For more than a decade, I have traveled to some of the poorest areas of the world’s poorest countries. I thought I had seen it all – but nothing prepared me for this, my first trip to Africa.

After two 10-hour plane rides and 30 hours of non-stop traveling, we arrive late at night in Kampala, the capital of Uganda. The drive from the airport is eerie as the city is in total darkness. The electricity is only on for certain hours every day.

Luckily our “hotel” had a generator and mosquito nets. No air conditioning (93 degrees) but it doesn’t matter after you’ve been traveling for 30 hours. We woke up early and went to a local clinic where The Smile Train has been helping children with clefts for more than a year.

Our host, Dr. Andrew Hodges, is not your typical Smile Train partner. He is a young, white, British plastic surgeon who recently moved back to Uganda from Britain with Sara, his wife and anesthesiologist and their three young children.

You may wonder why a successful and talented plastic surgeon who could easily earn hundreds of thousands of dollars a year and live quite a comfortable life in England would choose to take a 95% pay cut and move his family to one of the world’s poorest countries.

It is especially ironic because the vast majority of doctors and nurses in Africa are doing anything, they can to leave their country. There’s no doubt Hodges cares about helping the people of Uganda on many levels.

Seven years ago, he and his wife helped a Ugandan baby girl with a cleft who was abandoned days after birth. The Hodges not only fixed her cleft – they adopted her – and changed her life. After spending a few days with him I realized that the Hodges are extraordinary people and the Smile Train is very lucky to have them as partners. Uganda is lucky to have them too. There are less than 5 plastic surgeons in this country of 28 million people.

We spent the morning at the hospital meeting many children and their parents. There were lots of kids with clefts as well as all kinds of much more serious problems too. A two-year-old boy with elephantitis in his left leg that had quadrupled its size. Hodges told us quietly that the case was hopeless, and the leg would need to be amputated. An 8-month old that weighed 7 pounds.

A baby boy with boy legs amputated above the knee. The diseases and afflictions were just horrific. It seemed like the kids with clefts were the only ones with any hope of a happy ending.

We walked around the hospital and found a room where they were stripping old bicycles to make parts for home-made wheelchairs. We came across a table with a big pile to little black plastic prostheses.

Working at this clinic we met a diverse group of young and old, modern-day good Samaritans including doctors, nurses, social workers, college kids and volunteers who all shared a passion for helping the poor. They were from all over the world: Germany, Kenya, California, Uganda, Holland, Brazil, etc. Under very difficult circumstances, with pathetic budgets, limited equipment, government corruption and indifference, these brave souls were doing the best they could helping children that nobody else really cared about. They were putting up a good fight against a tide of suffering, hopelessness and extreme poverty. I would have lasted at this clinic for one week. Some of these folks had been there more than 10 years. It was both inspiring and depressing.

The next day we left at sunrise in a tiny 4-seater Cessna. Dr. Hodges was the pilot of one of the two planes.

We flew up the Nile to Northern Uganda and a God-forsaken place called Kumi. This area is much poorer than Kampala and afflicted with a broad range of misfortunes and tragedies.

A local insurgent group called The Lord’s Resistance Army has been fighting with the government and robbing and murdering thousands of people for many years. The week we were there they were cutting the lips off of “informants”.

Over the past decade they have abducted tens of thousands of 12-15-year-old girls to supply “wives” for their rebel leaders to generate new babies and recruits for their cause. There are cattle rustlers who use AK-47s. Highway bandits who rob anyone dumb enough to travel the roads at night. Waves of refugees fleeing Sudan. Corrupt politicians who siphon off much of the aid. And a whole host of severe diseases and serious health problems that explain why the average life expectancy in Uganda is 42 years. (The same life expectancy in Western Europe 200 years ago.)

Then there is the hospital. Kumi hospital is an old missionary hospital that was closed during the Ugandan civil war and re-opened ten years ago. It has no running water. Limited electricity. And no surgeon because “no surgeon in his right mind would ever agree to come live in such a place as Kumi.” That’s a direct quote from the head of the hospital who like Hodges is a living Saint and also a Martin Luther King look alike.

I interviewed him in front of his “Hall of Hope” where they begin every day with a prayer service. I was amazed at his upbeat, enthusiastic, positive attitude. I looked around and all I saw was hopelessness and desperation and yet he kept telling me how things were improving and looking up. He was grateful that The Smile Train could send him a surgeon every couple of months to help these children.

When Hodges flies up to Kumi, he operates on a full schedule of children with clefts and other problems too. He has provided free cleft surgery for 100+ children in Kumi. Over the past decade Hodges himself has probably performed more than a thousand cleft surgeries in Uganda. Flying in a surgeon is really the only way to help these children as traveling to Kampala is not even an option for these people. They are much too poor, too afraid and too sheltered to even think of making the long, dangerous and expensive trip to the big city. Hodges told us of heartbreaking conversations they have with parents of children with major health problems whom they beg to go to Kampala to get life-saving treatment. They never do. Instead, they go back to their small villages and their children die.

After spending the morning at the hospital, touring the wards, visiting the leper colony, we set off to visit some patients’ homes. In a rickety, 20-year-old range rover we drove many miles down bumpy dirt roads. Looking out the window, watching life in Kumi, Uganda, it felt like we were traveling back in time. There were no other cars or trucks. Just hundreds of people walking or on bicycles. Many women were walking along the road carrying branches of wood on their heads.

But it was what we saw in the planting fields that really dropped our jaws. In field after field, we saw hundreds of people scattered about hundreds of acres hacking at the dirt with simple garden backhoes – like something a weekend gardner would use and scattering seeds from a small bag. There were no oxen, no donkeys, no horses pulling plows. No plows period. No livestock. No tractors, equipment or vehicles of any kind. No irrigation. It was as if the agricultural and industrial revolution never happened.

We watched in shock and sympathy as hundreds, thousands of these people bent their backs and hacked away at the dirt with their crooked backhoes, desperately trying to scratch and claw a living out of the dirt. No wonder they’re starving. The pilgrims in Plymouth, Mass, almost 400 years ago, must have had better equipment, animals and resources. How is it that a country, an entire continent, can be going backwards in time and nobody can do anything about it?

The most memorable home was in a small village where a 10-year-old Smile Train patient lives. She and her family were waiting to meet us. We shook their hands and listened to their story. The young girl’s name is Ajok. That is the name Ugandans give to every girl who is born with a cleft. Every boy born with a cleft is named Ojok. The names both mean “cursed by God”. The perfect way to describe life for a child born with a cleft in Uganda.

Ajok was a very quiet, polite little 10-year-old girl who did her best to try and smile for us and my camera. Her cleft surgery went very well, and her result was excellent – but she is still “cursed by God.” I couldn’t take my eyes off of her Mother’s face. Believe it or not, her Mother is 35 years old. To me, she looked like she is in her mid to late 60s. Her face portrays what life is like in Uganda much better than my words ever could. Her face shows the worry and desperation in her life.

This woman has seven young children and her husband died of aids six months ago. I was sure she must be infected too. She does not know how she and her family will survive. They now have no income.

They all live in this thatched hut and sleep on a mud floor. They light a fire every night to fill the hut with smoke to keep the mosquitoes away. That works fine until 3 in the morning when the fire dies out and the mosquitoes come in. 150,000 people die every month in Africa of malaria. That’s like a tsunami every single month. Every month. Mosquito nets cost $4 apiece but for this woman, they might as well be $400.

For years, everyone in America has been talking about how cheap these mosquito nets are and how many lives they can save and why can’t we make them available to families like this. People keep talking in America and 15,000 people keep dying in Uganda. Every month. We keep talking in America where every kid seems to own a $250 PlayStation 2.

Before I went to Uganda, one of our top American surgeons told me not to bother. He said that Africa has so many bigger problems than clefts that The Smile Train shouldn’t waste its time or money.

It is true, that there are many much bigger health problems than clefts such as AIDS, malaria, river blindness, diarrhea, cholera, tuberculosis, etc. But I didn’t understand why this meant we shouldn’t try to help the hundreds of thousands of kids in Africa like Ajok who have virtually no chance of ever receiving surgery. In a sense, because their lives are so difficult and prospects so bleak, living with a cleft must make a difficult situation even worse. At least we can give them a fighting chance. I came back from my trip not depressed – but determined.

So while hundreds of billions of dollars pour into Africa trying to solve the big medical problems that you see on the nightly news, problems that are years, perhaps decades away from being solved, The Smile Train is building dozens of surgical programs all over Africa that are quietly, inexpensively, and safely providing free cleft surgery for thousands of little kids like Ajok who would otherwise never receive it.

Andrew Hodges and his wife are saints – and my heroes.

They are delivering miracles every day in places there they are in very short supply.

HERE IS A REPORT THE HODGES WROTE THAT YOU REALLY ENJOY…

CLAPA in Uganda
Andrew and Sarah Hodges

Leaving Uganda after our 1998 cleft project was hard. The project had been an overwhelming success; in the course of 8 months, we performed 377 deft repairs and trained 5 local surgeons. Settling back into life in England was difficult, however, knowing that there was still so much unmet need in Uganda.

The entire population of 21 million people is served by just one plastic surgeon. Most patients born with a cleft lip or palate have no prospect of
receiving treatment. So, last year, again with funding from CLAPA, we made another trip – this time taking with us two other surgeons so we could make maximum use of our time there. Our first week was spent back at Kagando Hospital, where we used to live and work.

Our idea was to spend a week there visiting old friends, but the local doctors had other plans! Around 50 patients with all sorts of conditions were waiting for us. We made an assessment of those patients we knew we could do something for and worked the theatre staff hard trying to operate on them all in the few days available. Though we performed some deft repairs, most children had severe bums – one child had his eye and ear burnt off and his neck was stuck to his chest.

At the beginning of the second week, we met up with fellow plastic surgeon Peter Saxby and flew off in a shaky little plane to Lira hospital. As we arrived on the grass landing strip, full of anticipation, we were disappointed that there was no one there to meet us. It turned out that
our letters had not arrived and no one was expecting us. For two days we were there with no patients – not a promising start.

The Medical Superintendent at the hospital was not discouraged and immediately put out an announcement on the local radio calling anyone with a deft to come as soon as they could. We were amazed by the response. Over the next two days, 44 cleft patients arrived. The boys were all called Ojok and the girls Ajock – this means “cursed by God’.

The Medical Superintendent urged us to stay longer as those living further
away would first need to raise money for travel by selling animals in the market. We had our deadline, however, and had to leave – even though more patients were turning up as we were packing our bags. We encouraged them not to despair and promised to try to return next
year. During our brief stay, we were again amazed by the dedication of the theatre staff.

Despite the early starts and late finishes, some of the staff who had been transferred to other wards requested to come back to the theatre to assist us. Before driving off, the local district governor received us into his office and presented us with gifts in appreciation of the service to his people.

From Lira, we drove to a nearby rural hospital and checked into their guest house. Here we diversified and operated on patients with burns, clefts, and huge keloids (bad scars). The guest house was simplicity itself with no running water or electricity and, judging by the evidence, a rather sizeable and hungry rat which lived in the bathroom and devoured the visiting surgeon’s soap!

In our final week, we returned to Kampala to work in a very well-equipped orthopaedic hospital. Here we were joined by another plastic surgeon from England, Tim Goodacre and, after the chaos of the previous hospitals, we were impressed at how well things were organized. This was important as we were performing a lot of complex reconstructive surgery in addition to cleft repairs. As well as many terrible burns contractures, we treated one two-year-old child who had been bitten on the face by the family pig.

Most of the cheek had been bitten off and scar tissue had grown in its place, leaving her unable to open her mouth at all. She had survived on liquids for a whole year. After a complex operation skin was moved from around the face and neck to reconstruct the cheek, lip, and eyelid. It was a privilege to be involved in such a life-transforming procedure.

As on previous visits to Uganda we were struck by the incredible need. We operated on 100 patients in the three weeks – 60 deft repairs and 40 other procedures. Many of the patients had been suffering from their problems for many years before receiving treatment, and many patients arrived after we had left. We feel compelled to attempt to help more patients. All of
the hospitals we visited would like us to return. The key to the future will lie in the hands of Ugandan surgeons but there is presently no training program for them to learn plastic surgery.

We would like to link up with some young surgeons on future visits so that, as well as treating patients, we can train local people and pass on skills. We have already identified three committed surgeons who we know well and who wish to be trained in plastic surgery.

Hopefully, they will join us when we visit in 2001. At CLAPA’s last AGM we were interested to hear about the changes to cleft care in the UK which will move treatment from “local’ hospitals to more specialised centres of excellence. It struck us, however, that, in a very different environment, we are aiming to do precisely the opposite in Uganda. Villagers in remote districts will not travel to Kampala for treatment and our aim is to send teams to the district hospitals in remote areas to treat patients where they
live.

CLAPA has enabled the beginnings of deft care in Uganda and lives are being transformed. There is still such a huge unmet need.

We look forward to continuing our links with CLAPA and bringing you news of future trips.

44 left Repairs in Lira
Immunization
Clean water
Schools

Uganda debt cut in half

20 million Africans have HIV, and Africa has 11 million aids orphans. Sniffing glue in Kenya.

Speak up for those who cannot speak for themselves.

Crumbs of compassion.

See your privileged world from a new perspective.

poverty eradication and action plan – the proportion of people living in poverty in Uganda fell from 56% in 1992 to 38% in 2002.

In Sub-Saharan Africa the number of people living in extreme poverty has risen by 74 million.

life expectancy = 42 years.

3 richest people in the world have more money than all 48 of the world’s poorest countries put together.

Kenya – schoolhouses with 100 students per teacher

One doctor per 20,000 people/.
Brain drain

Mosquito bed nets impregnated with insecticide – cost $4 but cut the risk of infants dying by up to 63%. But nets cost more to distribute than to make. Ugandan newspaper warned people to stop turning nets into wedding gowns.

76% of the drugs at private clinics “leaked” o to private Markey.

Graft and corruption at private clinics. No one pays the workers so they take kickbacks, sell drugs.

Kumi – Lord’s Resistance Army.

Since 1986, donors have given Uganda more than $11 billion. Overseas aid makes up half of Uganda’s budget. President Museveni is getting rid of term limits to stay in power,

Experts estimate that $100 – $175 million in aid is stolen every year.

Over the past 40 years, $450 billion in aid.

Charity on a grand scale. River blindness – drugs must be taken by 2./3s of a village for 20 years.

If you think you are too small to make a difference try sleeping with a mosquito.

River blindness

$78 billion in aid.
More than one billion people in the world live on less than one dollar a day. Another 2.7 billion struggle to survive on less than two dollars per day. Poverty in the developing world, however, goes far beyond income poverty. It means having to walk more than one mile every day simply to collect water and firewood; it means suffering diseases that were eradicated from rich countries decades ago. Every year eleven million children die-most under the age of five and more than six million from completely preventable causes like malaria, diarrhea, and pneumonia.
In some deeply impoverished nations less than half of the children are in primary school and under 20 percent go to secondary school. Around the world, a total of 114 million children do not get even a basic education and 584 million women are illiterate.
Following are basic facts outlining the roots and manifestations of poverty affecting more than one-third of our world.
Health
• Every year six million children die from malnutrition before their fifth birthday.
• More than 50 percent of Africans suffer from water-related diseases such as cholera and infant diarrhea.
• Everyday HIV/AIDS kills 6,000 people and another 8,200 people are infected with this deadly virus.
• Every 30 seconds an African child dies of malaria-more than one million child deaths a year.
• Each year, approximately 300 to 500 million people are infected with malaria. Approximately three million people die as a result.
• TB is the leading AIDS-related killer and in some parts of Africa, 75 percent of people with HIV also have TB.

Hunger
• More than 800 million people go to bed hungry every day…300 million are children.
• Of these 300 million children, only eight percent are victims of famine or other emergency situations. More than 90 percent are suffering from long-term malnourishment and micronutrient deficiency.
• Every 3.6 seconds another person dies of starvation and the large majority are children under the age of 5.

Water
• More than 2.6 billion people-over 40 percent of the world’s population do not have basic sanitation, and more than one billion people still use unsafe sources of drinking water.
• Four out of every ten people in the world don’t have access even to a simple latrine.
• Five million people, mostly children, die each year from water-borne diseases.

Agriculture:
• In 1960, Africa was a net exporter of food; today the continent imports one-third of its grain.
• More than 40 percent of Africans do not even have the ability to obtain sufficient food on a day-to-day basis.
• Declining soil fertility, land degradation, and the AIDS pandemic have led to a 23 percent decrease in food production per capita in the last 25 years even though the population has increased dramatically.
• For the African farmer, conventional fertilizers cost two to six times more than the world market price.

The devastating effect of poverty on women:
• Above 80 percent of farmers in Africa are women.
• More than 40 percent of women in Africa do not have access to basic education.
• If a girl is educated for six years or more, as an adult her prenatal care, postnatal care, and childbirth survival rates, will dramatically and consistently improve.
• Educated mothers immunize their children 50 percent more often than mothers who are not educated.
• AIDS spreads twice as quickly among uneducated girls than among girls that have even some schooling.
• The children of a woman with five years of primary school education have a survival rate 40 percent higher than children of women with no education.
• A woman living in sub-Saharan Africa has a 1 in 16 chance of dying in pregnancy. This compares with a 1 in 3,700 risks for a woman from North America.
• Every minute, a woman somewhere dies in pregnancy or childbirth. This adds up to 1,400 women dying each day-an estimated 529,000 each year-from pregnancy-related causes.
• Almost half of the births in developing countries take place without the help of a skilled birth attendant

Hope and generosity can triumph over hate

The Gleneagles G8 summit last week raised the trajectory of global ambition to end extreme poverty. By combining the world’s technological prowess with the long-standing promise of the rich countries to devote 0.7 percent of national income to official development assistance, extreme poverty can be ended by 2025, with the Millennium Development Goals of Âhalving poverty a midway success in 2015. Despite foot-dragging by the Americans, Tony Blair, the prime minister, who hosted the summit, nudged the world closer to this prospect.

With the backdrop of the bombs in London, the Gleneagles communiqué marked a triumph of hope and generosity over hate, offering an important, if incomplete, boost to the development prospects of the poorest countries. The rich countries agreed to increase annual aid flows by at least $50bn (£29bn) as of 2010. At least half the increase is to be directed to Africa, raising annual aid to Africa from $25bn to $50bn within five years. Europe provided the impetus for this breakthrough, demonstrating that Europe is the champion of globalisation based on international cooperation, development aid, and environmental stewardship.

Roughly four-fifths of the $50bn increase will come from the European Union, though Europe represents but two-fifths of the GNP of the donor countries. Notably, the pre-enlargement EU-15 has set a bold timetable to reach 0.56 percent of GNP in aid by 2010 and the
internationally agreed target of 0.7 percent of GNP by 2015. ÂCanada and Japan gave a nod to 0.7 but refused to commit to a timetable.

The US did worse, denying repeatedly in recent weeks it had ever pledged 0.7, although Mr Bush signed on to the March 2002 Monterrey Consensus to “make concrete efforts towards the Âtarget of 0.7 percent”. Instead, the US cobbled together some small programmes
backed by big spin. The new US effort against malaria is welcome, but $1.2bn over five years is paltry when $3bn each year is needed to fight the disease in Africa. The US five-year effort is less than one day of Pentagon spending, and two cents of every $1,000 of US national income.
Mr Blair struggled for months to bring the US into the fold not only on aid but also climate change. He could obscure the failure to win more from the US on aid because Europe proved ready to shoulder a disproportionate share of the burden. Mr. Blair could not, however,
paper over the failure on climate change. Here the Gleneagles communiqué is a clunker. Bland Âreconfirmations of the UN Framework
Convention on Climate Change and the Intergovernmental Panel on Climate Change are notable only because they are made necessary by so much US intransigence.

For ending poverty, the challenge is to translate the Gleneagles’ promises into life-saving action.
The day after the summit finished, I was in Ghana, one of the best governed and most hopeful of Africa’s young yet poverty-ridden democracies. More than 100 of every thousand Ghanaian children die before their fifth birthday, at least 10 times the rate of the rich countries. These deaths are preventable, but the health budget is only one-quarter of what is needed to tackle the crisis. The austerity budget supervised by the International Monetary Fund and World Bank constitutes a death warrant that results from Ghana’s poverty and the lack of sufficient donor aid.
The IMF and World Bank have a responsibility to help mobilise the required aid. Rather than tell Ghana to keep its health budget low to preserve macroeconomic stability, the IMF should tell donors to honour their commitment to Ghana, so that it can save its children and
break free of the disease-hunger-poverty trap. The executive boards of the IMF and World Bank should address this critical question when approving programs for low-income countries: Is the program sufficiently supported by donor aid and domestic budgetary
commitments to enable the country to achieve the Millennium Development Goals?
The $50bn a year in official aid for Africa translates into around $75 to $100 per African, depending on each country’s needs and commitments to use the aid effectively. Donor support for African health should be reaching $20 or more per capita per year, not the typical $5 or so on offer now. Donor support for agriculture and rural infrastructure should reach roughly the same amount. With suitable investments in farming systems, African food production can be tripled in a 21st-century African green revolution. Increased aid for schooling, urban water and sanitation, and other core infrastructure is also vital. The aid should be mainly spent on investments and
service delivery, not rich-country consultants or food shipments.

When world leaders gather at the United Nations summit in September, they can build quickly on the Gleneagles’ achievements. Th

Africa in the Balance
Eight men are about to decide the future of hundreds of millions of people in sub-Saharan Africa. The choices President Bush and his fellow leaders make this week in Scotland will help determine whether more than two million children under 5 will keep dying every year of diseases that can be easily and cheaply treated, whether 40 million young people will still be unable to go to school and whether 300 million Africans will continue to lack access to clean water.

A well-designed package of increased aid, further debt relief, and trade fairness could strikingly reduce these shaming indices of extreme poverty at a very affordable cost. America’s share of the $25 billion a year in additional aid for Africa sought by the British prime minister, Tony Blair – weighted for national income – comes out to less than $50 per person. But adding fairer trade to the package would actually leave taxpayers in wealthy countries better off than they are today because the rich world now pays more than $350 billion a year in agricultural subsidies.

In recent days Washington has announced welcome but largely unilateral aid initiatives and declined to join other countries in committing a fixed share of national income to development assistance. We hope that summit-meeting chemistry and Mr. Blair’s bold exhortations will lead Mr. Bush to go further. New aid money will go furthest if it is committed for several years ahead so African countries can invest in training new health workers and teachers. Donors need to harmonize their aid efforts so the various conditions demanded by different donors do not work against one another.

A growing number of African countries now recognize that development also requires effective and accountable governance, financial transparency, and a welcoming environment for enterprise and investment. South Africa has been a leader in this area, and important steps have also been taken by Mozambique, Tanzania, Ghana, and Uganda. Nigeria is finally starting to get serious about corruption. But these hopeful trends will produce results only if the rich world agrees to provide the financial support Africa cannot yet provide for itself. The point of this week’s push for aid is not to create permanent dependency but to unleash self-sustaining growth.