By Rebecca Costello

Friday, January 7, 2011, 11 a.m. – Buhoma, Uganda

Kirsten Lalli ’11 and Caroline Komanecky ’12 are wading in the middle of a shallow, rocky stream. Clad in jeans, pink T-shirts, and black knee-high Welly boots and 
rubber gloves, each tilts a blue-tinged 20-oz. bottle into the water and then holds it up to Professor Ellen Kraly, who’s crouching on the bank with a camera. Kraly snaps 
a close-up photograph of each bottle, and then the students fill small plastic vials with samples of the contents. Using a hand-held Global Positioning System (GPS) unit, Megan Snell ’12 calls out their location coordinates to Professor Peter Scull, who jots them down in a small, yellow notebook.
A few feet away, two young local women dressed in skirts, one in thin flip-flops, the other barefoot, are also standing in the stream. They are bent over, scrubbing an assortment of tin and colored plastic pans and dishes with their bare hands and small teal-blue rags. Like the Colgate group, these women hiked over steep jungle terrain to get to this site. But for them, this open stream isn’t a research site, but their source for drinking, cooking, and washing.
     The Colgate students (six total) and professors are accompanied by three staff members from Bwindi Community Hospital (BCH) in Buhoma who are serving as their guides and translators: Reverend Sam Bigaruka, the community health director, and Andrew Kagwa and Agnes Abigaba. Throughout the day, the group treks up and down sharp hillsides and through tea plantations, taking turns repeating the sampling and mapping process at different types of water sources. Some are open streams like the first site; others are either unprotected or protected (filtered) springs.
     At some sources, young children are filling 5-gallon yellow plastic jerricans with water. It’s their daily chore to lug those cans (a full one weighs 40 lbs.) back home to their mothers, who will use the water for drinking and cooking. At another source, cattle are plodding in for a drink, dropping dung at the water’s edge, upstream from where local residents are collecting their water.
     The students are here as part of a 14-day trip to Uganda with Kraly and Scull through the Alumni Memorial Scholars (AMS) fellowship program, which offers funding for research and travel related to academic interests. Their work on this water-sanitation survey is just one aspect of a unique research and training partnership that has developed between Colgate and BCH, generating opportunities both in the Bwindi region and on campus.

A community hospital

Bwindi Community Hospital is a private hospital affiliated with the Church of Uganda. Although the rugged, rural landscape might suggest otherwise, this part of southwestern Uganda is surrounded by one of the world’s highest population densities: BCH serves approximately 100,000 people in close to 14,000 households in three subcounties. Most people in the region live in extreme poverty, without access to basics such as running water, electricity, 
or nutritious food. Among the poorest are the Batwa, ethnic pygmies who were displaced following the creation of the Bwindi Impenetrable National Park as a preserve for the endangered mountain gorilla in 1993.
     In recent years, the village of Buhoma, which is dotted with tea and coffee plantations, has been transforming from an isolated community to a hub for international travelers. As a gateway for ecotourism into the Bwindi National Park, Buhoma has a burgeoning hospitality and travel industry that is bringing developments like an electricity grid and some improved roads. And with the Republic of Congo border just 2 kilometers away, the presence of international organizations and others responding to transborder and refugee issues is growing as well.
     But the area is still extremely remote — a 12-hour drive from the capital of Kampala — and traveling there is a challenge for both visitors and residents. Many of the roads require extremely rugged four-wheeling, so given the rough terrain, not to mention poverty, ready access to health care is limited.
     BCH was founded in 2003 by Scott and Carol Kellermann. What began as an outreach clinic under a tree has become a model for hospitals in Uganda, with a staff of 115 doctors, nurses, midwives, other health care workers, and support staff. In addition to providing exemplary patient care in the areas of children’s health, maternity care, HIV/AIDS, and 
tuberculosis, as well as general care, the hospital also engages in extensive public health initiatives, including preventive care through a variety 
of community outreach, health education, and 
other programs.
     Dependent upon philanthropy for 90 percent of its funding, BCH helps to maintain its high level of quality despite limited resources by making data-driven decisions, using research to identify needs, evaluate how their services are utilized, and then establish and adjust clinical and community programs accordingly.

Friday, January 7, 5 p.m. – Bwindi Community Hospital

After a long day of collecting water samples, the students set up an assembly line around a table. They need to grow cultures on an agar plate (petri dish) in order to test for waterborne bacteria. A dropperful of water from each source sample gets mixed with a solution and placed in an incubator. Certain types of bacteria produce certain enzymes, and an indicator in the solution will react with those enzymes. If the water is contaminated, the color of the growth will indicate the type of bacteria.
     Although many different bacteria colonies — whether harmful or benign, or both — might grow from the cultures, the students will specifically be looking for blue ones. Blue means E. coli, or fecal coliform. The World Health Organization uses measurements of fecal coliform as the standard for testing water quality because its presence suggests the presence of other types of bacteria or pathogens that could be infectious.
     Samples of any E. coli colonies that grow will be captured and brought back to Colgate for analysis in the lab of biology professor Frank Frey. It will take about 36 hours for the cultures to grow, so with the samples for the day processed, the team heads outside for a game of volleyball with some members of the hospital staff and the local community.
     The water-sanitation project is part of the hospital’s research to inform its intervention program. About 50 percent of illnesses in the region are water related, so identifying and eliminating mechanisms of disease transmission through contaminated water sources are key in addressing the problem.
     “The most likely causes are due to inappropriate practices,” explained Dr. Mutahunga Birungi, BCH’s medical superintendent. So, for example, if E. coli shows up in a stream used by both people and cows, they want to know: are the cows contaminating the water, or does the E. coli come from a human source farther away, such as runoff from improperly constructed latrines upstream? With that infor-mation, BCH will be able to better focus their intervention program, such as teaching residents how to avoid contaminating their water sources in the first place, he said. The hospital can also share the information with the local government to inform their planning and fundraising for infrastructure improvements such as building new protected springs where they are most needed.

University-hospital partnership
Colgate’s involvement with BCH started back in January of 2009 almost by happenstance. Frey, Kraly, and Scull were in Buhoma working on a previous project with a different group of AMS students when one of the students became ill.
     “We were at the hospital with the student, who was getting really excellent care,” said Scull. An expert in biogeography, Scull began chatting with Paul Williams, then the medical superintendent, about how he uses GIS mapping to determine patterns and associations in his research. “Williams asked me how they could put their data on a map; for example, to look for patterns of disease prevalence,” said Scull. “I literally handed him a GPS unit and showed him what it could do.”
     Meanwhile, Kraly, who counts medical geography among her specialties, got to talking with Williams about BCH’s community health survey of approximately 6,700 households in the hospital’s catchment area. The comprehensive survey covered instances of disease like diarrhea, malaria, tuberculosis, and HIV/AIDS; habits and behaviors surrounding disease prevention, screening, and treatment; child health issues such as malnutrition and immunization; family planning and childbirth practices; and living conditions such as sanitation and access to water sources. BCH’s staff needed assistance with analyzing the mountains of information they had collected.

     “I asked if any of the students on the trip would want to work on it during the spring semester, and Josie Johnson [’09] volunteered,” said Kraly, who set up an independent study course in which Johnson organized and statistically analyzed the data for the BCH staff. “Josie did such a great job that the hospital had the confidence we could be useful. She did the work that opened the door for us.” Johnson’s contributions are acknowledged in the final survey report. Simultaneously, the hospital staff took what they’d learned from Scull and began collecting the GPS coordinates for every single household in the catchment area, which could then be folded into the survey data.
     The Colgate professors were soon in regular dialogue with BCH’s staff, finding a variety of ways they could work together. Not only do the professors’ individual academic specialties dovetail well with the hospital’s needs in a way that lets them both help BCH and conduct their own scholarly work, but they also saw another opportunity.
     “We asked if we could bring students to learn from them,” said Frey, whose interests include using genetics to learn how environmental factors are contributing to disease transmission. Things just flowed from there. They have since made several return trips, often with students, to work with staff members from various branches of BCH. In addition to field research and laboratory work like the water-sanitation survey, and providing assistance on data crunching and analysis, they have conducted training for the staff such as GIS mapping and qualitative data collection workshops. In between visits, they work together in cyberspace. The household survey — which is now produced annually with the assistance of Colgate students and the faculty members — both helps BCH to recalibrate intervention programs in the short term and provides the basis for future research.
     A rich web of collaboration has emerged. For example, the HIV/AIDS and TB unit tapped Kraly to teach its staff how to conduct effective focus groups. They wanted to learn more about the social and geographic barriers to testing and treatment they had identified as important factors to consider in improving their diagnostic and clinical support for people with HIV and their families. Then, in the spring 2010 semester, Kraly, Scull, and Frey team-taught a course at Colgate called Environment and Community Health in Africa: A Case Study in Rural Uganda, which culminated in an extended study trip to Buhoma in May. While there, the students in that class observed focus groups on stigmas associated with HIV/AIDS conducted by the BCH staff members whom Kraly had trained. That student group also conducted the first round of sampling for the hospital’s water-sanitation survey.

     In describing how the work of the Colgate people contributes to the hospital’s operations, Dr. Birungi explained, “Our mission to offer holistic health care can only be possible if we can understand more of the health needs from our clients’ perspectives. The partnership with Colgate has been capacity building for our vision to be able to provide evidence-based community health intervention.” But, he added, “the information flows two ways, and the time spent together is time well spent. Our staff looks forward to such moments, because we gain different perspectives on health problems that could not have been addressed without that kind of sharing.”
     And make no mistake, “This isn’t service on our part,” Kraly stressed. “It is community-based research, with the questions coming from the hospital. We are facilitating the answers by applying critical and scientific skills, recognizing our place with modesty — and as we bring our students into it, they are learning shoulder to shoulder with the staff.”
     “Getting our students involved in research on 
the ground in this health context, interacting with the professionals at the hospital, is really interesting and educational for them,” Frey added. The projects have been supported by a number of sources, including alumni and Colgate’s Picker Institute for Interdisciplinary Studies in the Sciences and Mathematics.

Sunday, January 9, 6 p.m. – Bwindi Community Hospital

After spending Saturday gorilla tracking in the Bwindi Impenetrable National Forest Park, and most of today collecting water samples from 20 more sites, the students are back in the lab. They have finished plating their new samples and have pulled Friday’s water samples from the incubator. On some plates, the surface looks clear. But in others, colored blotches, squiggles, and dots of various sizes and densities in shades of pink, white, and blue have formed.
     For each plate, they count the number of blue colonies and record the number, take a photo, and then pluck the samples off, placing them onto special cards that lock in the DNA. The samples from the sites range from 0 units fecal coliform to thousands of units per 100 ml of water.

     In the United States, the standard is 0 units per 100 ml of water — anything reading above 0 is considered unacceptable and the water source would be shut down until the contamination were eliminated. But in places like Buhoma, that standard is just not feasible.

     Tomorrow, they will collect and process more water samples, and before they depart Buhoma, they will analyze the data and build a PowerPoint report with their photographs and graphs, which they will present to the hospital staff. (As part of their AMS fellowships, they will also present their findings on campus.) “So right then, the hospital staff will be able to map out which communities have direct access to safe water, moderately safe water, contaminated water, and really dangerous water, which will inform their outreach program in educating people about what’s safe to drink and not safe to drink,” said Frey. Back in his lab at Colgate, DNA analysis will help them learn more about where those fecal coliform bacteria might be coming from.

Ripples of impact
For students, the opportunities presented by the partnership with BCH have enhanced their academic experiences in many ways. “Colgate students want to do things that are real,” said Scull, “and with this program they get to work hand in hand with people who are fighting all kinds of difficult battles. There, they are learning 24/7. In fact, they are saturated half an hour after they arrive, and during the whole trip they’re trying to come to terms with everything they are confronting.”

     Lalli, a molecular biology major who wants to go into federal law enforcement in a field setting, said the January AMS trip gave her the chance to do field research. “The added cultural aspect made it very attractive, as well,” she said, noting that being totally immersed in the community gave them an inside look at the reality of life in places where tourists never venture. “It blows my mind that people will go to places like Uganda, and all they talk about is how they saw these cool animals. Granted, we saw a lot of cool animals, but the experience we had exposed us to a completely different way of life.”
      Snell, an English major who had taken electives in Africa and World Politics and Nature, Culture, and Politics, described how her experience in Buhoma dovetailed with her coursework. “The first couple of days there, my brain was looking for an indication of things I had learned in class — to fit them in a model, such as ‘regional integration,’” she said. “And then I relaxed a little bit and realized that there is only so much the theoretical can do, and it becomes practical. One of the things we talked about in class was, what is nature? Are people nature? The Batwa people are living in extreme poverty because their way of life was displaced. I was there, seeing those issues of, who should have access to what?” Snell was also proud to hold her own among the science and premed majors in the group: “It was a good test of the liberal arts to help with a water-sanitation project. I got to see how social sciences and humanities blend with hard sciences in the medical and health fields.”
      Although they know their work was helpful, the students didn’t want to take too much credit. As Zunaira Javed ’11, a math major from Lahore, Pakistan, put it, “I think we actually learned more than what we contributed.” She noted that the January trip was a perfect fit given her interest in medical and social health issues in rural areas.
      Buhoma seems to soak into the students’ skin. Echoing others’ comments, Javed said, “I wanted to continue the work from Uganda because I didn’t want it to be a one-time experience.” After returning to campus, Javed signed on for a medical geography independent study this spring with Scull and Kraly to work further on the water-sanitation survey, both by helping complete the report and by contributing to BCH’s public outreach. She created plaques that will be posted at each water site, showing their water bottle photos and the data about contamination levels. “This will encourage people to think about the fact that just because the water looks clear, it does not necessarily mean that it’s clean,” she explained. In addition, Javed and Lalli are working on the analysis for the latest iteration of BCH’s household survey with two people who went on the extended study trip last May — Annabelle Glass ’11 and Mike Palmer ’10, who even has offered his services as a graduate.
     In the spirit of community-based research, the professors find as many ways as possible to share what they have learned, both on campus and in the broader scholarly community. For example, last fall, two students who had observed the HIV/AIDS stigma focus groups the previous May, Lesley Parrish ’11 and Alexandra Pons ’11, analyzed the transcripts and worked with BCH staff members on a report as an independent study. In February, they gave a presentation to a packed house at a Center for Women’s Studies brown bag lunch discussion, where they talked about the implications of their findings. The pair also traveled with Kraly to present at the national Association of American Geographers conference and coauthored a paper with her.
     A surprising finding of the focus groups was that gestures meant to help can actually exacerbate stigma: white jerricans supplied by international donors in a basic care package to HIV/AIDS patients immediately identify those who are infected, because everyone else uses yellow cans to collect their water. It is hoped that this revelation will inform practices going forward. “Our experience revealed to me,” said Pons, “that medical geography can really be an agent for empowerment and a vehicle for social change.”

      By a rather remarkable coincidence, a Colgate alumna who works for an international aid organization can provide a strongly relevant outside perspective on the value of the capacity-building aspect of the partnership to which Dr. Birungi referred. Jo Kroes Randell ’91 is head of development at London-based The Eurochange Charity, whose mission is to provide funding, training, and education to enable the poorest and most undeveloped communities in the world to become self-sufficient. Eurochange has been supporting BCH in a variety of ways since 2008.
     “What we’re aiming to do, and the Colgate folks are doing as well, is help them build the skills and expertise to come up with solutions for themselves. The professionalism and amount of information we get from BCH, and their strategic thinking, is exceptional,” said Randell. “If they can give us a smart proposal, we are much more willing to make a decision to fund a project. We don’t have unlimited funding, so it is important to guarantee that we are helping the people who need it the most.”
      With that notion in mind, BCH asked Colgate to help develop a set of poverty assessment tools they could use to document the needs of the populations they serve; for example, to identify patients who would most benefit from a feeding program for which they might receive support from organizations like Eurochange. That request allowed Kraly to involve even more students, this time, on campus: she turned developing those tools into an assignment for her fall 2011 Community Based Research class.
      Johnson, who graduated in 2009, can already attest to longer-term benefits she’s received through her involvement in starting the BCH collaboration. “Since the professors have formed relationships with many people in Buhoma, we met people living there and got a taste of the culture, including attending a baptism ceremony and reception and playing several football (soccer) games with kids living there. I was able to form great relationships with community members, several of whom I maintain contact with today,” she said. And professionally, Johnson employs research methods similar to her work with BCH in her job as a trial consulting analyst, such as organizing and analyzing data from surveys through statistical tests, and leading focus groups. “It was great to have had that previous experience,” she said.

Thursday, February 24, 12:40 p.m.
– Ho Science Center

Back at Colgate, Emily Sabo ’11 (molecular biology), Laura Wood ’12 (biology) — both of whom were in Uganda on the May 2010 extended study trip — and Jeff Tompson ’11 (molecular biology), are in Frey’s lab, processing the water-sanitation survey samples as part of a semester-long independent study. There are a total of 250 water sample cards, and 150 with cow manure samples, taken in May and January.
     They start by taking nine punches out of a card and placing them in pink Eppendorf vials with a purifying solution. Running the material through several machines will release the DNA off the punches. It takes several hours to process a small batch of samples. The next step involves mixing other solutions with the DNA to amplify (make copies of) it, and then run them on a gel, where they will be able to see bands that reveal the genetic similarities and differences between the various colonies.
      “We do three separate trials for each sample so we can tell whether an allele [DNA sequence] is present or absent,” Tompson explained. “By doing that with different primers, we can build a phylogeny to see what’s related and what’s not, and how those alleles relate to each other.”
     “We’ll take the phylogenies, and we have the GIS maps of where the samples came from,” said Sabo, “so we can look at the locations and relate them. We’re hoping that the E. coli from the cows is the same as from the water so the hospital can say, ‘Stop taking your water from this stream.’” In addition to writing the report for BCH, the students will co-author a journal-style paper on the results.

      “What’s really great is that we were there,” 
said Wood. “It isn’t just random water samples — 
we collected these, we saw the people who were there, we met community members and the people 
at the hospital.”

Strengthening the bonds

In March, Colgate formalized the relationship with BCH when President Jeffrey Herbst signed a Memorandum of Understanding during a visit to campus by Charles Byarugaba, the hospital’s principal administrator. The gesture underscores the mutually beneficial nature of the partnership, and paves the way for new levels of educational collaboration.
     As Scull pointed out, that is what’s unique about what has evolved: “We have a relationship that doesn’t have anything to do with money, and the things we do are integrated both into our research and education program, and into the mission of the hospital.”
     “For the students, it’s not theoretical — there is a real deliverable,” Kraly added. “The stakes are high and they know that.”