and intestinal function, and 

problems related to imbalance of electrolytes when 

first admitted to hospital. Because of these problems, 

they are unable to tolerate the usual amounts of dietary 

protein, fat and sodium. It is important, therefore, that 

children begin feeding on a diet that is low in these 

nutrients, and high in carbohydrate. 

To this purpose UNICEF and WHO prepared two 

formula diets based on the Modified Cow’s Milk F75 

(starter 75 KCal/100 ml) and F100 (follow up 100 

KCal/100ml). 

These milks are given, in proportion of the body 

weight, at 3 hourly intervals. F75 has a moderate 

protein and energy content and is given in the early 

phase of severe malnutrition, F100 has a higher energy 

and protein content and is useful for maintenance. The 

milks have to be given frequently and in small amounts 

to avoid overloading the intestine, liver and kidneys. 

Children unable to drink are fed by plastic syringes 

and nasogastric tube. The theoretical daily supply of 

energy is 140 to 200 Calories/kg body weight. But 

this amount is very difficult to administer to any single 

child. Night feeds are generally not available. 

Table II shows the composition of the two milk feeds: 

F75 starter, to be given for the first few days and F100 

for follow up. From the table is clear that the feeds 

are based on skimmed milk with added sugar and 

vegetable oil. 

The mineral mix with potassium, magnesium and 

other essential minerals must be added to the diet. The 

potassium deficit, present in all malnourished children, 

adversely affects cardiac function and gastric emptying. 

Magnesium is essential for potassium to enter cells and 

be retained. The mineral mix does not contain iron as 

this is withheld during the initial phase. 

Unfortunately about 95.4% of African children have 

the C/C- 13910 genotype of the lactase-Y-phlorizin- 

hydrolase gene that causes adult-type hypolactasia (vs 

14.5% of Finnish children). The decline of the lactase 

activity in African children occurred earlier than 

Finnish children, as 30% of the children already had 

low levels of lactase (< 10 U/g protein) at the age of 

five years (9). 



Many studies have demonstrated that infants with acute 

diarrhoea had chemical markers for lactose intolerance 

(positive reducing substances (Clinitest) in the faeces 

and stool pH< 5) (10). A randomized controlled 

study evaluated the effect of lactose-free formula 

versus ordinary milk on the outcome of 80 children 

with acute diarrhoea. Lactose-free formula reduced 

by 20 hours the duration of diarrhoea, decreased stool 

frequency and increased the weight gain, as compared 

with lactose containing milk with otherwise the same 

composition. (11) 

While working at the Nutritional rehabilitation 

Unit of St. Mary’s Hospital, Lacor, Gulu, Uganda we 

observed acute diarrhoea following milk ingestion in 

many malnourished children. We had to suspect that 

severely ill children could not fully absorb the energy 

provided by the milk containing full lactose and sugar. 

Chemical markers for lactose intolerance (positive 

clinitest and stool pH< 5) were suggestive, too. 

These direct observations, supported by the awareness 

of high prevalence of lactose intolerance in Africans 

and the consideration that diarrhoea is one of the main 

causes of fatality in severely malnourished children, 

suggested that skim lactose-rich milk with added 

sugar may not be the best treatment for malnourished 

children with diarrhea (12,13). 

International agencies recommend supplementary 

feeding (5-8). Supplementary feeds are any types of 

food added to the standard diet: they can be based 

on cereals and legumes, can be prepared with locally 

available food in developing countries or packed 

industrially in developed countries as ready to use 

nutritional supplements. The efficacy of cereal-andlegume-based 

supplementary feeding in large-scale 

programs has yet to be demonstrated (14,15). Readyto-use 

food in the form of a fortified spread is effective in 

treating malnourished children (16). According WHO/ 

UNICEF/WFP/SCN Ready-to-use food (RUTF) has to 

be a high energy, fortified ready to eat food suitable for 

treatment of severely malnourished children.. At least 

half of the proteins contained in the industrial product 

come from milk products. To prepare locally RUTF 

four basic ingredients are suggested: Sugar, Dried 

Skimmed Milk, Oil, Vitamin and Mineral Supplement 

(CMV). In addition, up to 25% of a product’s weight 

can come from oil-seeds, groundnuts or cereals like 

fortified spread is effective in treating 

malnourished children (16). According 

WHO/UNICEF/WFP/SCN Ready-to-use 

food (RUTF) has to be a high energy, 

fortified ready to eat food suitable for 

treatment of severely malnourished 

oats. children.. As well At as least containing half of the the necessary proteins proteins, 

energy and micronutrients. 

contained in the industrial product come 

from milk products. To prepare locally 

Among Ready-to-Use Therapeutic Food is Plumpy’nut, 

a 

RUTF 

peanut-based 

four basic 

food 

ingredients 

formulated 

are 

in 1999. 

suggested: 

It is a high 

protein Sugar, Dried and high Skimmed energy peanut-based Milk, Oil, Vitamin paste in a foil 

wrapper. and Mineral Supplement (CMV). In 

There addition, is no up doubt to 25% that RUTF of a product’s is a tremendous weight progress 

on can the come path from to cure oil-seeds, malnourished groundnuts children. or But we 

have cereals to consider like oats. that: As well as containing the 

a necessary is still based proteins, on lactose-containing energy milkand 

a 

micronutrients. 

there is a remarkable load of simple 

carbohydrates (sugars) 

a is a typical western-style industrial packet which 

give to mothers more the message to be a ‘special 

drug’ than a supplementary feed. 

So…is milk the sole “drug” to cure malnutrition? 

Fig. 1: Proportional mortality among under fives (WHO 20 

Fig. 1: Proportional mortality among under fives 

(WHO 2005) 

TABLES 

13 

Gulu University Medical Students’ Association (GUMSA) Passion for life 14 

Plumpy 

in 1999 

peanut 

There 

tremen 

malnou 

consid 

So…i 

malnut


Table I: Nutritional Status Classification (WHO 2005) 


I: Nutritional Status Classification (WHO 2005) 


Weight/ Mid-upper arm Oedema Body 

Weight/ Mid-upper arm Oedema Body 

Weight/ Mid-upper Height arm circumference Oedema Body 

Mass 

Height circumference 

Mass 

Height circumference 

Mass 

Index 

Index 

Good Nutritional >85% >135 mm Index No 

Good Nutritional >85% >135 mm No 

Good Nutritional >85% Status >135 mm No 

Status 

Status 

Mild Acute 80-85% 125-135 mm No 

Mild Acute 80-85% 125-135 mm No 

Mild Acute 80-85% Malnutrition (at 125-135 mm No 

Malnutrition (at 

Malnutrition (at risk) 

risk) 

risk) 

Moderate Acute 70-80% 110-125 mm No 16-18 

Moderate Acute 70-80% 110-125 mm No 16-18 

Moderate Acute 70-80% Malnutrition 110-125 mm No 16-18 

Malnutrition 

Malnutrition Severe Acute


References 

1. WHO Global Database on Child Growth and Malnutrition www.who.int/nutgrowthdb 

2. Pelletier DL, Frongillo EA,. Dirk JR, Schroederj G and Habicht JP. A Methodology for Estimating the 

Contribution of Malnutrition to Child Mortality in Developing Countries. J Nutr 1994; 124:2106-22. 

3. Caufield LE, de Onis M, Blossner M, et al. Undernutrition as an underlying cause of child death associated 

with diarrhea, pneumonia, malaria and measles. Am J Clin Nutr 2004; 80:193-8 

4. Olumese PE, Sodeinde O, Ademowo OG, et al. Protein energy malnutrition and cerebral malaria in Nigerian 

children. J Trop Pediatr 1997; 43:217-9 

5. W.H.O. Management of the child with a serious infection or severe malnutrition. IMCI. WHO/FCH/ 

CAH/00.1, 2000. www.who.int/child-adolescent-health 

6. Pocket book of hospital care for children: guidelines for the management of common illnesses with limited 

resources. WHO Press 2005 

7. Management of severe malnutrition: a manual for physicians and other senior health workers World Health 

Organization Geneva 1999 

8. Deen Jl, Funk M, Guevara VC, et al. Implementation of WHO guidelines on management of severe 

malnutrition in hospitals in Africa. Bull World Health Organ 2003; 81: 237-43. 

9. Rasinperä H, Savilahti E, Enattah NS et al. A genetic test which can be used to diagnose adult-type hypolactasia 

in children. Gut. 2004 Nov; 53(11):1571-6. 

10. Sabul TK, Basu S, Bhattacharjee P et al Are lactose free feeds necessary in infants after diarrhoea with lactose 

intolerance ? J. Pediatr Gastroenterol Nutr, 2004 , 39 Suppl : S276 

11. Simakachorn N, Tongpenayi Y, Tongtan O et al . Randomized , double blind clinical trial of a lactose-free and 

lactose-containing formula in dietary management of acute childhood diarrhea. J. Pediatr Gastroenterol Nutr, 

2004 , 39 Suppl : S485 

12. Penny ME, Brown KH. Lactose feeding during persistent diarrhoea. Acta Paediatr Suppl 1992; 381:133-8 

13. Brewster D. Improving quality of care for severe malnutrition. Lancet 2004;363:2088-9 Beaton GH, Ghassemi 

H. Supplementary feeding programs for young children in developing countries. Am J Clin Nutr 1982; 35: 

864-916 

14. Brown KH, Dewey K, Allen L. Complementary feeding of young children in developing countries: a review 

of current scientific knowledge. Geneva: WHO, 1998 

15. Allen LH, Gillespie SR. What works? A review of the efficacy and effectiveness of nutritional intervention. 

Manila 2001.United Nation Administrative Committee on Coordination, Sub-Committee on Nutrition (ACC/ 

SCN) in collaboration with the Asian Development Bank. 

16. Maleta K, Kuittinen J, Duggan MB, et al. Supplementary feeding of underweight, stunted Malawian children 

with a Ready-to-Use-Food. J. Pediatr Gastroenterol Nutr 2004; 38: 152-158. 



Nutricam: The food that saves! 

Luigi Greco, M.Sc. (MCH), M.D., D.C.H., PhD (Hon) 

Department of Pediatrics, University of Naples Federico II and European Laboratory for Food Induced Disease 

Valentina Fiorito, M.D. Department of Pediatrics, University of Naples Federico II 

According to WHO recommendations (1), we 

attempted to find local solutions to improve nutritional 

rehabilitation in St Mary’s Hospital Nutritional Unit in 

Lacor (Gulu, Northern Uganda) (2,3). We decided to 

evaluate the possibility to introduce a new nutritional 

intervention, to be added to the UNICEF milk, for the 

following reasons: 

- results of the nutritional rehabilitation with the 

UNICEF milk were discouraging 

- the large amount of lactose and sugar of therapeutic 

milks might facilitate diarrhoea, malabsorption and 

fatality 

- the UNICEF milk, as any other powdered milk, is 

not available outside the hospital: many children do 

relapse, because they are poorly fed when the milk 

is interrupted by the discharge from the hospital 

- milk feeds are not available and not traditional to 

the Acholi children of North Uganda 

Following the observation of the traditional feeding 

habits of the Acholi people, and a further check of the 

availability of the food items at the local market, we 

purchased at the market outside the hospital maize 

flour, rice, millet, peas and beans, peanuts, small 

dry fishes, cow’s meat, chicken and vegetable oil. 

We prepared a thick semi-solid porridge, with a cereal 

flour base as carbohydrates, proteins (fish, legumes, 

meats on rotation) and fats (peanut butter and vegetable 

oil). The porridge was named NUTRICAM that in the 

local language, Acholi, means “nutritional feed”. 

A 150-g serving of Nutricam made with 20g flour (65 

Cal, 274 J), 10g fish, meat or dry legumes (20 Cal, 

84 J), 5g peanut butter (30 Cal, 122 J) and 5g oil (45 

Cal,185 J), provides a total of 160 calories (665 J) and 

6.3g proteins (Table I). 

Each child admitted in the Nutrition Unit according 

the WHO criteria and in the phase of rehabilitation 

II (1), was offered two 150-g servings of Nutricam 

each day in addition to the scheduled amount of milk. 

Table II shows the week rotation of the feeds, in order 

to provide for different sources of proteins. 100 child/ 

day/servings are prepared each morning and 100 each 

afternoon. A single daily feed (two servings) for a child 

costs about 5,9 cents of Euro. The total monthly cost, 

including ingredients, fuel and salary for the cook 

is about 528,000 Ush (264 USA $ and 220 Euros). 

Table III shows the cost of the milk feeds for the same 

100 children and the ratio Nutricam/milk cost. The 

cost of NUTRICAM is about 8% of the actual cost of 

UNICEF milk. 

The porridge can be made at home as follows: (1) Cook 

two tablespoons of maize flour (or millet or rice) in 1 

cup of boiling water; (2) cook for about 15 min then 

slowly add one tablespoon of powdered fish and a half 

a tablespoon of peanut butter, stir vigorously until a 

thick porridge is obtained; (3) add a half a tablespoon 

of vegetable oil to make the porridge more creamy. 

The source of protein can be fish, beef, poultry or beans 

depending on availability. 

The NUTRICAM feed has been accepted with 

enthusiasm by the local population and by the children. 

They completely consumed two servings each day, 

while not interrupting the milk feed. We could not 

observe adverse reactions, as vomiting, diarrhoea, food 

intolerance. 

To evaluate the mean growth increments before and 

after the Nutricam intervention, to avoid seasonal 

effects, we randomly sampled 100 case files dismissed 

in the months October, November and December in 

the years 2001, 2002, 2003. For each case we reported 

the length of stay in the unit and the weight gain 

reached at discharge. To avoid complications with 

oedematous children, we have computed for all cases 

with oedema > 1+, the increment between the lowest 

weight reached and the weight at discharge. 

The analysis of 20 weight growth curves of children 



without oedema (Figure 1) admitted to the Lacor 

hospital in June and July 2002, before the administration 

of Nutricam, did not show, in most cases, the expected 

catch-up growth after nutritional rehabilitation with 

milk. Finally, a significant proportion (>10%) of 

mothers dropped out of the programme, often because 

of discouraging results. 

Figure 2 shows the weight curves, in grams of body 

weight, of 20 children, without oedema, who received 

Nutricam starting from the first week of August 2002. 

There was a conspicuous improvement in the slope of 

many weight curves compared with pre-Nutricam 

values. The average daily oedema-free weight gain was 

21 g (12–29 g) with milk alone in 2001, 35 g (25–45 

g) immediately after the intervention in 2002 and 59 

g (51–68 g) at the end of the first year of intervention 

2003 (See Figure 3). 

Days-in-care correlated with weight increments, but 

did not change significantly over the three years of the 

study, whereas the mean weight increments during 

treatment (an average of 20 days) increased from 525 

g in 2001 (before Nutricam), to 771 g in 2002, and 

1,274 g in 2003. Mean growth increments increased 

significantly as the study progressed. 

Figure 4 shows the numbers and trend of survival 

outcome as a per cent of cases admitted to hospital 

each month. The top regression line shows the per cent 

of cases discharged as ‘cured’ (namely, children who 

attained 85% weight-for-length, which increased from 

54.5% in January 2002 to 93.3% in August 2004. 

The lower regression line shows the per cent deaths 

and per cent of ‘lost’ cases. Mortality and ‘lost’ rates are 

considered collectively as ‘overall failures’: these were 

45.5% in January 2002 and 6.7% in August 2004. 

The death rate was 21.2% in January 2002 versus 

2.9% in August 2004. 

Table IV shows the averages (and standard error) for 

each outcome variable (cure, death, lost –default) in the 

three years of the study after correction for the number 

of cases admitted in each study period (multivariate 

analysis). Again, the differences among years are highly 

significant. 

The results were so good that the hospital decided 

to introduce permanently Nutricam in the nutritional 

rehabilitation. 

In a further study, six years later, we demonstrate 

conclusively how Nutricam helped to treat malnutrition. 

5620 patients admitted in the St.Mary’s Hospital in 

Lacor, Uganda, were studied from the second half of 

2002 (after introduction of Nutricam) to 2007, in 

order to observe long term results. 

We included in the study all the patients admitted to 

the Nutrition Unit according to the WHO criteria (7) 

avoiding any selection bias. Over these 6 years 74,7% 

of patients were admitted because of marked oedema, 

17,3% because of low weight for height and 6,1% 

because of very low Mid Upper Arm Circumference. 

As you can see in Figure 5, the average oedema-free 

weight gain was 1694 gr for cured patients. The average 

daily oedema–free weight increment was 66,7 gr for 

males and 62gr for females. The survival outcome is 

still confirmed, as the previous paper. Figure 6 shows 

that the overall percent of children cured is 78% and 

the percent of dead is 11%. These results are similar to 

those published in the previous study and very different 

from those one of the before-Nutricam period. 

Mortality in this setting is still very high. To understand 

the causes of this finding we explored the clinical 

data of the children. The average of days in care was 

23,9 days/child but the distribution shows two peaks 

(fig 7). The first peak is in the first few days after 

admission: this is the cohort where most of deaths are 

endowed. They come to the Unit in extremely severe 

conditions and just cannot take any advantage from 

the nutritional program. In our setting, more than 

50% of patients who died did not survive to the sixth 

day after admission and the highest peaks of deaths are 

in the second and third day after admission These data 

show that this high mortality cannot be attributed 

to a failure of the nutritional program but it is due 

to the late referral of the extremely wasted children 

with severe complications. Intensive care facilities, not 

jet available in the unit, could reduce these fatalities, 

but will not be the most adequate solution to the 

problem. 

It is clear that the best solution is to intensify the 

nutritional screening in the villages and, then, 

support community-based treatment for moderated 

malnourished children. 



In conclusion, Nutricam plus milk was more effective 

than milk alone in nutritional rehabilitation of 

severely malnourished children. Oedema disappeared 

rapidly and daily weight increments rose significantly 

compared to treatment with milk only. Nutricam 

did not affect the length of stay in the unit, probably 

because the children were severely ill and were affected 

by severe acute diseases (diarrhoea, malaria, pneumonia, 

tuberculosis etc) besides malnutrition. 

The change observed over time in the outcome 

variables (increments in weight and survival) may 

not be entirely due to the nutritional intervention. 

During the two years after the intervention started, 

various improvements were made in the Nutritional 

Rehabilitation Unit, although the care of severely 

malnourished children remained unchanged. Moreover, 

the number and category of medical personnel in the 

Nutrition Unit did not change, and no additional 

motivation was given to medical personnel or 

caretakers/mother to improve care. During the study, 

the number of admissions increased and the status of 

the children at admission was worse probably of the 

instability caused by insurgency that caused many 

families to abandon their villages. 

Nutricam is locally feasible at a low cost (about 134 

Ush/serving, including labour and fuel). It is well 

accepted by the local population, easy to prepare and 

very effective for nutritional rehabilitation. Nutricam 

was not intended to supply all the daily energy 

requirements, but is well suited as a supplement to 

mother’s milk. 

At the Nutritional Unit, mothers/caretakers are 

offered nutritional education twice daily by the Health 

Educator and they participate in the preparation 

of Nutricam for at least 5 days before their child is 

discharged from hospital. The nutritional intervention 

is not persistent if it is not handed to the mother’s 

responsibility, in order to transfer this attitude to the 

daily village life. 

Nutritional failures decreased by more than 50% after 

Nutricam. From August 2002 to September 2004, 

we estimated that 454 children were saved from 

nutritional failure: 216 less deaths and 238 patients 

less lost-to-treatment versus the period from January 

to July 2002. 

This study demonstrates the efficacy of supplemental 

feeding with a varied protein source for severely 

malnourished children. This intervention did not 

require a special project or sponsors, just one person 

at a cost of only 220 Euro/month for the entire action. 

The hospital management continued this intervention, 

which was also implemented in other hospitals in the 

region. It cost about 3000 Euros to build the kitchen 

and purchase equipment for each new therapeutic 

feeding centre. The cost of providing powdered milk 

by international agencies is 32,370 Euro/year for the 

same group of children who entered our study. The 

results of nutritional rehabilitation with milk alone 

are often disappointing. Moreover, milk is not always 

available out of the hospital, which means that many 

children relapse. The widespread use of the porridge 

together with milk, which resulted in better outcomes 

than milk alone, could produce saving thus releasing 

resources for other uses. 

Lastly, nutritional rehabilitation is essential to survival 

for the many children with malnutrition in developing 

countries, but it cannot be based solely on powdered 

milk. The Lacor study highlights the need to involve 

local communities in the selection of locally available 

nutritious foods for children to prevent and treat 

malnutrition. In conclusion the most effective treatment 

of children’s malnutrition is early local identification 

of at risk children and secondary prevention: which 

means to treat the moderately malnourished children 

before severe malnutrition ensues. 

Immediately after this intervention the use of local 

ingredients to prepare supplementary feeds for 

breast fed children has been proven to be an effective 

intervention at very low cost. Also in the hospital 

settings, an especially in the Nutrition Rehabilitation 

units, widespread all over the developing world, 

supplementary feeds made by local ingredients are 

largely preferable to expensive, industrially packages 

feed supplements. The solution to malnutrition is not 

to produce, transport and distribute ‘therapeutic’ feed 

supplements: they are received as drugs and as such 

do not change the familial attitudes towards children 

feeding. These products are not available at home and 

are finally very expensive in terms of local currency. 

Many mothers sell their goats and garden products to 

pay for a tin of dried milk or few packages of RTUF 

on the black market. Western-type intervention is 

justified in emergency, but children malnutrition is 



often a chronic condition, which cannot be handled by the specialist’s intervention only. Mothers and families have 

in their own hands the very solution to prevent and treat children malnutrition: locally available low cost foods, 

wisely prepared by reinforcing local traditions are more than often the single most cost-effective intervention to cure 

malnutrition. 

Figures: 

Fig. 2 Individual weight curves (weight in g) during Nutricam administration (August 2002). 

Fig. 3 Length of treatment (days in care) and mean daily weight increments before and after Nutricam. 



Fig. 4 Outcome of nutritional rehabilitation before and after Nutricam. The numbers and trends (regression line) 

of survival outcome are shown as per cent of cases admitted to hospital each month. The top regression line refers 

to cases discharged as ‘cured’ (namely, children above the 85% weight for length). The lower regression line refers 

to overall failures (dead and lost cases). 

Fig. 5 Average weight gain over more than 5 years of Nutricam administration 



Fig. 6 Outcome of nutritional rehabilitation program without and with Nutricam administration 

Fig. 7 Distribution of days in care over more than 5 years. 



Table I: Content of one 150 grams serving of Nutricam. 

Ingredient Grams Calories Proteins g Fat g Carbohydrate Fe Zn 

(kJ) 

s mg mg 

Cereal Flour (ex. Maize) 20 64,8 (274 ) 1,4 0,6 13,3 0,5 0,1 

Fish (or meat, poultry, 

beans) 

10 20,0 (84,2) 2,4 0,6 0,2 0,2 

Peanut Butter 5 29,2 (121) 0,2 2,5 0,5 0,1 0,3 

Vegetable oil 5 45,0 (185) 0 5 

Water to 150 g 0 

TOTAL 159 (664,8) 4,0 8,7 13,7 0,8 0,6 

Table II: Weekly menu of “Nutricam” for 200 servings/day 

DAY Carbohydrates Proteins Fat 

Kg/day Kg/day Kg/day 

Monday Maize 4 kg Dry fishes 2 kg Peanut Butter 1kg + Oil 1lt 

Tuesday Rice 5 kg Meat 2 kg Peanut Butter 1kg + Oil 1lt 

Wednesday Millet 4 kg Dry fishes 2 kg Peanut Butter 1kg + Oil 1lt 

Thursday Maize 4 kg Chicken meat 2 kg Peanut Butter 1kg + Oil 1lt 

Friday Rice 5 kg Dry fishes 2 kg Peanut Butter 1kg + Oil 1lt 

Saturday Maize 4 kg Beans 2 kg Peanut Butter 1kg + Oil 1lt 

Sunday Maize 4 kg Peas 2 kg Peanut Butter 1kg + Oil 1lt 


24 

Tables:


Table III 

FEEDING COST for 100 CHILDREN EVERY DAY 

EUROS 

One Day One One Year 

Table III 

Month 

FEEDING F75 Milk COST for 9,96 100 CHILDREN 299 EVERY DAY 3588 

F100 Milk 79,95 EUROS 2398 28782 

TOTAL MILK One 89,91 Day 2697 One One 32370 Year 

Month 

NUTRICAM F75 Milk 

F100 Milk 

7,35 9,96 

79,95 

220 299 

2398 

2648 3588 

28782 

TOTAL Cost Rate MILK Nutricam/Milk 89,91 2697 % 32370 8,18 

NUTRICAM 7,35 220 2648 

Cost Rate Nutricam/Milk % 8,18 

Table IV: Outcome at the Nutritional Unit over time 

Year % Cured 

% Dead % Defaulters 

(SE) 

(SE) 

(SE) 

2002 59.6 (3.7) 17.0 (1.2) 

Table 

2003 

IV: Outcome at 

78.7 

the Nutritional 

(1.7) 

Unit over 

10.2 

time 

(0.9) 

Year 

2004 

% 

83.5 

Cured 

(2.0) 9.2 

% Dead 

(1.5) 

ANOVA* F=21.2 

(SE) 

P < 0.0001 F=12.5 

(SE) 

P < 0.0001 

SE, standard 

2002 

error; F, variance 

59.6 (3.7) 

ratio 

17.0 (1.2) 

*Analysis 

2003 

of variance 

78.7 (1.7) 10.2 (0.9) 

2004 83.5 (2.0) 9.2 (1.5) 

18.2 (2.1) 

10.5 (1.3) 

% 

3.7 

Defaulters 

(1.2) 

F=10.9 

(SE) 

P < 0.0001 

18.2 (2.1) 

10.5 (1.3) 

3.7 (1.2) 

ANOVA* F=21.2 P < 0.0001 F=12.5 P < 0.0001 F=10.9 P < 0.0001 

SE, standard error; F, variance ratio 

*Analysis of variance 

References 

1. W.H.O. Management of the child with a serious infection or severe malnutrition. IMCI. WHO/FCH/CAH/00.1, 

2000. www.who.int/child-adolescent-health 25 

2. Greco L, Balungi J, Amono K, Iriso R, Corrado B Effect of a Low-Cost Food on the Recovery and Death Rate 

of Malnourished Children J Ped Gastr Nutr 43:512-517, 2006 

3. Low-cost, local food supplement improves efficacy of treatment for malnourishment Nature Clinical Practice 

gastroenterology & hepatology Jan 2007 Vol 4:1 www.nature.com/clinicalpractice/gasthep 

25 



A Social Medicine Approach To Malnutrition 

A seven-month-old boy presents to Lacor Hospital in northern 

Uganda with a four day history of diarrhea. His abdomen 

is swollen, and he is diffusely edematous. His hair is thin 

with a reddish tinge. His mother weaned him from the breast 

several months ago because she was pregnant again, and he 

has never eaten much since then. His diet consists primarily of 

millet meal and fruit. His parents are peasant farmers with 

5 other children. They returned from living in an IDP camp 

one year ago. 

The diagnosis of kwashiorkor is relatively 

straightforward for this child. He has many of the 

classic signs of protein deficiency: thin discolored hair, 

diffuse edema, abdominal distension. The treatment 

is also uncomplicated: replenishment of the deficient 

nutrients. What is less straightforward, but just as 

critical for understanding his current state of health is 

the social context in which he and his family live—the 

many layers of disadvantage and structural violence 

under which they struggle to survive. Social medicine 

is an approach that calls the clinician to investigate, 

understand, and address these many levels of social 

context that lead to their patients’ illnesses, deter 

treatment, and preclude recovery. The scope of these 

factors extends from international politics to family 

context. 

In the case of the child presented above, the fact that he 

is the youngest of six children may mean that his parents 

need to stretch what little food they have between many 

mouths. He was weaned before the recommended 6 

month point because his mother was pregnant again. 

While one can continue to breastfeed while pregnant, 

his mother held a belief that this was harmful to the 

fetus. She was pregnant again because she and her 

husband did not have access to contraception, despite 

their desire to not have another child at this time. The 

family struggles financially because their only means 

of income is selling their harvest in the market, but 

this season produced a smaller harvest than expected. 

The price of the food that they buy in the market has 

been going up because of inflating world food prices, 

a reflection of a global food shortage, international 

Laura Janneck, MBChB IV 

Case Western Reserve University School of Medicine 

tariffs, and a variety of other trade agreements. His 

family lived in an IDP camp where they lived in fear of 

abductions, attacks, and violence until shortly before 

the child was born. While there, the family depended 

on World Food Programme (WFP) handouts, which 

ended when they returned to their farm and they were 

expected to be self-sufficient with what they could 

grow and sell. 

As these examples demonstrate, a social medicine 

approach elucidates a variety of factors that impose 

upon a person’s susceptibility to disease and the course 

of their illness. When applied to several patients, or 

an entire population, it can point to public health 

and policy interventions that can address the roots 

of disease and prevent future cases. In the case of 

malnutrition, for example, the WFP is aware that by 

importing large amounts of food into a region for free 

distribution, they not only provide food for people that 

may have no other source of nourishment, they also 

depress local food prices. The WFP tries to minimize 

these effects by limiting the chances that the food it 

distributes gets into the marketplace rather than in 

beneficiaries’ stomachs. It is also quick to pull out as 

soon as possible to allow for local food producers to 

take over production and be profitable in local markets. 

But if this is done too quickly or without attention to 

individual households’ capacity for food production or 

acquisition, many people can be left suddenly without 

a food source. 

The solutions to public health and policy challenges 

like this are often not as straightforward or simple as 

the diagnosis and treatment of malnutrition. But their 

effects can be more far-reaching and effective in the 

long run. It is the responsibility of those in the medical 

profession, in partnership with public health officials 

and policymakers, to be able to take this approach to 

health and illness for the sake of our patients and the 

communities we serve. 



Social Medicine 2010: Studying The Social 

Determinants Of Health 

Authors: Judith Naiga Lubega, Kiiza Kweyunga Peter, and Michael Westerhaus 

on behalf of the entire Social Medicine 2010 class 

Introduction and Course Description 

Social Medicine is defined as exploring the social 

determinants of health that impact the health of 

individuals and the community. In our view, these 

determinants include poverty, political and historical 

factors (i.e. colonialism, globalization, and war), gender 

inequality, human rights violations, and psychological 

and cultural factors in a community. These factors, by 

influencing who has access to standard medical care 

and treatment, play a major role in determining who 

is healthy and who is ill both in the short and longterm. 

Throughout the world, however, most medical school 

curricula leave little room for teaching social medicine, 

as conceptualized above. In Uganda, medical students 

typically have a course in sociology limited to patientdoctor 

relations, dealing with dying and death, cultures 

of different populations, and understanding stress in 

the lives of patients. In the United States, similar topics 

are often taught as the foundation of understanding the 

social aspects of disease. In both places, this teaching 

is often confined to the classroom and only pays 

cursory attention to the social determinants of health 

listed above. As a result, medical practitioners enter 

communities viewing patients as biological “halves”, 

not biosocial “wholes”. 

In view of the above, a course, entitled Beyond the 

Biologic Basis of Disease: The Social and Economic 

Causation of Illness was offered from January 18 

– February 12, 2010 at the Lacor Campus of Gulu 

University Faculty of Medicine. This course brought 

together nine students from abroad (eight from the 

U.S. and one from Holland) with twelve students from 

Gulu University for four weeks of intensive immersion 

in the study of social determinants of health, global 

health interventions, social justice and communitybased 

healthcare, and health and human rights. 

Course objectives 

The objectives of the course were as follows: 

• To have a real feel of how various social factors 

affect the health of individuals by visiting different 

communities. 

• To create international social links which could 

help bridge the identified gaps in access to medical 

care. 

• To come up with projects that aim to address the 

social problems of the people. 

• To draw on the varied medical backgrounds/ 

experiences in order to generate creative solutions 

to the identified problems. 

• To facilitate the development of a clinical approach 

to disease and illness using a biosocial model 

through structured supervision and teaching. 

• To build an understanding and skill set associated 

with physician advocacy. 

• To study issues related to global health in a 

resource-limited setting with an emphasis on 

local and global context. 

• To build international solidarity. 

Course content and Typical Day 

The course curriculum incorporated both clinical 

tropical medicine and social medicine topics. These 

topics were taught through a combination of lectures, 

discussions, films, community field visits, ward rounds, 

and clinical case discussions. A typical day started 

with a case discussion emblematic of the disease topic 

for the day followed by bedside teaching with a preselected 

patient with the illness. Special emphasis 

was placed on gathering a social history from patients 

and performing careful physical exams. Clinical 

topics covered during the course included malaria, 

tuberculosis, tetanus, malnutrition, HIV/AIDS, mental 

health, schistosomiasis, acute respiratory infections, 

measles, and rheumatic heart disease. 

In the afternoon, the students engaged in social 

medicine topics. These topics were covered through 



small and large group discussions, panels with invited 

guests, films, and lectures from individuals actively 

involved in work related to the day’s topics. Efforts 

were continually made to link the clinical conditions 

discussed in the morning with the afternoon’s social 

medicine topics to clearly delineate the ways in which 

social factors translate into biological disease. Social 

medicine topics covered included colonialism, the 

historical and political context of northern Uganda, 

globalization, international trade, structural violence, 

the impact of war on health, health and human rights, 

training physicians as advocates, narrative medicine, 

social justice, and models of community-based 

healthcare. 

Classroom based teaching was supplemented with 

field visits to different types of health interventions. 

Field visits to The AIDS Service Organization (TASO) 

– Gulu, the Northern Uganda Malaria, AIDS, and TB 

Initiative (NUMAT), and Amuru Health Center III 

were included. These visits allowed students to contrast 

and compare the philosophies, funding mechanisms, 

concrete activities, and impacts of different types of 

health interventions. 

Evening film showings provided another venue for 

students to engage the course content. Some of the 

films shown in the course included Uganda Rising, State 

of Denial, War Dance, A Closer Walk, Sudden Flowers 

Productions, Invisible Children, This Magnificent 

African Cake, and some films put together about the 

work of Partners in Health. 

Achievement/Results 

This year’s social medicine course made a number of 

significant achievements. First, students gained a 

broad knowledge of the social determinants of health 

through intensive, real-world interactions with patients 

and practitioners. Students developed the ability to 

not only identify these factors, but also to critically 

analyze the social, political, economic, historical, and 

cultural sources of illness and devise potential solutions 

that address both the social and biological causes of 

disease. For example, in relation to this volume’s focus 

on children and mothers, social medicine students 

repeatedly witnessed and identified the ways in which 

poverty, inequality, illiteracy, and gender inequality 

heavily contribute to the mortality and morbidity of 

both infants and mothers by preventing them from 

accessing healthcare services. 

Secondly, at a time when interest in the study and 

practice of global health has dramatically risen amongst 

medical students, the course provided a structured 

environment for students to critically engage with the 

different ways in which global health can be practiced. 

Careful attention was paid to distinguishing amongst 

the different types of global health interventions 

operating in northern Uganda. The logic, ethics, 

philosophies, practices, and tangible outcomes 

associated with different interventions were given 

careful study. Students gained the ability to assess 

various interventions and determine how they may one 

day participate in the practice of global health. 

Thirdly, students developed skills to work as advocates 

for improved health in their communities. Student 

members of Students for Equality in Healthcare 

(SEHC) provided a half-day training on advocacy 

skills and representatives from various advocacy 

organizations exposed students to the different ways 

in which they can work as advocates. Thus, students 

emerged from the course with the ability to concretely 

act on the problems witnessed in local, national, and 

international contexts of patient’s lives. By the end of 

the course, students had identified a number of issues, 

such as drug stockouts and malnutrition, which they 

then decided to design advocacy strategies to address. 

Finally, and perhaps most importantly, international 

solidarity was built between Ugandan and international 

(U.S./Europe) medical students. The collaborative 

nature of the course allowed for international students 

to learn from Ugandan students about the challenges 

of providing healthcare in Uganda and for Ugandan 

students to learn from international students about 

the challenges in their countries. Group discussions 

allowed for a mutual exchange of information and 

the co-creation of understandings of global health 

by all students. This aspect of the course allowed for 

the formation of deep trust, careful listening skills, 

and respect for varied perspectives, which are all key 

ingredients in building long-lasting partnerships. 

Limitations/Challenges 

The course faced a number of challenges, which offer 

the opportunity for improvement in the coming years. 

Scheduling conflicts existed for Ugandan students, 



whose semester started before the end of the course, and 

for international students, some of whom had difficulty 

completing internship interviews in the US before the 

course began. Students from Gulu University faced 

accommodation and transportation difficulties because 

of the course location at Lacor Hospital. The need for 

many Ugandan students to commute between Lacor 

and Gulu town made it difficult for Ugandan students 

to consistently arrive on time in the morning and 

prevented some of them from staying for evening film 

showings. Finally, significant challenges were faced in 

trying to raise enough funding to pay for the course. 

We met limited success in our efforts to secure funding 

from NGOs, foundations, and involved universities. 

The Way Forward 

Given the great success of this year’s course, the social 

medicine course will again be offered from January 10 

– February 4, 2011 and all Gulu University students 

will be welcome to apply. In July 2010, SEHC plans to 

do extensive publicity to encourage applications. This 

year’s course participants also plan to share the lessons 

learnt from this course through film screenings and 

discussions open to all members of the Gulu University 

Faculty of Medicine. Furthermore, these students will 

continue to work on advocacy and research projects 

related to drug stockouts and malnutrition, which 

have began as a result of the course. 

In order to enhance next year’s course, efforts will be 

made to find accommodation for Ugandan students 

near Lacor Hospital for the full duration of the course. 

Intensified efforts to find creative sources of funding 

for the course will be made. These efforts will include 

asking Gulu University to extend financial support for 

subsequent years given the great benefit of the course 

for its students and the surrounding community. 

Conclusion 

The social medicine course provided the opportunity for 

an intensive study of the social determinants of health. 

Together, students from around the world, developed 

a map of these determinants of health in northern 

Uganda. Gender inequality, minimal educational 

opportunities, poverty, unemployment, food insecurity, 

political instability, racism, and unequal global trade 

and exploitation were factors identified as significant 

contributors to the epidemiology of disease. 

These themes are intricately linked in both simple and 

complicated ways to this issue’s theme of maternal 

and child morbidity and mortality. Tracing these 

linkages reveals that gender inequality often results 

in men accessing the best nutrition, opportunities for 

education, and opportunities to have their voices heard. 

Meanwhile, too often women and children are left with 

inadequate nutrition, poor educational opportunities, 

and a near silencing of their perspectives. Genderbased 

violence leads to physical abuse of women in an 

environment that dismisses their concerns. In settings 

of extreme poverty, women turn to transactional sex for 

survival, putting themselves at great risk of HIV/AIDS. 

Inadequate water and sanitation contributes to excess 

disease amongst children who play in contaminated 

areas and drink unpurified water. Such social factors 

clearly worsen the health of women and children. 

Women and children are not only at greater risk of 

disease but have difficulty accessing adequate health 

services. Frail health systems are unable to provide 

proper prenatal and gynecological care. Mosquito 

nets, a central tool in malaria prevention, are often too 

expensive for families. Health centers in rural areas are 

often understaffed and lack the necessary medicines. 

Thereby, the common and treatable diseases of children 

and women, such as helminthiasis, uncomplicated 

malaria, mild malnutrition, respiratory tract infections, 

and complications associated with delivery, are not 

properly addressed in the community at early stages 

and become serious medical problems. 

We can likely all agree that some of these social factors 

identified above have a negative impact upon the health 

of women and children. But, then, we might ask, why 

do these factors continue to preferentially contribute to a 

heavy burden of disease amongst women and children? 

Analysis through the lens of social medicine reveals 

that these circumstances are very often shaped by the 

distribution of money, power and resources at global, 

national and local levels in ways that disadvantage the 

health of women and children. Thus, we must remind 

ourselves to continually ask, “Why treat mothers and 

children without changing what makes them sick?” 



Effects Of IDP Resettlement Programme On 

The Management Of HIV/AIDS In Gulu District, 

Northern Uganda 

1 Hellen Mghoi, 2Mshilla Maghanga, 3Steven Langole 

1, .2, 3 Gulu University, P.O. Box 166 Gulu, Northern Uganda 

Background 

Due to 20 years of the Lord’s Resistance Army (LRA) 

insurgence in northern Uganda, most people moved 

from their homes to IDP camps. At the height of 

the insurgence in 2004, the number of IDPs stood at 

1.7 million (UNAIDS, 2006) in about two hundred 

IDP camps in Gulu, Amuru, Kitgum, Pader, Lira and 

Apach districts (UNICEF 2006). However, following 

positive progress of the Juba Peace Talks in 2006, 

the Government initiated an IDPs resettlement 

programme. While this was a very positive development 

it was envisaged that the access to health care services 

and specifically the management of HIV/AIDS faced 

heavy challenges. 

By 2004, Gulu was second to Kampala in terms of 

HIV/AIDS prevalence (GoU, 2005). To alleviate 

this problem, health authorities in both government 

and Non-Governmental Organizations (NGOs) set 

up various programmes around IDP centres mostly 

concentrated within urban centres to attend to the 

patients and their families. This in a way eased the 

intensity of problems related to HIV/AIDS care and 

Management. The management of HIV/AIDS as 

IDPs moved back to their village homes faced heavy 

challenges. This was due to both operational changes 

on the part of health care and support givers, overall 

economic difficulties, as well as the changes in demand 

for psychosocial support by patients’ and home based 

care givers’ that went along with relocation. For 

example, results of the Uganda Demographic and 

Health Survey 2006 had revealed that 65% of people 

in Northern Uganda would not accept a female with 

HIV/AIDS to teach. This indicated that in the event 

of returning to their villages, HIV/AIDS patients were 

likely to face stigma related discrimination. According 

to TASO as cited in Carter (2008), displaced HIV 

positive children who start antiretroviral therapy can 

do as well as children who start ARVs in politically 

stable settings, though; maintaining good outcomes in 

such populations is likely to be a challenge particularly 

because of population movement 

The general objective of this study was to investigate 

the challenges faced by HIV/AIDS infected and 

affected IDPs who have since resettled in their homes 

in Gulu District, Northern Uganda. Specifically, the 

study sought to establish the measures being used in 

HIV/AIDS management of resettled communities, the 

successfulness of the management, and the challenges 

experienced. 

Overview of HIV/ AIDS 

HIV/AIDS is an incurable disease that is an enormous 

threat to the society especially in Sub-Saharan Africa 

(SSA) where Uganda is located. By the year 2004 there 

were 39.4 million infected people globally, 25.4 million 

of these from SSA, while an estimated 3.1 million, 2.3 

million of these in SSA, had died of the disease that 

same year (UNAIDS, 2004, as quoted in Bannister 

et al, 2006). As of 2007, the estimated global figure 

of people living with HIV/AIDS appeared to have 

dropped to 33 million (UNAIDS, 2008). However, 

there were significant increases of new infections in 

SSA. According to the Uganda AIDS Commission 

(UAC), (2008) the first incident of HIV/AIDS in the 

country was reported in Rakai and it is estimated that 

5.4% Ugandan adults are HIV positive. According to 

(GoU, 2008), the number of people living with HIV 

is higher in urban areas (10.1% prevalence) than rural 

areas (5.7%); it is also higher among women (7.5%) 

than men (5.0%). 

Measures used in HIV/AIDS Management 

HIV/AIDS management strategies focus on preventing 

new infections, prolonging the lives of those infected 



through treatment of opportunistic infections and 

provision of Antiretroviral (ARV) drugs to boost their 

immunity, as well as provision of psychosocial support to 

the infected and affected. They also include provision of 

septrin prophylaxis to prevent opportunistic infections, 

counseling services, home based care, Voluntary 

Counseling and Testing (VCT), monitoring CD4 cell 

counts and other laboratory procedures, dissemination 

of information education and communication (IEC) 

materials addressing sexual behavior and reduction of 

stigma against the infected and affected, Prevention 

of Mother to Child Transmission (PMTCT), provision 

of nutritional and economic livelihood support to the 

infected, the care and support of the Orphaned and 

Vulnerable Children (OVC), and promotion of condom 

use, among others. All this is done through a combined 

and coordinated effort right from the Global level 

through the Global AIDS fund, UNAIDS and other 

multinational strategies, to the grassroots level where 

CBOs and volunteer care givers are involved in care 

and support of the infected and affected. 

Policies that have come into place in Uganda as 

relates to HIV/AIDS include HIV Counseling and 

Testing (HCT), Anti-Retroviral Therapy (ART), care 

for Orphans and Other Vulnerable Children (OVC), 

Condom use, and on Prevention of Mother-To- 

Child HIV Transmission (PMTCT) among others. In 

addition, Uganda National HIV & AIDS Strategic 

Plan (NSP) 2007/08 to 2011/12 which interrelated 

with the Country’s Poverty Eradication Action Plan 

(PEAP) concentrates on human development, and 

emphasizes on preventive health care (UAC, 2008). 

Challenges in HIV/AIDS Management 

HIV/AIDS still has no cure, while the disease continues 

to spread. For example, looking at the SSA, 22 million 

people were by 2007 estimated to have been living with 

the disease while the figures in other regions ranged 

between a low of 4.5 million to 730,000 (UNAIDS, 

2009). 

Another emerging challenge to HIV/AIDS is the 

increasing levels of the disease’s resistance to drugs. 

This has ignited fears of possible emergence of stronger 

strains of the disease. Since there is still no cure, 

stronger strains could escalate the rate of infections and 

accompanying consequences. Resistance to the ARVs 

is partly related to failure by patients to adhere to 

ARV treatment, continued transmission, and poverty, 

especially in SSA. At the same time, there has been lack 

of STI medication, insufficient medical personnel, lack 

of equipment and erratic supply of laboratory reagents 

and chemicals among others (International Migration 

Organization [IOM], 2008). 

There was also shortage of health facilities, inadequate 

staffing, and overwhelming numbers of service 

demand cases that hampered the provision of health 

services such as provision of ARVs, follow up of patient 

referrals, dissemination of Information, Education and 

Communication (IEC) to create awareness against HIV/ 

AIDS, and other psychosocial support to the People 

Living with HIV/AIDS (PLWHA) and Orphans and 

Vulnerable Children (OVC) (IOM 2008). 

The research revealed that the numbers of PLWHA 

who required care and support were overwhelming. In 

Gulu district provision of OVC assistance programmes 

were at a low of 29 %. Most assistance included 

educational support, medical, psychosocial and at a 

low level, nutritional support. This included provision 

of ARVs. 

At the same time, while medical experts define effective 

ARV adherence to a high of 95% (Kalichman 2008), in a 

clinical study, Chesney (2003, pp 17:169-77) as quoted 

in Kalichman (2008) reported that 26% to 35% of 

HIV-positive patients have difficulty maintaining even 

80% adherence. This shows that much more efforts are 

needed to encourage adherence to ARVs if the overall 

positive effect of ARTs is to be maximized. 

According to 2007 estimates, in Uganda, about 

80,000 people were on ARVs, out of the one million 

people living with HIV/AIDS. Of the one million 

about 250,000 people needed ARVs. This showed that 

chances of people getting ARVs were far from being 

achieved (UNGASS, 2008). 

Moreover, AVERT (2008) noted that HIV prevalence 

in Uganda by then may have been rising again, and 

that by that time the number of deaths out of this 

disease matched that of its infections. To address this 

challenge there would be need for appropriate IEC 

especially in villages where IDPs had resettled. Yet the 

IOM research cited above revealed that 34% of IDP 

locations were not receiving IEC. 



With many of the IDPs who were subject to the 

IOM survey relocated to villages, the researcher had 

envisaged that the same problem was likely among 

the resettled persons in addition to the then foreseen 

various challenges. 

RESEARCH METHODOLOGY 

The research was a descriptive study and was both 

quantitative and qualitative. It was carried out in Gulu 

district, among HIV infected people registered in 

TASO Gulu, who had lived in Koro Abili and Palenga 

IDP camps. The sample size included 100 respondents, 

among them 25 health workers from TASO Gulu. Of 

the 75 HIV positive patients, 37 were those who had 

lived in Palenga IDP camp while 38 had lived in Koro 

Abili IDP camp. Random sampling procedure was used 

to select HIV/AIDS patients and their care and support 

givers, while a purposive sampling technique was used 

for the health care providers. Data were collected using 

questionnaires, interviews, and secondary data review 

and analysed using the SPSS version 12. 

RESULTS AND DISCUSSIONS: 

While about 50% of the respondents were aged below 

35 years old, 82.8% fell within the age bracket of 18 to 

45 years age. There were 64.0% female against 36.0% 

male respondents. Majority of the respondents were 

either peasant farmers or housewives (44.3% and 37.1% 

respectively) while 7.1 % were teachers and 4.3% were 

security guards. The implication is that majority of the 

respondents had very low income yet they regularly 

fall sick and their nutritional requirements are very 

high. Poverty as it were is a major contributor towards 

high morbidity and mortality amongst the HIV/AIDS 

positive clients. At the same time, majority of these 

patients are poorly schooled with only a few having 

attained a degree or a diploma. 

Continuation of HIV/AIDS Healthcare Management 

The study established that all the respondents (100%) 

agreed that the delivery of the HIV/AIDS management 

services did not stop with the resettlement of the IDPS. 

However, 11 (15.7%) respondents felt that the services 

reduced to less than half of what they were getting 

before resettlement. The continued service delivery 

can be attributed to the continued follow up by 

health workers of clients to their villages and effective 

counselling sessions where the clients were educated 

on the importance of meeting all their appointments. 

The Success of HIV/AIDS Management of Resettled 

Communities of Gulu District 

Of the total respondents who sought for HIV/AIDS 

management services 80% were on ARVs. It was 

established that, even those not on ARVs were eager 

to get other HIV/AIDS management services such as 

septrin-prophylaxis. Whereas those not on ARVs were 

made to understand that they were not ready to be put 

on the treatment, 7% believed that it was because of 

non-availability of these medicines, while 14.3% were 

not sure as to why they were not put on the ARVs 

despite testing HIV positive. 

Duration the Respondents have been on ARVS 

According to Figure 1, 46.4% of respondents had been 

on ARVs for two years and 32.1% for one year, as the 

two periods with the largest clients. About 9% of them 

had been on the medicines for more than three years 

and about 7% for less than 6 months. 

Figure 1: Duration the Respondents have been 

on ARVS 

Source: Primary Data 



Level of Availability of HIV/AIDS Management 

Services as Rated by the Respondents 

The level of availability of HIV/AIDS management 

services as rated by the respondents, is shown in Figure 

2. It can be seen that most of the services scored highly 

except for food rations and financial support. In other 

words, whereas most of the services were adequately 

rendered, the clients felt that there would have been 

need for them to be supplied with food and/or given 

financial support. The highest rated (above 90%) were 

ARVs supply and septrin-prophylaxis. These findings 

agree with the IOM (2006) that there is poor supply of 

food and financial support to HIV positive patients. 

Figure 2: Availability of HIV/AIDS Management 

Services 

Source: Primary Data Source: Primary Data 

This may be because the provision of food has not 

been an integral part in the health care package of 

HIV/AIDS clients as much as it is appreciated that 

such patients need good nutrition care. A number of 

organizations, TASO inclusive, have ventured along 

this line but on a limited scale. According to the UAC 

(2008) treatment of opportunistic infections is a core 

focus of the GoU in combating HIV/AIDS. Therefore 

availability of the medicines is considered paramount 

and as such the 94.3% and 97.1% for the ARVs supply 

and septrin-prophylaxis are commendable. 

Level of Satisfaction about HIV/AIDS Management 

Services 

As illustrated in Figure 3, the satisfaction of HIV/AIDS 

Management Services as rated by the respondents there 

was at an average level of 70% except for food ration 

and financial support. Of course the supply of food to 

the patients may be logistical, but definitely not giving 

the money. 

Figure 3: Level of Satisfaction about HIV/AIDS 

Management Services 



It can, however, be understood that patients would 

wish to be supported financially because they may in 

the cause of the disease have lost their jobs or income 

generating abilities or opportunities. It, therefore, 

becomes necessary to provide to such clients guidance 

for self-reliance activities since it may never be possible 

to financially support them considering that it is 

already financially straining to the national budget to 

even provide the ARVs. 

The Challenges of Management of HIV /AIDS of 

Resettled IDPs 

Figure 4 indicate that inadequate funding, difficulties 

in locating the new homes of resettled clients, high 

stigma, long distances from the current homes to the 

ART centre and bad roads are the major challenges 

in the HIV/AIDS management of the resettled IDPs. 

These challenges were expected bearing in mind that 

the IDPs initially came from far and wide as they ran 

away from the atrocities of the LRA. Now that they 

have resettled, a number of them are staying far from 

the health facilities and even some in areas that are not 

easily accessible by motor vehicles. 

Figure 4: HIV/AIDS Management Challenges 

Source: Primary Data 

Conclusion 

It is clear that the HIV/AIDS management has not 

been affected much by the resettlement programme. 

Of course, there have been a number of challenges 

such as the need for financial support and more food 

rations for the patients. The fact that food continues 

to be a problem among the HIV positive is an issue 

that demands attention as this increases the level of 

suffering among them. The findings that high stigma 

and long distance to medical facilities still pose a 

high challenge to the HIV/AIDS management of the 

resettled IDPs remain the main areas of concern and 

it is recommended that the Government addresses 

them. 



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26/11/ 2008 



Prevention of Mother To Child Transmission 

(PMTCT) of HIV: A Review of Service Delivery 

and challenges in Uganda 

1Alobo Jackie, 2Mshilla Maghanga 

1Gulu University Third Year Medical Student, 2Lecturer, Gulu University 

Background 

HIV/AIDS is a key threat to global health. It has 

been estimated that over 20 million people have died 

of AIDS since it was first diagnosed in 1981 and that 

there was an increase in the number of people living 

with disease from 35 million in 2001 to 38 million 

in 2003 (UNAIDS, 2004). According to UNAIDS 

(2006), at least 63% of the adults and children with 

HIV globally live in sub-Saharan Africa and that 72% 

of AIDS related deaths by 2006 had occurred in this 

region. To curb this trend, a comprehensive HIV/ 

AIDS strategy linking prevention, treatment, care 

and support for people living with the virus has been 

setup by the World Health Organisation (WHO) and 

adopted by individual countries worldwide. 

Mother-to-child transmission (MTCT) is when an 

HIV-infected woman passes the virus to her baby. 

This can occur during pregnancy, labour and delivery, 

or breastfeeding. Without intervention, HIV infected 

mothers have a 35% overall risk of transmitting HIV 

to their children PEPFAR (2009). Indeed, around 

15-30% of babies born to HIV positive women will 

become infected with HIV during pregnancy and 

delivery. A further 5-20% will become infected through 

breastfeeding (AVERT, 2010). In Africa, especially 

in the countries of eastern and southern Africa most 

severely affected by the HIV/AIDS epidemic, the 

transmission of HIV from mother to child during 

pregnancy, birth, and during the breastfeeding period 

is by far the most common way of HIV infection in 

children. It is believed that in sub-Saharan Africa each 

year more than 500,000 women who live with HIV/ 

AIDS become pregnant and give birth (Gundel et al 

2003) hence a high percentage of babies are expected 

to be infected. MTCT of HIV accounts for the vast 

majority of the more than 700,000 new HIV infections 

in children worldwide annually. 

In December 2002 around, 3.2 million children were 

infected with the virus around the world, 90% of them 

in Africa. Since the prognosis is poor in children than 

in adults, 20% to 25% of them will die within the 

first two years of life, and 60% to 70% before reaching 

their fifth birthday (Gundel et al 2003). 

In 2001, the number of infants who became HIV positive 

through MTCT of HIV virus during pregnancy, birth 

and during breastfeeding was estimated at 800,000. 

Almost 90% of them lived in Sub Saharan Africa. At 

the country level, according to a study by Gundel et al 

(2003), this translated to an estimated 40,000 AIDSrelated 

infant deaths in Uganda and 56,000. It was 

recognized that the most effective way of protecting 

children is by preventing infection in parents UN 

IRIN (2008) According to the Ministry of Health of 

Uganda (MoH, 2006), HIV prevalence was as high as 

40% among antenatal care attendees in some parts of 

Africa and AIDS related maternal deaths had increased 

dramatically and had begun to out space those due to 

obstetric causes. 

MoH (2006) reported that MTCT of HIV is virtually the 

only way those children under five years of age acquire 

the virus in Uganda, and the burden among children 

is of great concern to the health sector. For example, 

the Financial Year (FY) 2004/05 sero behavior survey 

reported a national HIV prevalence among women 

of reproductive age of 6.5%. This would translate to 

almost 25,000 HIV infections among children each 

year unless effective interventions of preventing vertical 

transmission are implemented. 

The most important approach for avoiding mother 

to child transmission (MTCT) of HIV is still the 

primary prevention of HIV infection in young women 

through education, counseling, sexually transmitted 

disease (STD) treatment, condom use and so on, 



within the scope of comprehensive multisectoral HIV/ 

AIDS control programmes (Gundel et al 2003). The 

provision of antiretroviral (ARV) drugs to pregnant 

women living with HIV can reduce transmission to 

below 2%, yet 20,000 children in Uganda become 

infected annually, accounting for an estimated 42% of 

all new infections in the country according to Family 

Health International [FHI] (2007). 

According to Gundel et al (2003), “the major 

components of the PMTCT Programmes are 

sensitisation of the general and the target population, 

continuous support and training of the health personnel, 

improvement of infrastructure in the intervention sites 

and implementation of voluntary counselling and 

testing services (VCT).” Others include procurement 

of reagents, supplies, test kits, drugs, offering of 

nevirapine, infant feeding counselling and replacement 

feeding, if wanted, HAART for mothers, their children 

and partners, implementation of a monitoring and 

evaluation system, and accompanying research. 

The high prevalence of both obstetric related maternal 

mortality and HIV among pregnant women in most 

African nations shows the need for programmes that 

simultaneously address both problems (CHANGE, 

2005). The FHI (2007) reported that integrating 

PMTCT within the health care delivery system has 

proven that it is possible to provide services to pregnant 

women living with HIV and their families with better 

outcome. In Tororo Uganda, 90% of pregnancies 

among HIV positive women were observed to have 

been unintended and this highlighted the need to 

integrate the country’s family planning and HIV 

services. Providing such services could help HIV 

positive women avoid unintended pregnancies and 

where pregnancies occur, contribute to PMTCT. For 

example, it was established that integrating family 

planning services within Voluntary Counseling and 

Testing (VCT) centers improved family planning 

service provision without compromising VCT quality 

of care in Kenya (FHI, 2007). Similarly, an assessment 

of the cost of two models of integrating HIV VCT into 

family planning clinics in South Africa’s Northwest 

province found that the integration made either service 

less expensive. 

PMTCT programmes in Uganda were first piloted in 

the year 2000 in Kampala and in the northern districts 

of Arua and Gulu but the services are now available in 

most health facilities all over the country (UN IRIN, 

2008). Studies have also shown that knowledge of 

the availability of services and correct infant feeding 

options after birth are still low. Many HIV positive 

women do not know what food or drink to give their 

breast feeding babies. Instead, cultural beliefs, social 

stigma, ignorance and economic status influence 

their attitude and preference for the different feeding 

alternatives being used (UN IRIN, 2008). 

The benefits of the PMTCT programme 

According to Nuwagaba, Mayon, and Okong (2007) 

the benefits of the PMTCT programme in their 

study included improved health seeking behaviour 

among women, acquisition or refurbishment of new 

buildings put in place to accommodate the PMTCT 

staff plus new equipment, training of hospital staff 

and the first PMTCT sites to be established becoming 

resource centres for training other health workers. 

Other benefits included sharing experience and giving 

technical advice, improved obstetric care and laboratory 

services, increase in the number of women delivering 

in the hospital, and reduced chances of MTCT of HIV 

among others. 

In northern Uganda where conflict has severely affected 

health services, an estimated 70% of women have access 

to PMTCT services. The MoH had intended to scale 

up the services to all county level health centers by 

2010 and indeed the services are now available at most 

county level health centers (UN IRIN, 2008). As such, 

despite the insecurity caused by a two-decade-long 

war, PMTCT programmes in the region are reported 

as largely successful. For instance, the Association of 

Volunteers in International service (AVSI), reported an 

acceptance rate of above 90% of its HIV testing and 

counseling programmes in Kitgum and Pader districts 

between May 2002 and September 2003; and that 

more women are now attending an antenatal clinics 

and delivering in health facilities (UN IRIN, 2008). 

At the same time, the HIV prevalence ranged between 

5% and 9% so in these two districts 

(Ciantia et al., 2004). 



The PMTCT Policy in Uganda: 

The MoH of Uganda with support from development 

partners initiated and scaled up a programme for 

PMTCT under the first Health Sector Strategic Plan 

(HSSP I). The broad objective was to reduce MTCT of 

HIV by 50% by the year 2010 with a goal of achieving 

a HIV and AIDS free generation in the long run (MoH, 

2006). In line with this, all pregnant women are to be 

given the antiretroviral medicines (ARVs) under the 

highly active antiretroviral therapy (HAART). HAART 

is a combination of three or more life prolonging ARV 

drugs rather than single dose Nevirapine which was 

initially used. 

The WHO now recommends the use of ARVs starting 

at 14 weeks of gestation and continuing through to the 

end of the breastfeeding period and that breastfeeding 

should continue until the infant is one year old (UN 

IRIN (2008). Since there are several possible effective 

combinations of ARVs, the policy on PMTCT of 

Uganda recommends that pregnant women with HIV 

infection should be treated with one of the following 

ARVs regimens (MoH, 2003): 

i. Nevirapine tablet 200mg orally as single dose at 

the onset of labour and Nevirapine syrup 2mg/ 

kg body weight single dose to the baby within 72 

hours of birth. 

ii. Zidovudine (ZDV, AZT) tablets 300mg orally 

twice a day from 36 weeks of gestation until onset 

of labour; then 300mg orally, 3 hourly from onset 

of labour until delivery of the baby; followed 

by 300mg orally twice a day for one week after 

delivery. And Zidovudine syrup 4mg/kg body 

weight, twice a day to the baby for the first week 

after birth. 

iii. Zidovudine (ZDV, AZT) tablets 300mg and 

Lamivudine (3TC) tablets 150mg orally twice 

a day from 36 weeks of gestation until onset of 

labour; then 600mg-loading dose of Zidovudine 

orally followed by 300mg 3 hourly, with 150mg of 

Lamivudine twice a day from onset of labour; and 

then 300mg Zidovudine with 150mg Lamivudine 

twice a day for one week after delivery of the baby. 

And Zidovudine syrup 4mg/kg body weight with 

Lamivudine syrup 2mg/kg-body weight, twice a 

day to the baby for the first week after birth. 

Uganda’s PMTCT policy follows WHO guidelines, 

but acknowledges that the majority of Ugandan 

mothers can not afford formula feeds because of high 

levels of poverty, the low status of women, stigma, 

and an almost universal breast feeding culture (MoH, 

2003). For example, the rising cost of food in northern 

Uganda is forcing HIV positive new mothers to turn 

to the risky alternatives to formula milk instead of 

exclusive breast feeding as recommended by health 

professionals (UN IRIN (2008). 

Challenges Facing PMTCT Services in Uganda 

Despite the severally reported successes of the 

PMTCT programme, a number of challenges have 

been experienced. For instance, the insurgency in 

northern Uganda resulted into displacement of the 

population and disruption of the delivery of health 

services including the PMTCT services as relates to 

accessibility of PMTCT sites and the delivery of test 

kits, drugs, and sundries. In line with this, there were 

reduced ANC attendance and health facility deliveries 

(Ciantia et al., 2004). 

Another challenge is that the large and growing unmet 

need for paediatric HIV/AIDS services demonstrates 

the failure of PMTCT programmes to avert MTCT. 

Whereas about 50, 000 children are thought to be in 

need of the ARVs, just over half of Uganda’s 310 ARV 

sites actually provide paediatric HIV/AIDS treatment 

despite the WHO recommendations that every HIV 

positive child under one year be put on treatment 

(UNGASS (2008). 

At the same time, many women in the rural setup 

are still giving birth at home making it impossible to 

administer the ARVs that could prevent the MTCT of 

HIV. Despite about 98% of pregnant women agreeing 

to HIV testing and counseling, only 67% return for 

their results (UN IRIN (2008). Further to this, of those 

who test HIV positive, very few of them deliver their 

babies in the health facilities. This situation has been 

blamed on the long distances to the health facilities 

(especially in rural areas), poor quality of services, lack 

of qualified health workers in the health facilities, and 

lack of adequate maternity infrastructure. There is also 

a low male involvement in PMTCT, and sometimes 

the men even prohibit their spouses from participating 

in the programme. 

There are also several challenges to the PMTCT 

programme that are experienced by the health 



workers at the health facilities. For examples, a study 

by Nuwagaba et al (2007) reported that there was 

reluctance of women to be tested for HIV (possibly 

due to spouses’ influence), incomplete follow-up 

of participants, non-disclosure of HIV status, and 

difficulties with infant feeding of babies born of 

HIV positive mothers. At the same time, there were 

shortages of PMTCT trained staff, lack of motivation to 

deal with the increased workload, and lack of adequate 

skills and training of health workers rendering the 

PMTCT services. 

There is also shortage of space for counseling, and 

hence, privacy and confidentiality are sometimes 

compromised. This is made worse by long waiting 

periods for post-test counseling. Laboratories are also 

lacking in adequate space and facilities, the notable 

ones being those used for liver and renal functioning 

tests, viral load determination, confirmatory HIV serostatus 

and the like. 

Conclusion 

There has been a tremendous increase in the PMTCT 

coverage in Uganda in the last two decades. However, 

there have also been several challenges that have 

been faced at all levels of service delivery as faced by 

the health workers, the patients and at the health 

facilities. These have contributed to the low paediatric 

ART access. Most mothers in Uganda and especially 

those in post-conflict northern Uganda can not 

afford infant formulae and yet MTCT of HIV can be 

reduced if support towards baby feeding is provided. 

In general, the recommended PMTCT interventions 

can be undermined if the all-round approach 

targeting the provision of ARVs, equipping of health 

facilities, training of health workers, mobilization and 

sensitization of pregnant mothers, and the provision of 

paediatric HIV/AIDS services is not strengthened. 

Recommendations: 

In line with the magnitude of the challenges facing the 

PMTCT programme, the following recommendations 

are worth noting: 

i. The MOH and NGO service providers should 

mobilize resources for nutritional support 

for replacement of feeding for babies born to 

HIV positive mothers who have registered for 

prevention of vertical transmission services. 

ii. Pediatric HIV/AIDS services should be made 

more available, accessible and sustainable by 

majority of the Ugandan population in need of 

those services. 

iii. Empowerment of women in Uganda should 

continue so that poverty is alleviated amongst 

the women, so they would afford replacement 

therapy. 

iv. Male involvement in PMTCT should be 

encouraged so that they provide support to the 

HIV positive mother hence reducing MTCT of 

HIV. 

v. The Government of Uganda should improve 

hospital laboratories and install modern diagnostic 

equipment so that babies can be tested early for 

HIV and their status is known as this is important 

in guiding the intervention measures. 



References: 

AVERT (2010): Preventing mother-to-child transmission of HIV (PMTCT). Accessed on June 12th, 2010 from 

http://www.avert.org/motherchild.htm 

CHANGE Project (2005). Academy for educational development - 

Ciantia F, Zucca M, Azzimonti G, Castelli L, Caracciolo C (2004); International Conference on AIDS (15th : 2004 : 

Bangkok, Thailand): Challenges of running PMTCT in conflict areas: AVSI’s experience in northern Uganda. 

Accessed June 12th, 2010 from http://gateway.nlm.nih.gov/MeetingAbstracts/ma?f=102283158.html 

FHI (2007), Family Health International. Family Health Research, South Africa, March 2007 volume 1issue1, 

pages 1-4. 

Gundel Harms, Angelika Mayer and Heiko Karcher (2003): PMTCT Prevention of Mother-to-Child Transmission 

of HIV in Kenya, Tanzania and Uganda. Accessed on June 12th, 2010 from http://www.gtz.de/de/dokumente/ 

en-gtz-pmtct.pdf 

MoH (2003): Policy for Reduction of the Mother-To-Child HIV Transmission in Uganda. Accessed on June 15th, 

2010 from http://www.aidsuganda.org/website%20general%20info/PMTCT%20Policy.pdf 

MoH (2006): Ministry of Health Policy Guidelines for PMTCT of HIV in Uganda - 2006 to 2010. Accessed on June 

12th, 2010 from http://www.health.go.ug/index.php? 

Nuwagaba-Biribonwoha, H., Mayon-White R. T., Okong, P. (2007): Challenges faced by health workers in 

implementing the prevention of mother-to-child HIV transmission (PMTCT) programme in Uganda. Journal 

of Public Health 2007 29(3):269-274; doi:10.1093/pubmed/ fdm025 

PEPFAR (2009): United States President’s Emergency Plan for AIDS Relief. PEPFAR-PMTCT report 2009. Accessed 

June 12th, 2010 from http://www.pepfar.gov/press, 2009) 

UN IRIN (2008): UN Integrated Regional Information Networks, Uganda: Home births hamper PMTCT 

programme. Accessed May 28th, 2010 from http:/www.Irinnews.org. 

UNAIDS (2004) Report on the global HIV/AIDS epidemic. 4th global report.WHO Library Cataloguing-in- 

Publication Data. Accessed June 12th, 2010 from http://www.unaids.org/bangkok2004/gar2004_html/ 

GAR2004_00_en.htm 

UNAIDS (2006). Report on the global HIV/AIDS epidemic. Accessed June 10th, 2010 from http://earthtrends. 

wri.org/updates/node/41 

UNGASS (2008). Country Progress Report Uganda: January 2006 to December 2007. Accessed June 12th, 2010 

from http://www.pepfar.gov/press, 2009) 



Potential factors in Neurocognitive Development 

in the unborn and young infants 

in Northern Uganda 

A number of potential factors together affect the 

neurocognitive development of the human unborn, 

infants and young children in rural Northern Uganda. 

The need to appreciate the complex interplay between 

these factors should be obvious in health sciences 

education in the hope that future health care practice 

will integrate and be influenced by holistic social, 

cultural and scientific knowledge and evidence base. 

This paper provides and overview of the various 

factors that might affect the early stages of human 

development from pregnancy to the first three years 

of life. 

Socio-cultural factors 

Members of rural communities are closely linked 

and interdependent. The larger rural community 

discourages free expression of diversity in opinion 

among individual members. Social cohesion between 

groups shapes and determines how pregnant and 

lactating mothers should care for their unborn, the 

infant and young child, and how mothers and their 

immediate family members must behave and relate to 

one another in the upbringing of their children. The 

fear of taboo, supernatural forces, and ancestral spirits 

and ostracism for non-compliance with wider rules of 

conduct in the community may limit free exploration 

required for neurocognitive development and growth 

of infants and young children. Cognitive development 

and functioning is shaped by the general expectations 

and environmental dictates of communities. 

Domestic violence 

Violence in homes, particularly against women and 

young children is common. Much of this violence 

is secondary to alcohol abuse or dependence. 

Unrecognized psychological disorder among spouses 

may be an additional factor. The impact of domestic 

violence on both the mother and her children (born or 

Emilio Ovuga 

Gulu University Faculty of Medicine 

emilio.ovuga@gu.ac.ug / emilio.ovuga@gmail.com 

unborn) can be both diverse and adverse, including the 

development of depressive disorder, anxiety disorders 

and general feelings of insecurity. Poor mental health 

of mothers impairs their ability to care for their young 

children. Childhood emotional disorders impacts 

negatively on school performance and personality 

development. The long-term results of domestic 

violence may include the internalization of violence by 

young children who may themselves become violent in 

their adulthood, and consequence that can only serve 

to propagate violence in future generations. 

Child rearing practices 

Child rearing practices in rural communities are generally 

harsh and children frequently receive severe beating, 

threats and intimidation in addition to being denied 

basic needs of life, such as food, health care, education 

and protection. In the name of disciplining young 

children, traumatized children continuously become 

re-traumatized on a regular basis. The problems arising 

from harsh rearing practices might result in severe 

but unrecognized symptoms of depression, anxiety 

disorders and suicidal and or behavioral problems. The 

role of health sciences education in this context should 

be community education and advocacy for improved 

child rearing practices and the promotion of the rights 

of children to health and safety and protection that are 

prerequisites for optimal neurocognitive development. 

Mass violence in Northern Uganda 

The more than two decades of mass violence and 

war in rural Northern Uganda left many children 

orphaned and having to become heads of their 

respective homes with no or limited access to the basic 

needs of life. The prevalence of post-traumatic stress 

disorder and depression among former child soldiers 

has been reported respectively at 87% and 58%. 

Neuro-imaging studies have demonstrated the long- 



term effects of exposure to gross violence on the brain, 

which in children can be expected to impair optimal 

brain development and growth. A recent study among 

children in Northern Uganda has similarly documented 

that at least one in every three children aged between 

7 and 17 years suffers from moderate to severe social 

functioning, anxiety disorder, depression or suicidal 

behavior. These results further highlight the need to 

recognize that violence has negative psychological, 

emotional and intellectual consequences and need to 

be integrated in health sciences curricula. 

HIV/AIDS 

Children who live with HIV/AIDS occupy nearly 70% 

of paediatric beds at Gulu Regional Referral Hospital 

(GRRH). It has been estimated that 70% of adult 

patients who suffer from HIV/AIDS at GRRH also 

suffer from concurrent tuberculosis, and the same 

situation might be the case for children in Northern 

Uganda. The early invasion of the brain by HIV is 

expected to affect the optimal development of children 

who live with HIV/AIDS. The negative impact of HIV 

infection on the brain arises not only from the early 

invasion of the brain by the virus but also the negative 

nutritional consequences of the disease on the body. 

Malnutrition 

Under nutrition among children aged less than 5 years 

is estimated at 35% in rural Northern Uganda. This 

finding may be related to the effects of the recent war in 

Northern Uganda combined with long spells of drought 

and poor crop yield. A systematic degradation of arable 

land in Northern Uganda associated with land overuse 

might mean that crop yields are progressively poor 

in essential nutrient content. Under the circumstances 

neurocognitive development is also expected to be less 

than optimal. 

Sensory impairment 

Between 3-5% of school children suffer from learning 

disability; the majority of these are due to unrecognized 

impaired hearing or impaired vision. A small proportion 

of school children suffer from mild brain damage that 

they sustained during childbirth. While the effects of 

brain injury during childbirth on brain and intellectual 

development might be difficult to mitigate, the early 

recognition of visual and auditory impairment and their 

correction can significantly improvement academic 

performance and social development of school children. 

Efforts by the Faculty of Medicine to address modifiable 

sensory impairment could significantly improve 

academic performance on national examinations, thus 

improving the chances of children from Northern 

Uganda to compete favorably for university and other 

tertiary institutions admissions. 

Potential Roles of the Faculty of Medicine and 

Medical Students. 

The Faculty of Medicine and its students have 

significant roles in the following areas: a) contributing 

to the body of knowledge in the field of neurocognitive 

impairment and its associated factors including efforts 

to identify and mitigate the negative effects of sensory 

impairment, under-nutrition and early child health 

problems b) influencing educational policy reform and 

educational services provision c) impacting on best 

clinical practices in the field of maternal and child health 

d) influencing policy on environmental protection and 

management for optimal crop yield e) understanding 

the long-term effects of war and organized violence 

on the growth and development of infant and young 

children’s brains exposed to violence, trauma and loss. 



HIV/AIDS stigmatization amongst the youths in 

Gulu, Northern Uganda. 

1D.L Kitara, 2E, Odongo-Aginya, 2 SO Balmoi 

1Dr. Kitara David Lagoro (PhD Fellow) 

(MBCHB, MMED, MPH, FCS (ECSA), PGD (PPM) 

Gulu University, Faculty of Medicine, Department of Surgery, P.O Box 166, Gulu, Uganda. 

2Dr. Emmanuel Odongo-Aginya (PhD) 

Associate Professor of Parasitology & Immunology, Faculty of Medicine, Gulu University. 

2Mr. Odong Stephen Balmoi (Dip. In Clinical medicine) 

Background 

Right from the beginning, the HIV/AIDs epidemic has 

been accompanied by an epidemic of fear, ignorance, 

and denial leading to stigmatization of and the 

decriminalization against people with HIV/AIDs and 

their family members (International center for Research 

on women, 2002). HIV/AIDs related stigma and the 

resulting discriminatory acts create circumstances that 

fuel the spread of HIV. The fear of being identified with 

HIV prevents people from learning their sero-status, 

changing unsafe behaviours and caring for the people 

living with HIV/AIDs. 

A study in Botswana and Zambia found that stigma 

against HIV positive people and fear of mistreatment 

prevented people from participating in voluntary 

counseling and testing and programs to prevent the 

mother to child transmission. The author argued that 

stigma and its resulting discrimination also intensifies 

the pain and the suffering of both people living with 

HIV/AIDs and their families. People living with 

HIV/AIDs are unfairly treated and or discriminated 

against because of their actual or suspected HIV 

status (Aggleton, Busza 1999), International center 

for Research on women 2002, Gilmore and Someville, 

1994, Goldin 1994). Discrimination against people 

living with HIV/AIDs, apart from denying them their 

basic rights, and is also an ineffective public health 

measure. The London declaration on AIDs prevention 

following the world summit of ministers of health on 

programs for the HIV prevention in January of 1988 

was the first international statement to recognize that 

“Discrimination against and stigmatization of HIV 

infected people and people living with AIDs and the 

population groups undermine public health and must 

be avoided.” 

Methodology 

This was a descriptive cross sectional study where 

both qualitative and quantitative data were obtained 

from amongst the youths in pece division in Gulu 

district. A structured questionnaire was administered 

to the youths of age ranging from 18 to 30 years in 

the Pece Vanguard parish in Gulu Municipality. Data 

was cleaned and analyzed manually. A total of 100 

respondents were interviewed from a random selection 

of the respondents. The level of knowledge, attitude 

and practices regarding HIV stigma was assessed. 

Findings summarized in to tables, charts and graphs. 

Results 

The results showed that 52% of the respondents 

were male and 48% females, 51% of the youths did 

not know about HIV stigma, of those who knew and 

understood stigma, 74% of the them received the 

information from the radios, 10% from friends, 5% 

from the youth clinic. 97% of the youths knew the 

location of the youth friendly clinic. 43% of the youths 

did not test for HIV/AIDs because of fear of stigma. 

Only 4% of the youths would carryout stigmatization 

to their family members while 90% of the youths have 

practiced stigma on other people and are still willing 

to continue doing it as a method of HIV prevention. 

56% of the respondents believe that stigmatization to 

HIV/AIDs is the only and sure way of reducing HIV 

infection. 

Conclusion 

There is sufficient knowledge (49%) about HIV 

stigmatization; however there is a poor attitude of the 

youths towards HIV stigma. 56% of the youths in 

this region believe that HIV stigma is the way forward 

in reducing the spread of HIV/AIDs. There is a poor 



practice where (90%) admitted to have practiced 

stigma on those they suspected of being infected with 

HIV/AIDs. 

Recommendations 

The ministries of health, Ministry of Education should 

help introduce HIV related stigma issues in the syllabus 

in the secondary and primary schools in order to reduce 

it amongst the youths. 

Prevention and mitigation of stigmatization on HIV 

person should be made in to policy, adopted and spread 

among the youths by the ministry of health. 

Introduction 

HIV/AIDs related stigma and discrimination has 

been called an epidemic in its own right (Mann 1987) 

and the single greatest obstacle to effective national 

response to HIV/AIDs. The concept and practice 

of stigma originated in the ancient Greece with the 

use of bodily marking to identify socially deviant or 

inferior members of the society (Varas Diaz et al). In 

the context of the HIV/AIDs epidemic, HIV related 

stigma is described as a process of devaluation of people 

either living with or associated with HIV and AIDs 

discrimination following stigma and is the unfair and 

unjust treatment of an individual based on his or her 

real or perceived HIV status (UNAIDs 2003). 

HIV/AIDs stigmatization & culture (HASD) 

HASD has been identified and described all over the 

world in both national population and ethnic subgroups 

with the most negative impact on a variety of issues 

ranging from HIV prevention and testing (Brooks 

et al 2005) access to treatment and care (Aggleton 

2000), identity (Flowers et al 2006), (Hernandez and 

Torres 2005) disclosure of status (Liu et al, Clark et 

al 2005), there is greater stigmatization of particular 

groups due to preexisting prejudices against particular 

sexual lifestyle. In this study, the majority of the youths 

agreed that they could place stigma on their sister who 

were prostituting in order to discourage others from 

joining the group. Norman and Carr 2005, Norman et 

al 2006 found generally high levels of stigmatization 

among University students in Jamaica and significantly 

less sympathy for those considered “sex/gender 

transgressors”. Women were found more under HASD 

than men because of the presumption of promiscuityculturally 

unacceptable behaviours for women (Hong 

et al 2004) persons living with HIV/AIDs were able 

to evade much HASD through what Anderson (2007) 

calls “stigma avoidance strategies” the most important 

of these are limited to disclosure, deception and 

engaging in casual and doomed relationships or in no 

relationships at all, secrecy is then the key part of living 

with HIV. Norman et al 2006 found that most of the 

students they interviewed claimed that they would 

not place stigma on an HIV- positive family member 

or a friend, this non avoidance was associated with 

sympathy, HIV knowledge, education and awareness. 

This argument is also reflected in this research where 

90% of the respondents admitted to have ever practiced 

stigmatization and that only 8.9% of them have ever 

placed it on their friend and only 4.5% of them have 

ostracized a family member as a result of sympathy 

they have for some of their family members they hold 

so dear compared to the 73.3% placed on someone 

known to them but 13.3% on strangers. 

The impact of stigmatization on the fight against 

HIV/AIDs: 

Stigmatization has exacerbated the problems faced 

by children orphaned by AIDs. Orphans encounter 

hostility from their extended families and communities 

and may be rejected, denied access to schooling and 

health care and left to fend for themselves. 

The wide spread of stigmatization is held accountable 

for the relatively low uptake of prevention of mother 

to child transmission (PMTCT) programs in countries 

where treatment is free. In Botswana for example, 

despite the fact that antenatal services is available 

and free in every antenatal clinic in the country, only 

26% of the pregnant women availed themselves for 

the opportunity to protect their unborn children. Over 

half refused to take tests and nearly half of those who 

tested positive did not accept treatment. 

Despite the relatively cheap institutional support for 

HIV/AIDs, patients still shy away from the services 

(Mildmay center Mugisha Kemirembe et al 2000). 

At HIV clinic, patients seeking HIV/AIDs care and 

treatment were closely observed with regard to their 

social and psychological behaviours and the nature of 

the complaints they presented with or their relatives’ 

complaints. It was noticed that stigma was a major 

problem to the patients and their caregivers. Majority 

of the patients presented in stage III of the disease 

progression, with multiple opportunistic infections and 

would always be forced to the clinics by the relatives. 



The patients who presented early were characterized 

with false identity, multiple registrations with different 

names to avoid being known. They would try to get out 

of the center as soon as possible, usually not completing 

all the necessary care procedures. Some families refuse 

to take their relatives to the clinic for fear of being 

identified with HIV/AIDs themselves. Some religious 

faiths in Uganda act as a deterrent to the seeking HIV/ 

AIDs care at all or early enough, therefore despite the 

massive education in Uganda, still some HIV/AIDs 

patients decline to go to the health care centers because 

of stigma (Mugisha Kemirembe et al 2000). 

HIV/AIDs stigmatization and mental health. 

Dr. Ben Olley 2004 concluded that HIV/AIDs stigma 

is usually associated with high rates of psychiatric and 

emotional problems. He found out that these problems 

contribute to the people not sticking to their drug 

regiments. It can even speed up the progression of the 

disease and hasten the death of the patients. 

The level of HIV/AIDs stigma is high in Uganda and 

particularly Northern Uganda and has highly and 

negatively impacted on the progress of the prevention 

because people fear to disclose their status (Neoman 

Kaleeba TASO, 2008). 

Unfortunately the risk of transmission has been 

used by numerous employers to terminate or refuse 

employment for the victims. It has also been found 

that if people living with HIV/AIDs (PLHA) were open 

about their status at work, they may well experience 

stigmatization and discrimination by fellow employees. 

In some developing countries some instances of 

compulsory pre-employment testing took place; some 

of these industries have used the information to deny 

employment to people with HIV or AIDs (Herek GM, 

Mitnick, L 1998). 

The same associated with AIDs – a manifestation 

of stigma has been described by some writers as 

“internalized” stigma- may also prevent people 

living with HIV from seeking treatment, care and 

support and exercising other rights such as working, 

attending school etc. Such shame can have a powerful 

psychological influence over how people with HIV see 

themselves and adjust to their status, making them 

vulnerable to blame, depression and self-imposed 

isolation (UNAIDs 2005) 

Methodology 

This was a cross sectional study using a prepared 

questionnaire designed to collect data randomly from 

the youths aged between 18 to 30years in Pece division 

in Gulu Municipality. The data collected was obtained 

using a questionnaire that was designed in English 

focusing on the study objectives and the other sociodemographic 

characteristics of the respondents. During 

the interview the research assistants interpreted the 

questions in to the local language in the case of those 

who could not understand English. 

Total random samples of 100 respondents were 

selected, interviewed from different households, 

villages and parishes to complete the numbers for the 

study population. 

The study variables were controlled by interviewing 

only respondents who were residents of the area of study. 

The data was analyzed and presented in tabulations, 

figures, charts and graphs for easy interpretation. 

The study was conducted in accordance with the 

ethical protocol for the conduction of research projects 

on humans through observing confidentiality and 

obtaining of informed consent from the respondents. 

Results 

The respondents were interviewed to assess their level 

of knowledge, attitude and practices towards HIV/ 

AIDs stigmatization. A total of 100 respondents were 

interviewed and results presented in figures, tables and 

graphs 

The ages: 

The patients’ ages ranged from 18 to 30 with a mean 

of 25 years and the peak being the age set of 25 -28 

years. 

The sex: 

Male to female ratio of 1.1:1 (52%:48%). Most of the 

respondents were males. 

Knowledge: 

Knowledge of the respondents to HIV stigma: 

There was fair knowledge of respondents to HIV 

stigma (49%) but the majority 51% did not know 

exactly what the meaning of stigma was. According to 

them abuse, denial of food and refusal to share utilities 

was HIV stigma. 



Sources of information about HIV stigma: 

74% of the respondents were informed through radios, 

15% from friends, 10% from youth friendly clinics and 

1% from others. 

Knowledge of respondents about the proximity of 

any youth friendly clinics: 

97% of the respondents knew the location of the youth 

friendly clinics whereas 3% did not know at all. 

Attitudes: 

Distribution of the respondents by attitudes towards 

HIV testing: 

43% have not or did not test for HIV/AIDs and only 

57% tested for the virus. 

Respondent’s feeling about disclosing their 

status: 

82% of the respondents who tested could easily disclose 

their status. And only 18% felt bad about disclosure of 

status. 

Categories of people affected by stigmatization on 

HIV/AIDs: 

Family members 4.5%, friend 8.9%, someone you 

know 73.3% and a stranger 13.3%. 

Distribution of respondents who thought 

stigmatization of those with HIV/AIDs could 

reduce HIV/AIDs spread: 

56% of the respondents’ reason for stigmatization 

on HIV/AIDs was to reduce infection and only 44% 

believed it would not reduce infection with HIV/ 

AIDs. 

Discussions: 

Knowledge on HIV/AIDs stigma: 

The study revealed that the knowledge of the 

respondents were relatively universal with almost half 

of the respondents 49% able to define correctly what 

HIV stigma was, and most of those who learnt about 

HIV stigma heard about it from the radio, others 

from friends and youth friendly clinics. The radio 

was found to be the best medium for communication 

and dissemination of information about HIV related 

stigma. Those who could define the stigma well (51%) 

only thought stigma only occurred when a suspected 

HIV positive victim was abused verbally for which 

many authors including Gilmore and Somerville 1994 

would not agree since they said stigma should be felt, 

perceived or enacted and some of these youths learnt 

about stigma from friends. 

The majorities of the youths were able to define at least 

what stigma was and gave two or more examples of 

HIV related stigma most of them talked about isolation 

of those suspected to be infected from social activities 

such as cooking, eating from the same plate with other 

people and even sharing the same beddings. 

The majority of the respondents (90%) who admitted 

having practiced stigmatization said they did so basing 

on some of the perceived defining characteristics that 

are usually associated with people suspected to be HIV 

positive like weight loss, red lips, body rashes and 

persistent cough among others. Some of the youths 

admitted that they stigmatized some people on the 

basis of their lifestyles which were deemed unfit for a 

particular society for example when one is suspected 

of being a prostitute, it is suspected that she would be 

infecting others. 

The majority of the youths in the Municipality (97%) 

knew at least one or two of the youth friendly clinics 

though only 59% were able to attend the clinics and 

obtain the required services of HCT and out of all that 

10.3% were able to get information about HIV related 

stigma from these clinics. 

Attitude towards HIV stigma: 

The majority of the respondents who tested (82 felt 

good about disclosing their status only after finding 

out that they were HIV negative while the others 18% 

who were HIV positive were not at ease of disclosing 

their status for the fear of losing their friends and being 

talked about and stigmatized further. 

Of Those who ever practiced stigmatization (90%), 

73.3% have comfortably done them on people they 

knew, 13.3% practiced on strangers and only 8.9% have 

done it on a friend and 4.5% practiced stigmatization 

on their family members. When the youths were 

asked specifically if they would place stigma on one 

of their family members, 96% said they would not 

do such a thing on their family members while 4% 

said they would not have any problem placing it on 

their family members as long as it would help others 

avoid contracting the infection and if that process of 

stigmatization would discourage other members of the 

family making the same mistake. This was because 

most of the respondents believe immorality was the 



main source of contraction of HIV and these immoral 

acts such as prostitution should be discouraged. 

In this study the majority of the respondents believe 

that stigmatization of those suspected of being HIV 

positive is one of the ways by which the spread of the 

pandemic could be controlled, it is in their believe and 

thinking that when one is suspected of being HIV 

positive and is frequently talked about, he/she would 

be made known to the community members and 

therefore those in the community would take extra 

care in choosing their sexual partners in which case, thy 

would probably not go for the suspected HIV positive 

member of the community. 

Many of the respondents who subscribe to this notion of 

pointing a finger believed that by constantly pointing 

a finger at those suspected to be infected would go a 

long way in reducing the spread of the pandemic since 

one day all members of the society will know them and 

stop choosing them as sexual partners and this could 

isolate them one by one and one day they would die 

and leave the society free of HIV/AIDs. 

Practices to HIV/AIDs stigma: 

The study revealed that the majority of the respondents 

were practicing HIV related stigma with 90% of the 

respondents having practiced stigmatization to a 

suspected HIV positive patient though only 62% of 

those agreed that it was the best way of controlling the 

spread of HIV pandemic within their community. 

The study also revealed that the majority (97%) of the 

youths knew the location of the youth friendly services 

and with only 3% of the respondents having admitted 

that they were not aware or had no clue of such clinics 

and out of those who knew about the location of the 

clinics and the services only 59% of them went to visit 

the clinic and tested for HIV and again only 10.3% of 

them were able to get information about HIV related 

stigma from these youth friendly clinics therefore it 

looked even certain that at the youths centers, youths 

were not provided with the adequate information on 

HIV related stigma during interactions between the 

service providers and the youths in question. 

Conclusion: 

1. There is adequate knowledge of the youths to 

HIV stigma 

2. There is poor attitude of the youths towards HIV 

stigma with 56% of the youths believing that 

HIV stigma is the way forward in reducing the 

spread of HIV/AIDs. 

3. The practice of HIV stigma is still rampant 

with 90% of the respondents admitting to have 

practiced stigmatization on those they suspected 

of being infected with the HIV virus. 

Recommendations: 

The challenges facing Northern Uganda are enormous 

and especially given the severity of the HIV/AIDs 

epidemics. The following recommendations have been 

made: 

1. The ministries of health, Ministry of Education 

help introduce HIV related stigma issues in the 

syllabus in the secondary and primary schools in 

order to reduce it amongst the youths. 

2. Prevention and mitigation of stigmatization on 

HIV person should be made in to policy, adopted 

and spread among the youths by the ministry of 

health. 



References 

1. International center on women, 2002: stigmatization and women. 

2. Janice and Hogle: Declining HIV prevalence, behaviour change and national response. 

3. Man J (1987): Statement at informal briefing on AIDs to the 42nd Session of the United Nations General 

Assembly, 20th October. 

4. Herek GM and Capito JP (1993): Public relations to AIDs in the United States, a second decade of stigma. 

5. Coates SM, Christopher TJ, Lazarus JL (1989): Perception of AIDs, the continuing saga of AIDs related 

stigma. 

6. Malcolm A, Aggleton PJ, Bromfman, MM, Galvao J, Mane P and Verral J (1998): HIV and AIDs related 

stigmatization and discriminatory journal. 

7. UNAIDS (2003): Report on HIV/AIDs and its stigma and impact on the fight against the pandemic 

8. UNAIDs (2005): Report on HIV/AIDs and the stigma and its impact on the fight against the pandemic: 

9. UNAIDs (2007): Report on HIV/ AIDs and stigma and its impact on the fight against the pandemic: www. 

unaids.com/report2008 

10. Mugisha Kemirembe et al (2000). Mild may center report on HIV/AIDs 



Dealing with traditional fracture splint 

Figure 2: Tight splint immobilizing only the fracture 

Traditional fracture splints are locally made pieces of 

wood knitted together with either pieces of clothes, 

banana fibres, or sisal to form a rigid framework that 

can be used to immobilize the broken limbs of victims 

of road crush, falls, and or domestic violence. 

With the increasing number of physical body trauma 

especially due to automobiles, falling off heights, 

especially off mango trees, tall buildings under 

construction, and overloaded lorries, the majority of 

the victims sustain broken bones of the limbs either 

Mr. Kisige Michael 

Orthopaedic Surgeon, Gulu Regional Referral hospital 

kisigemichael@gmail.com 

the upper limbs or lower limbs, at far places away 

from health units. More often than not due to lack 

of paramedical ambulance services in our society, 

the community makes simple wooden splints as an 

alternative to help transport the victim with minimum 

pain to either the bonesetter or to hospital for 

treatment. 

The wooden splints locally made have existed in the 

community for a long time. However, few people seem 

to recognize what the community does to help the 

patients who have sustained broken long bones. They 

are the oldest splint before a British bonesetter Hugh 

Owen Thomas (1834- 1891) invented the famously 

used hospital Thomas’ splint that is used to splint 

lower limb long bone fractures. 

The community designs local splints used to stop the 

injured limb from dangling during transportation, or 

to facilitate healing. In Modern orthopaedics, Thomas’ 

splints, Cremer wires and other industrially made 

splints are used for immobilization of fractures of limb 

bones. 

Learning how to make traditional splints is through 

participatory observation. Various communities use 

the available materials; for example in Buganda 

wooden sticks (Obuuti) or reeds and banana fibres or 

cloth, in northern Uganda commonly bamboo sticks 

(kor in Luo) are used with pieces of cloth or fibres from 

back of trees. Urban communities may make use of 

hard paper boxes that are wrapped round to suite the 

injured limb. The knitted splint or sticks are organized 

well round the injured limb, and then strapped by the 

pieces of cloths, sisal or banana fibres. 

During splintage, pressure is exerted through skin 

adequate enough to stop excessive movement of broken 

bones during transportation or muscle contractions, 

but not to compromise blood supply to the distal part 

of the injured limb. 

There should be adequate padding between skin and 



splint using cotton wool, cloths or any cushioning 

material available to avoid pressure to the skin that can 

result into skin forming blisters and subsequently open 

sores. Some people have used the normal limb to splint 

the injured one especially for lower limb fractures. 

Blood flow to the fractured limb should be keenly 

observed to ensure blood flow to its distal region which 

could be the hand or foot. Ideally preventing mobility 

at the site of fracture entails splinting the joint above 

and below the injured site, such that no movement is 

possible at the joints adjacent to fracture site. 

After immobilization of a fractured limb, it is possible to 

transport the injured patient from the scene of accident 

to home, hospital, bonesetter or from bonesetter to 

hospital with minimal pain. 

The traditional splints are easy to make using available 

local materials in community, and at no cost. 

They are a substitute to hospital fracture splints which 

are not there in the community or nearby health units 

and are acceptable by the communities. They are also 

used by traditional bonesetters to immobilize and 

maintain the broken bones together during treatment. 

Though they have helped society so much, if there is 

no adequate padding at all between skin and the sticks 

used, the patient usually develops pressure blisters and 

later sores. 

In most cases splints cannot stop mobility at the two 

nearby joints, this permits movements at the fracture 

ends causing further injury to soft tissues, and inciting 

much pain. The bone ends may pierce through the skin 

and protrude to the outside can pierce a nearby big 

blood vessel causing severe bleeding and even loss of 

the limb. If the sharp bone ends pierce through the skin 

and are exposed to the outside, they get contaminated 

with soil, grass, dung, that predisposes the patient to 

bacterial infections and worst is tetanus. In such a case, 

the bone ends should be covered with a piece of cloth 

or gauze and the patient should be taken to a health 

unit as soon as possible to get professional attention. 

When the splint is wrapped so tightly to the skin in 

order to achieve a firm immobilization of the fracture 

site; blood flow to the foot or hand can be interrupted 

or completely cut off. This result into swelling of the 

affected limb grossly, severe pain, and the patient may 

end up with dead hand or foot, and subsequently 

amputation of the leg or forearm. When the splint 

is too tight and causing severe pain, normally people 

tend to think that the pain is arising from the broken 

bone, and when the leg or arm increases to swell, still 

the community believes that the swelling is a normal 

feature following the trauma. 

If the splint has become too tight, or has stayed on the 

limb up to 2hours, relax the inelastic straps, and take 

patient quickly to a health unit to be assessed by a 

medical personnel. The Wooden splints may have spikes 

or thorns which can pierce the skin causing puncher 

wounds or sores. While making a wooden splint, it’s 

advisable to pad the skin with cotton, sponge, piece 

of cotton cloth, and use smooth round or rectangular 

pieces of wood. 



Abstract 

Helminth Infection in Gulu Municipality 

Sjoerd Redeker1; Peter Kizza2; Ambrose Katungi2; Julius Ocakacon2. 

1 Leiden University Holland; 2 Gulu University Uganda 

Introduction: Knowledge of the presence, the 

distribution and the intensity of helminth infections, 

is needed at different levels. At the National level, 

it is a prerequisite for the planning of prevention 

and control strategies. At the hospital level or at the 

local level in general, it is of paramount importance 

to decide on diagnostic strategies at the Out patient 

Department (OPD) and in the Laboratory. Uganda is 

one of the few countries in Africa South of the Sahara 

with extensive control programs for schistosomiasis 

and soil transmitted helminthes. Nonetheless, and in 

spite of the availability of nation-wide data, the data 

are not always accessible for use at the hospital or local 

level. To create data that are suitable to complement 

data generated by the national control programs, it is 

essential to make use of a comparable methodology 

Polderman et al. 2010; Odongo-Aginya et al.1995. 

Study objectives 

Data from the period before the war in North Uganda 

suggest that Schistosoma mansoni could be highly 

prevalent in certain parts of Gulu towns itself and 

probably in villages around as well . The poor socioeconomic 

conditions in the area have undoubtedly 

resulted in high prevalence of at least some of the soil 

transmitted helminths in Gulu area. On the basis of 

these considerations the objectives of the research was 

formulated as follows. 

• To assess the prevalence and intensity of infection 

of the most important intestinal helminths and 

schistosomiasis in Gulu and adjacent townships. 

• To compare the efficacy and the sensitivity of some 

diagnostic procedures, 

• (1) the Kato-Katz-procedure as used by the 

National control programs, 

• (2) The Aginya staining-procedure as developed 

by Odongo-Aginya, 

• (3) The Polderman direct-smear examination 

as commonly used in hospital laboratories,in 

Holland. 

• (4) The stool culture procedure for Strongyloides 

stercoralis, hookworms and Oesophagostomum 

bifurcum, as extensively used by Polderman. 

• (5) And the molecular procedure PCR in the 

diagnostic of pathogenic intestinal Parasites 

Study areas. 

• Four schools in divisions of Gulu Municipality 

were selected 

• Kasubi Primary school, 

• Baptist primary school Layibi, 

• Pece pawel primary school 

• Laro day primary school 

Study design 

Cross-sectional study was designed to assess the 

prevalence and intensity of infection of the most 

important intestinal helminths and schistosomiasis in 

the adjacent of Gulu municipality. 

Methods 

All patients were registered using their name, age, 

residential location and the duration. No attempts 

were made to enquiries into complaints to avoid biasing 

the microscopic results. Twenty pupils were selected 

randomly using paper picking method 

• The stool samples were examined by each of these 

different procedures. 

• The Aginya adaptation of the Kato-Katzprocedure 

• Polderman adaptation of the Kato-Katz the 

classical direct smear method. 

• The Kato-Katz-procedure as used by the National 

Schistosomiasis control programme 

• The filter-paper Stool culture in Petri-dishes 



Results 

The results of the study showed that a total of 603 

participants mainly school pupils from Kasubi, Pece 

Pawel, Baptist and Laro primary schools and a few of 

the staff of the schools were recruited in the study but 

only 582 of them gave stool specimens to be screened 

microscopically for Schistosoma mansoni and other 

helminthes infections. Out of 582 specimens screened 

117 (20.1%) were infected with S.mansoni. The males 

74 (12.7%) were more infected than the females 

42(7.2%). Other intestinal helminthes were infrequent. 

Nevertheless Kasubi primary school showed the highest 

percentage of infection 47.2% (59/125); followed by 

Laro 25.6 %( 32/125); Pece Pawel 16.0% (20/125) and 

the Baptist school had the lowest percentage of infected 

participants 11.2% (14/125). The results obtained by 

all the diagnostic methods were comparable. 

Conclusion 

Schistosoma mansoni infection is a big problem in all 

the schools. Therefore treatment is necessary for all the 

children in the schools and those with the same age 

group in the villages within the study areas. Although 

other intestinal helminthes were infrequent, there is 

need to deworm the children against these parasites 

periodically. Because of the similarity in the sensitivity 

of the diagnostic methods used in this study any of 

them can be used in a similar study. 

This study was guided by Professors Odongo-Aginya 

Emmanuel Gulu University and Ton A.Polderman 

University of Leiden Holland. 



I guess one of the happiest moments of a woman’s life is 

when she hears the first cry of her new born. However, 

it comes at a cost of enormous investment of time, 

effort, prayer and of course money. This scenario was 

synonymous with “Mother Faculty of Medicine Gulu 

University” on January/27th/2010 when she delivered 

her pioneer doctors who made themselves heard with a 

mighty cry of thank you Lord, we have made it. 

It was a ‘must’ witness for anyone who loves success 

because the joy was palpable as the “new borns” were 

donned in their black gowns, with the traditional 

crowns pitched on their heads walking heads high. 

The organizers had everything in place and 

all was clear on the programme that the day’s activities 

were to start with the inauguration of the new faculty 

building at 9:00am. 

Nine o’clock it was, and trust me, the décor was no 

disappointment. The atmosphere was lively and 

full of anticipation for what was to come and one 

interesting aspect was the topic of discussion as the 

young doctors bundled to share a few ideas about their 

new experiences. It was mostly about internship and 

statements like “how is it at your internship site?” 

And “Dr! Congratulations” were common sound 

stimuli. Being among the few continuing students 

around, I had to graduate from the old greetings of 

“Hi! wats up” to the only appropriate one of “Good 

morning Doctor”. Ideally we were guided by the ‘11th 

commandment’ -‘’Thou shall greet politely”. 

The inauguration of the new building of the Faculty 

of Medicine at the site of the faculty was no doubt a 

graduation of sorts, because mother Faculty was giving 

up an old and smaller uterus for a bigger and new one, 

ready in addition to the Lacor campus to carry to term 

the other pregnancies. No wonder it is a common 

utterance that ‘you educate a woman and you have 

educated a nation’. 

Patience always pays: 

What a climax it was! 

Kigonya Victor MBChB IV 2009/2010 

This heavy ‘starter’ prior to the main course of the 

day was honored by many dignitaries including 

the representative of the Italian Ambassador to 

Uganda, the Vice Chancellor (VC), the Chairman 

University Council, the University Secretary and 

many other guests of various capacities. Inspirational 

and appreciation messages were delivered flanked by 

moments of laughter and testimonies of achievement, 

as it was evident that it was a day of harvest. Finally 

the mega structure was officially handed over to 

the University by the Representative of the Italian 

Ambassador. Thereafter all roads were leading to the 

graduation grounds at the main Campus, about 800m 

away. Those who didn’t mind boarded the Faculty of 

Medicine bus because pride was at stake. 

Security at the grounds was tight as usual because you 

had to be among the short listed VIPs to get there. 

First on the list were the invited guests, then staff, 

graduands and their invited guests and of course the 

story tellers like me couldn’t be forgotten. 

The ceremony was not behind schedule as anticipated 

and it was not long before the Chancellor’s procession 

made its way to the graduation grounds and the special 

tents. Graduands from the different faculties each 

pitched at special camps and excitement matted with 

joy were looming the atmosphere because they could 

not wait to cross the finishing line. The VC set the ball 

rolling with a word for he couldn’t help but point out 

that Gulu University was sending out into the medical 

arena its first doctors (40 in total). “It all started in a 

dirty maternity ward”, he said, “which reminds me of 

the many mothers who never mind the circumstances 

of conception through pregnancy, but struggle to cross 

the finishing line in the labor suite, shanty house, hut, 

name it”. 

The criteria for awarding the respective achievements 

were well stipulated. The specific Deans were to step 

up to the podium, call up their graduands to whom 

the Chancellor gracefully awarded the respective 



achievements. Trust me it was a big day for many 

but most activities were punctuated by praises and 

appreciations for the great strides the Faculty of 

Medicine had made. In recognition for their great 

contributions many personalities were recognized 

including Prof. Ogwal Jasper Okeng (founder Dean), 

Prof. Luigi Greco (Associate Dean from University of 

Naples, Italy) and Prof. Emilio Ovuga (current Dean). 

Prof Luigi was awarded an Honorary Degree of science 

in recognition of his hard work and became the first 

recipient of such an award from Gulu University and 

no doubt he had been through it all to ensure success 

of the faculty. His acceptance speech was a road map 

to true success. 

When the Dean FoM walked up to read out the Doctors’ 

names, it was all chants and applause because what 

had been thought inconceivable was to be conceived 

in broad day light and history made. The chants were 

so deafening that activities came to a halt for a solid 

10 minutes. At this juncture no pride was at stake 

because parents, teaching and non teaching staff were 

all up in arms for the moment had come for doctors 

to walk down the aisle. As the Dean scrolled down 

his list alphabetically, every name was punctuated by 

the trademark Acholi scream. It was not over yet. The 

“new borns” had to recite the famous Hippocratic Oath 

amidst all the day’s dignitaries including the guest of 

honour, Hon. Amanya Mushega the State Minister for 

Education. If you have not yet imagined the extent 

of the excitement I have been talking about you can 

imagine how much I had to take snap shots because 

when it came to reciting the Oath, the five cameras I 

had hanging around my neck were all flashing with a 

low battery signal. 

In recognition for their endurance, hard work and 

ability to hold the light through the dark tunnel each 

of the doctors received a medal of appreciation from 

the Mayor of Naples, Italy. They were handed over by 

the Chancellor who congratulated them individually 

with a hand shake and a pat on the back. History had 

been written. 

VIVA PIONEERS for the path has been cleared. 



Graduation Pictorial 





I was a virgin 

Young, beautiful school girl 

I had my parents 

I was natured well 

We used to sleep in our traditional homes 

Not the cities of IDP Camps. 

The IDP Camps with poverty, disease and death as its 

only exit 

I used not to go hungry 

I was clothed well 

I had love given. 

But now I am suffering. 

Like an abandoned African Pot. 

Am abused 

Am stigmatised 

Am left to suffer 

My life’s now hopeless 

Filled up with sexual exploitations’ 

And now am very weak 

Emaciated 

My mosquito leg can’t move me 

My sunken eyes can’t see the sun, 

My head like a drum stick, beating the drum hard as 

sorrow fills the entire village 

No companionship 

No shelter 

Nothing at all to wet my lips 

My dry tongues searches in vain. 

Yet others dine with their puppies on the same table 

Just very hopeless life 

I live in my old mama patchy thatches 

All surroundings so dump 

My immediate neighbour the African toads 

The giant African toads that leave under my grandees’ 

old pot 

It kisses my cheek on the same floor 

It croaks and despises me. 

Very loudly; 

Croak, 

Croak 

It wasn’t my choice. 

By Sande Ojara MBChB III 2009-2010 

…croak! 

It’s your parents’ choice 

Your family chose it 

Croak, 

Croak, 

You suffer. 

Suf-fer.er.er.er! 

Croak, croak 

Why again scream. 

Wake up! 

This leaves my anger like an angry cobra. 

I lament, I am helpless 

It wasn’t my choice 

Neither my parents chose it. 

It wasn’t my choice…I cry 

All those to care for me perished 

Now I leave like a bustard 

A real street girl 

Others nick-named me prostitute 

Sir name ‘Apoli’ and many technically brushed me off 

as de-tooters. 

Tears roll over my wrinkled scaly face. 

Oh, no! 

My belly flap rest on the scattered papyrus mat, the 

only left animal skins my neighbour’s dog grabbed it. 

I now sleep barely on ground 

I yelled all night with insect stings mostly that of 

‘Cukulung’ stung. 

Again my grumbling stomach could provoke the giant 

African toad. 

And revenges’ with provocative croaking’s 

Oh no! 



I had no choice 

I had to loose my virginity for my survival 

Some men convinced me 

Those I respected as my late father 

They betrayed me 

They broke my virginity in turns of their money to 

sustain my life 

Days and night 

They sucked my mouth with alcohol-cigar mix, very 

offensive smell. 

And there giant’s hands rub my youthful face without 

mercy. 

My mushrooming nipple is pressed hard for that it’s 

never to develop but left shrink only. 

Yes they did me, some are like you 

I sold my body for survival. 

And now I am a victim. 

I have AIDS. 

I have HIV /AIDS 

Eeeeh…...eeeeh! 

It wasn’t my choice. 

It wasn’t my choice… 

I am now wasted 

The world has dictated upon my life. 

Don’t despise me 

Don’t neglect me 

Don’t segregate me 

Don’t laugh at me 

Don’t wait for help 

Help when most needed. 

Help those who are elsewhere in the world not to be 

like me. 

Stop being greedy 

Stop the injustice in the world 

Oh no, 

I cry out help. 

It wasn’t my choice 



In 1997, war by the Lords’ Resistance Army (LRA) is 

ravaging throughout the whole of northern Uganda 

but about 350km away, in Kampala, there are no signs 

that such a thing is happening anywhere in the country. 

Despite the fact that the war had already lasted over 

a decade by then, people of northern Uganda, both 

in the region and away, had the belief that one day 

home would be safe again. The people in Kampala 

knew very well that a war was going on down north 

but one wonders how they were able to put it out of 

their minds for most of the time. Well, they did that 

the same way a person goes to bed at night, closes his 

eyes well wishing to open them later the next morning 

when things are better. 

Human beings go out to do something with the belief 

that their desired goal(s) will be achieved at the end of 

it all. In difficulty circumstances, one closes his eyes to 

sleep hoping to open them the next morning to a better 

world. After 6 years of college, we apply to medical 

school knowing very well that admission depends on 

results to come in a couple of a months’ time and that 

the competition is high for the few available slots in 

all the medical schools in the four universities offering 

the course in Uganda. But we do this hoping to excel 

in the exams and make it to the prestigious medical 

schools. Even when we get to medical school, we 

have faith that we will eventually complete five years 

of reading difficult books and passing hard exams to 

become doctors…….HOPE! 

By the same principle a man walks up to a woman 

and asks her out on a date knowing very well that the 

possibility of her saying no is well over 60%, but he 

does it anyway with the hope that she will say yes. 

Even better, a man goes down on his knees and asks a 

woman to be his wife for life knowing the probability 

of her saying yes is minimal. But he does it anyway, 

because he is human enough to wish for the best. 

In 2001, when the Americans announced that they 

would be invading Afghanistan, the Afghans did not 

beg for mercy but simply said bring it on ignoring the 

American superior weaponry because they had hope 

that they would make it through the war and overcome 

Hope 

Man’s best strength 

Okello Innocent, MBChB IV 2009/2010. 

their invaders. The same thing happened in Iraq. 

In 1971, when Idi Amin Dada, staged a coup and took 

over the presidency from Dr. Milton Obote, Ugandans 

jubilated because they thought things would get better 

after undergoing a lot of economic hardships. Months 

later they discovered that life was actually better before 

Amin’s take over. Driven by hope for a better life, a 

new struggle to dislodge the Amin administration 

from power started and this was finally ‘rewarded’ in 

25th January, 1979. 

When a woman gets pregnant, she takes good care of 

herself so that after nine months she can be a proud 

mother of a healthy and happy baby. It is even with 

greater faith that she hopes her child will grow up to 

be important to her and her country. When it comes 

to maternal and child health, by giving the women 

hope for a better future, a good deal of the job is 

already done. Programs like prevention of mother to 

child transmission (PMTCT), free Antenatal care and 

saying no to domestic violence, all go a long way in 

showing that things can get better for the mother and 

her child. 

We are simply human, with no powers of fortune 

telling about what tomorrow will be but we always 

know what we want tomorrow to be like. Just as a 

man with a hangman’s noose around his neck has hope 

of living to see the next few minutes of his life, so do 

you of seeing your grandchildren grow or of her saying 

yes to a question you asked two months ago. As human 

beings we are only defeated when we have lost hope of 

achieving our goals and for those we love, however far 

or close, we are to achieve them. 

So the next time we hear something about promoting 

maternal and child health, it becomes our duty to give 

these women and their children the idea of a better 

tomorrow for her and her child. 



PART 1 

Lamunu a one year old Acholi female toddler from 

Amuru district Northern Uganda was brought into 

Dr Doreen’s office by her mother who reported history 

of (h/o) difficulty in breathing (DIB) for 4 days and 

fever and cough for 3days. Although these were about 

the only statements she could articulate in English, she 

resented Dr. Doreen’s suggestion to use an interpreter. 

“English no problem to me!” She exclaimed. History 

taking was technical but Dr. Doreen gathered that the 

patient was not growing as the mother expected and is 

always crying in addition to the DIB, fever and cough. 

The DIB was moderate, of sudden onset, constant 

throughout the day, aggravated by attempt to play, 

move around, lying flat or breastfeed with history of 

gasping for air when breastfeeding and mildly relieved 

by rest. It was associated with fast breathing but not 

noisy. A day later she developed a dry cough which was 

of sudden onset with no aggravating or relieving factors. 

There is no known h/o TB contact or anyone at home 

coughing. There is history of easy tiring while moving 

around and breast feeding, however, no reported body 

swelling. She developed a low grade fever too which 

was of sudden onset, intermittent, relieved by tepid 

sponging with no aggravating factors but associated 

chills however, no convulsions, loss of consciousness or 

vomiting. 

Questions 

1. Is it possible for Dr Dorine to come up with a 

diagnosis at this point? Which ones could you 

think of? 

2. Support your answer. 

PART 2 

There was no significant finding on review of other 

systems. 

This is the child’s third admission. Index admission 

was at 2 months of age at a private clinic with similar 

symptoms. With a provisional diagnosis of pneumonia, 

she received O2 therapy and other unspecified 

medication on which she slightly improved 2 days 

later, however, had regular visits to various clinics 

Gumj Quiz 

with similar symptoms. The second admission was 4 

months ago at a referral hospital. Mother says she was 

told, her daughter has a “hole in the heart” though she 

had no medical documents to support this. She is too 

concerned about her child’s unchanging health because 

during her last visit to the hospital the Dr informed 

her, the “hole” would close on its own. The infant has 

frequently been on unknown medication, however, 

with no h/o drug or food allergies and is of unknown 

HIV sero status. She has not been diagnosed with any 

chronic diseases like sickle cell disease. 

She was transfused with half a unit of blood during the 

last admission but no h/o surgical operations. 

In the prenatal, natal and neonatal history, mother 

conceived at 20years old, had 4 Antenatal Care visits, 

was screened for syphilis and HIV infection (results not 

given), and received folic acid tablets but not malaria 

prophylaxis. She reports no h/o febrile illness, rash-like 

illness, smoking cigarettes, taking alcohol, other drugs 

of abuse or unprescribed drugs during the pregnancy. 

She has never been diagnosed with any chronic disease 

like Diabetes Mellitus (DM) or Hypertension (HT). 

Labor lasted 6hrs, membranes ruptured spontaneously 

and delivery was preterm (7 months) at home, by 

spontaneous vertex delivery (SVD), assisted by a 

traditional birth attendant (TBA). The cord was cut 

with a razor blade from a nearby shop and tired with 

pieces of thread from a clean cloth. 

Child cried immediately and the weight taken 2 days 

later was 2.2kg. No history of yellowing of body or 

eyes or any admissions during the first 28 days of life. 

Mother says the child has lost weight. She was 

breastfed exclusively for 5mo. Breastfeeding (B/F) was 

on demand though her poor health would frequently 

interfere with desire to B/F. Complementary feeds 

were introduced at 5mo due to insufficient breast milk. 

They comprised of bean and fish soup with smashed 

Irish potatoes. Currently she takes both breast milk 

and complementary feeds including millet porridge 

with milk, green vegetables, simsim, beans and sweet 

potatoes. Meals are thrice a day prepared by mother or 

siblings and eats about a handful. 

The child received BCG (scar was observed) 2 days 

after birth, but schedule was completed. 

Growth and development had a slow progress. She can 

laugh, bubble and make unspecific noises. She doesn’t 



want to play much. 

Had a social smile at 2mo, sat without support at 

6mo. 

She stays with both her parents and her 2 siblings 

(both females of 6 and 4 years old and in good health) 

in a slum area in a wattle house. The house doubles as 

a bedroom and a kitchen. They collect water from an 

unprotected well. Drinking water is not boiled and has 

no separate containers. 

Both parents are subsistence farmers reserving some of 

their produce for income generation. 

There is no family history of chronic diseases like HT, 

DM or any heart conditions. 

Questions 

3. What significant aspects of the history have been 

captured to help with the diagnosis? 

PART 3 

On examination child was sick looking having labored 

breathing and wasted. She had no jaundice, cyanosis, 

finger clubbing, lymphadenopathy or edema, but had 

moderate to severe pallor. 

Length = 68cm Wt = 7kg Head Circumference = 

44cm Mid Upper Arm Circumference = 12.8cm 

Weight/Age is 7/10.15 *100 = 68.9%. She is 

underweight 

Weight/Length is between -1SD and median weight 

for length 

CVS 

PR=110bpm. Pulse was of full volume and collapsing. 

BP= 90/60 mmHg 

No Radial Femoral delay. Brachial, radial, popliteal 

and pedal pulses were present and synchronous. 

The jugular venous pressure was not raised. 

Apex beat was displaced laterally; there was a left 

parasternal heave and a systolic thrill in the left lower 

sternal border. 

There were no Osler’s nodes, splinter hemorrhages or 

Jane way lesions. 

There was tachycardia. 

Heart sounds S1 and 2 were heard with a mid systolic 

murmur at the left lower sternal border. 

Respiratory System 

RR= 52bpmin with mild nasal flaring. SaO2 was 86%. 

The chest was symmetrically moving with respiration, 

of normal elliptical shape. 

It was not tender and no masses were felt in the 

anterior, lateral or posterior chest walls bilaterally. 

Chest expansion and movement were normal and 

symmetrical. 

The upper ant., lat., and post., chest walls were resonant 

bilaterally with dullness at the lung bases more marked 

posteriorly. Air entry was normal with vesicular breath 

sounds in the upper chest walls, however, had coarse 

bilateral crepitating at the lung bases. 

CNS 

The child was conscious and alert with a GCS of 15/15. 

Cranial nerves are normal. Child was wasted with 

reduced muscle tone. 

Other systems were unremarkable. 

The child was put on an Oxygen concentrator at 3mls/ 

min. 

Questions 

4. What impression could Dr Doreen have at this 

point? 

Investigations 

ECG was done which revealed a large R-wave in V5 

and V6 and the S wave was deeper than normal. 

Echocardiography showed a moderately large defect in 

the upper aspect of the ventricular wall just below the 

aortic valve. 

Chest X-ray showed a prominent Left Ventricular 

contour. Hemodynamic and angiographic study may 

be employed to assess the status of the pulmonary 

vascular bed and clarify details of the altered anatomy. 

In addition DNA-PCR HIV sero-status was important 

to assist with proper management. HIV sero-status 

was negative. 

Questions 

5. What is the diagnosis? 

6. What management plan is appropriate? 

7. What are the possible complications? 

8. List any differential diagnoses. 



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Gulu University Medical Journal: 

Guide lines for contributors. 

Gulu University Medical Journal (GUMJ) is an annual 

publication. 

Potential authors are encouraged to submit 

contributions to the following areas as per the theme 

communicated annually: 

1. Methodologically sound primary medical 

research. 

2. Critical analysis of the current or proposed health 

policy measures based on national and international 

experiences. 

3. Case studies, real life situations and experiences 

relevant to the annual theme communicated. 

4. Review of relevant books in the field of health and 

development. 

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views and suggestions on fields of potential interest 

to the journal readership. 

6. Short communications on forthcoming or other 

events relevant to the journal readership. 

The approach should be practical, academic and not 

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The following guidelines should be adhered to: 

• Articles must be original, must not exceed 500 

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and all references listed alphabetically at the end 

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or as a superscript, e.g. “…. As reported by Ogola (3)” 

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they should be in numerical order following the order 

in which they appear in the text. 

• Only one system must be used, consistently, in the 

same article. 

• All references must be complete and accurate and 

must contain the following details: 

Journal articles: 

1. Names and initials of authors. 

2. Date of publication. 

3. Title of the article 

4. Name of the journal. 

5. Volume number. 

6. Number of the first and the last page of the quoted 

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Examples of how to write references in the 

reference list: 

Wheeler, M. and Ngcougo, N (1990). “ Health 

Manpower planning in Botswana”. World Health 

Forum, 11, 394-405. 

Hornby, P., Ray, D., Shipp, P.J., Hall, T.L., 1980, 

Guidelines For Health Manpower planning. WHO, 

Geneva. 

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by the author, e.g..http:/www.who/articles.html. 

Retrieved October 31, 2007. 

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Gulu University medical Journal 

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The views expressed in the journal are those of the 

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1. A diagnosis is most likely not possible at this stage 

because history is not adequate. Though she may 

have a few rough ideas in mind. 

Possible impressions could be; 

• Pneumonia in view of the cough associated with 

difficulty in breastfeeding. 

• Febrile illness in view of the fever for example 

malaria and bacterial meningitis. 

• Anaemia in view of difficulty in breathing. 

2. At this stage she has only been able to ascertain 

the presenting complaint, history of presenting 

complaint, review of other systems. So she has to 

inquire more about other aspects of the history and 

examine the patient to be sure of the diagnosis. 

3. Right from the beginning as Dr Doreen gets 

engraved into a conversation with the patient’s 

mother, you have to keep in mind important aspects 

like DIB * 4/7 and cough *3/7. It’s important to 

note that the DIB is not worsened on lying down 

and no h/o body swelling. As you proceed, it’s 

wise to ask yourself a few questions like: why is 

the child always in and out of health facilities? , 

what does the ‘hole in the heart” imply? 

Other aspects are that she delivered from home; the 

child’s birth was preterm and she was under weight. 

She was breastfed less than the recommended 6 

months, and does not feed adequately. 

4. From the history and examination results, the child 

most likely has a congenital heart disease (CHD). 

5. The diagnosis is Ventricular Septal Defect (VSD). 

Congenital means existing before or at birth. 

Congenital heart diseases can be classified according 

to whether they cause cyanosis or characterized by 

presence of a shunt. 

They can present with a heart murmur (which Lamunu 

had), heart failure or cyanosis. Examination revealed no 

cyanosis. Hence the condition is acyanotic. The shunt 

can be at the atrial wall or the ventricular wall level. 

Lamunu has ventricular septal defect with a left to 

right shunt. 

Defects of the ventricular septum are the commonest and 

usually occur as isolated defects and as one component 

Quiz Answers 

of a combination of anomalies. The opening is usually 

single and situated in the membranous portion of the 

septum i.e. perimembranous (75%). Malalignment 

defects may due to malalignment of infundibular 

septum and trabecular muscular septum; muscular 

defects may be located anywhere in the muscular 

septum (5-20%). Presentation depends primarily on 

defect size and status of the pulmonary vascular bed, 

rather than on the location of the defect. 

Shunting depends on the relative pulmonary and 

systemic vascular resistance. In large defects there is 

equilibration of right and left ventricular pressures. A 

large VSD with a low pulmonary resistance, degree of 

left to right shunt is increased. 

Usually large defects come to medical and, often, 

surgical attention very early in life. Natural history 

of ventricular septal defect ranges from spontaneous 

closure to congestive cardiac failure (CCF) and death 

in early infancy. The patient’s defect is of moderate 

size and spontaneous closure has not taken place and it 

could be that she has developed in view of the dyspnea, 

little interest in playing and difficulty in B/F. Among 

others are the possible development of pulmonary 

vascular obstruction (more with large) defects, Right 

Ventricular (RV) outflow tract obstruction, aortic 

regurgitation, and infective endocarditis. 

Lamunu’s DIB and cough indicate pulmonary 

hypertension though no haemoptysis as yet, though 

no worry for severe pulmonary vascular obstruction 

(Eisenmenger Syndrome) which usually presents with 

symptoms in adult life including exertional dyspnea, 

chest pain, syncope, and haemoptysis. Thus, the 

importance of correcting moderate-large defects 

surgically early in life when pulmonary vascular 

disease is still reversible or not yet developed. The 

right-to-left shunt leads to cyanosis, clubbing, and 

erythrocytosis. In all patients, the degree to which 

pulmonary vascular resistance is elevated before 

operation is a critical factor determining prognosis. 

If the pulmonary vascular resistance is one-third or 

less of the systemic value, progression of pulmonary 

vascular disease after operation is unusual. However, 

for a moderate to severe increase in pulmonary 

vascular resistance preoperatively, either no change or 

a progression of pulmonary vascular disease is common 



postoperatively. 

RV outflow tract obstruction usually develops in 

5 to 10% of patients who present in infancy with a 

moderate to large left-to-right shunt. With time, as 

subvalvular RV outflow tract obstruction progresses, 

findings in the patients begin to resemble more closely 

those of the cyanotic tetralogy of Fallot. 5% of patients 

develop incompetence of the aortic valve due to 

insufficient cusp tissue or prolapse of the cusp through 

the inter ventricular defect; the aortic regurgitation 

then complicates and usually dominates the clinical 

course. 

6. Management depends mainly on the child 

presents and presence of complications. 

With a low SaO2, the child needs oxygen therapy. To 

control CCF you need to limit her physical activity and 

reducing salt intake but increase caloric intake. She 

needs to be started on an inotropic like digoxin and a 

loop diuretic furosemide 1mg/kg. 

In this child it’s evident that the defect is persistent 

and surgery is likely option. 

Surgery is not recommended for patients with normal 

pulmonary arterial 

pressures with small shunts (pulmonary-to-systemic 

flow ratios of 1.5 to 2.0:1.0). Operative correction is 

indicated when there is a moderate to large left-toright 

shunt with a pulmonary-to-systemic flow ratio of 

1.5:1.0 or 2.0:1.0, in the absence of prohibitively high 

levels of pulmonary vascular resistance. 

The patient has mild malnutrition due to reduced 

intake. In such a case correcting the primary cause 

is baseline for management. In addition the parents 

have to be counseled and educated about the child’s 

condition. This prepares them for any outcome. 

Natural course depends on size of defect. 

30%- 50% small defects close spontaneously in 

first 2years of life. Observation and prophylaxis for 

indicated procedures are important in this case. 

7. Complications 

• Left ventricular volume overload 

• Pulmonary over circulation 

• Compromise of systemic 

• Endoocarditis 

8. Differentials 

• Mitral or tricuspid regurgitation 

• Patent ductus arteriosus 

• Atrial septal defects 

• AV canal defects 



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