1.3 Primary environmental care: a beginning in Pallisa!

Uganda's Pallisa district is located 120km to the north east of Kampala in a lush, hilly area near the shores of Lake Kyoga. The district's residents, mostly Iteso people, subsist almost entirely on small-scale agriculture, livestock, and fishing. The district was badly affected by the violence and civil war that tore the country apart and resulted in over a million dead under the rule of Idi Amin and Milton Obote. In the 1980s armed gangs of nomadic peoples from the north (the Karimojong) raided the Iteso's cattle. After repeated attempts to get the government to intercede on their behalf, some Iteso mounted an armed uprising that lasted for several months. Peace returned to the area in 1989. It was time for the people of Pallisa district to rebuild their lives and, by organizing themselves in the Pallisa Community Development Trust (PACODET), that is precisely what some of them have been doing.

Organizing and addressing priority problems

It was early morning in January 1993 and Stanley had gathered together 13 members of PACODET's executive committee. Over the course of the week, the same group would meet every day beneath a mango tree in Kapuwai, a village in the Pallisa district. Stanley, a thoughtful man with a quiet manner and bright eyes, was very much the leader of PACODET. Another prominent member was Lawrence, the headmaster of the local primary school, an upright, talkative man with an explosive laugh. James and Amos were teachers too, James assuming the role of scribe and Amos, with his broad smile, bringing a touch of levity to the meetings (except when discussing his own subject, which was geography).

Several of those who attended the meetings came from other villages. Vincent, a government agricultural extension agent who could discourse freely on any matter related to farming, traveled an hour by bike each way. Then there was Simeon Osire, a retired public health inspector from Kagoli. The world he saw today was profoundly different from that of his childhood, when food was plentiful, forests were large and luxuriant, and lions, leopards and giraffes roamed the countryside. There were many fewer women at these daily meetings than men, and only two attended regularly. Stanley's wife Ann was a young and exceedingly gentle woman, while Filder, who was married to Lawrence, was more forceful and forthcoming. She had seven children, the youngest of whom, a two-month-old boy, came along to the meetings.

In addition to the local participants, the meeting included two health experts from Makerere University. John Arube-Wani had almost 20 years' experience in hospital social work; since 1985 he had spent much of his time studying health issues in the countryside, where 90 percent of the Ugandan population resides. Dr. Tom Barton, an American physician-turned-anthropologist, arrived in Uganda in 1989; an expert on sexually transmitted diseases - a tenth of Uganda's population is HIV positive and destined to die of AIDS - he was a technical advisor to the Child Health and Development Center at the University. Tom was a keen supporter of PACODET's approach to primary health care and was also helping Stanley and his colleagues think about the ways in which they could tackle the district's environmental problems.

"When we first decided to do something," recalled Stanley, who returned to Pallisa district in 1989 having completed his studies in zoology at Makerere University, "we saw that the most pressing problem was ill-health. Malaria was rampant and too many women died in childbirth. Many of the children died too. Not a week passed without deaths in every village. Then one day an elderly woman died just down there." He pointed towards the cart track which led to the primary school. "We decided to count the number of deaths and look at the diseases which were killing people. We knew the government wouldn't do anything - we had to act ourselves." So PACODET set to work and in just three years made great strides in promoting primary health care. "Now," said Stanley, after welcoming everyone under the mango tree, "it's time to look at other issues."

PACODET's history offers a good insight into the way in which a dedicated group of people can shape their own destiny. In 1986 half a dozen students born in the Kapuwai parish of Pallisa district decided to work out ways of improving their community's standard of living. They founded the Kapuwai Students' Progressive Association (KSPA) but, before they could start work, the armed rebellion had begun. After the disruptions, KSPA reconvened in 1989 as the Pallisa Community Development Trust (PACODET). Student associations are common in Uganda, but this one was different. Rather than remaining a social organization dedicated to parties and festivities, the members of PACODET decided that they wanted to serve the community. The students talked to the elders about the health problems in the villages and the elders said: "You tell us that something can be done. Show us that what you say is true, and we will give you our support!"

The students called a meeting. Over a hundred people turned up and together they discussed ways in which they might improve health. Funds were obviously required, and each individual who wanted to join PACODET contributed 100 shillings (approximately US$0.50 in those days). Four hundred people attended the next meeting; before long, PACODET had raised 40,000 shillings and its work could begin. Given the high incidence of malaria in the district, one of the first things they did was to purchase chloroquine to treat the sufferers. Another major killer, especially of young children, was measles, and PACODET saw that there was an urgent need for a vaccination program. The association approached Pallisa's district medical officer and requested that the government help train some of the villagers in basic health care. Since 1989, 40 community health workers and 15 traditional birth attendants have been trained in and around Kapuwai. The vaccination program began, and PACODET's health workers were soon vaccinating more than 700 children a month against measles, TB, tetanus, polio, diphtheria and whooping cough.

The program has been a resounding success. Child mortality has fallen dramatically and the health of the adult population has also improved. During the past year John Arube-Wani had carried out a qualitative survey of five successful primary health projects around the country. "This is the only one which was initiated by the community itself," he said, "and you really notice the difference. Here the villagers can discuss the concepts thoroughly; they feel in control and they know that they will continue to be successful. The other groups I've seen are much more fearful about their future as they're so dependent on outside help." The Ministry of Health has recognized PACODET's Health Care Project as one of the best in Uganda. The Ministry, incidentally, supplied a refrigerator, vaccine carriers and bicycles, and provided training when requested to do so. However, most of the input, whether financial or technical, has always come from PACODET, whose members now pay an annual subscription of 500 shillings per household and an enrollment fee of 3,500 shillings. At the time of the January 1993 meeting, PACODET was mid-way through its most ambitious project to date: the construction of a health center that would eventually serve around 100,000 people.

Appraising the local environment

The human population was conspicuously healthier now to local eyes than it had been in 1989, but the same could not be said of the environment. Most of PACODET's executive team were eager to tackle the area's environmental problems, yet they seemed unclear about their precise nature. Tom suggested that they conduct a simple exercise which would help to clarify their thoughts, and they spent the whole of one afternoon drawing up two lists. One described all the features of the environment and aspects of their lives that they appreciated and enjoyed; the other concentrated on dislikes and grievances.

On the 'appreciation' list, a number of items came up quickly. The leafy environment, good soils and adequate rainfall. The wide varieties of birds and insects. The rocky hills, which provided a home for wild animals and stone with which to build. The swamps, which provided fresh water and a habitat for wildlife. Certain herbs for their medicinal qualities. Termites as a source of protein, and for the fine-particle clay useful for brick building. The large variety of trees, including bread fruit, mango, oil palm, pawpaw and flowering frangipani. Nature had been kind to the people of Pallisa district, and they knew it. And the society was friendly: in less abundant times everyone could be counted on to come together and share resources.

When it came to discussing dislikes, nature was only occasionally accused of making their lives difficult: monkeys raided crops, especially around their granitoid hideaways; termites occasionally caused crop damage; and mosaic disease had had a serious impact on cassava yields in recent years. And, of course, there was the mosquito, vector of the malaria parasite and scourge of the tropics. However, it was the human condition, and the improprieties and weaknesses of the people themselves, which dominated the group's list of grievances. Education standards were poor because parents didn't value or couldn't afford to give their kids an education. Classrooms were in a bad state due to lack of money, and many people felt schooling was unnecessary, despite the fact that they themselves acknowledged that their problems often stemmed from 'lack of knowledge'. Alcoholism was a problem, and so was contamination of water sources and poor sanitation, even though half the homes in the area now had pit latrines. Cooking stoves were inefficient and filled the houses with smoke. Women spent too much time collecting and transporting water. Domestic refuse left to rot in the open attracted rats, and many people lacked proper storage facilities and regularly lost part of their crops to pests and decay. Some crops appeared to be succumbing to diseases and pests which had become resistant to sprays. Local children inappropriately used a pesticide on white ants, and hundreds of birds had died after eating the poisoned ants.

Indeed, nature seemed to be suffering on all fronts: for some time women had been cutting green wood (as opposed to natural die-off) to burn at home, thus damaging the local forests; the wetlands had been increasingly reclaimed for rice cultivation and so shrunken that a day of fishing was producing hardly a handful of fish; hunting and killing of animals had been so intense that even the commonest wild creatures, such as monkeys and snakes, were becoming rare. There were other familiar grouses such as you would hear in rural areas throughout the developing world: roads were poor or non-existent; there was no electricity or power; security was a problem, especially at night.

It took some time before anyone mentioned what many agreed to be the most complex and pressing problem: the rapidly rising population which was inevitably having an impact on the land. "Talk to any of the elders," Vincent said, "and they'll tell you that the productivity of the fields is falling. In the old days, people used to rest their land to allow it to recover. Now, they simply can't afford to leave it lying idle and the soils are becoming exhausted." The loss of cattle - providers of draught power, meat, milk and manure - has made matters worse. "Family planning is long overdue," suggested Simeon. "We're reproducing much too fast. If there's a calamity in the future, we'll all die off. I've got fifteen children and I'm beginning to realize the scale of the problem. I own thirty acres of land, which is a lot round here, but that won't be enough to support my children when they grow up."

Women's status was also deemed to be a significant problem. If a couple had difficulty bearing children, or if a child died, women got the blame. In keeping with local custom, when approaching a man - say with a cup of tea, or to introduce themselves - women of all ages sank to their knees. Whenever men and women are together, the latter always behaved with exaggerated deference.

During the meetings under the mango tree in Kapuwai, the men talked with surprising candor about the failings of their own sex. "Men want to drink every day," said Lawrence, "even if they don't have the money. Sometimes you see a father spending all the family money on himself, and that can lead to malnutrition of the children." The lobola system, whereby men paid a bride-price for their wives, meant that men often regarded their wives - and most have two - as little more than a form of economic investment. Women were relatively powerless, even though, as Vincent pointed out, they were the most productive members of the community; they did most of the farm work, looked after the home, fetched water and fuel, cooked meals and took care of children and the sick. Despite this, wife-beating was a widespread problem in Pallisa district.

During the previous year a Women's Association had been formed, and a small group of women met to discuss pertinent issues every Saturday. Half the executive committee and over two-thirds of PACODET's dues-paying members are women, and female emancipation is one of the organization's most significant tasks. According to Stanley, "Women are more prudent, and they think far more about the future than men. It's very important - not just for them, but for all of us - that they assert themselves and participate fully in the development of this area."

Transects, priorities, and group work

On the second evening in Kapuwai the villagers decided to go on a series of walks in the surrounding countryside. This would enable them to make a thorough assessment of the key environmental issues. The group began by walking through a patch of woodland. In the old days, commented one farmer, there used to be some fine woods here, with big trees and plenty of game. Today the only large animals to be seen were monkeys and the occasional antelope, and this particular wood had been heavily degraded by cutting - for fuel wood and building materials. Each year farmers nibbled away at its periphery. "It'll all be gone if we carry on doing this," explained Stanley, waving his hands at the recently ploughed furrows which ran up to a plot of burnt scrub. "But if you challenge people who do this, they'll say: 'How else can we make a living?'''

Then the group reached a marsh that was leading to a small lake. Over the past few years many marshy areas had been converted to rice paddy. Rice farming is certainly a good way of making money: rice grows well, keeps well and sells well. However, the conversion of marshes into paddy had caused much controversy. Elderly women have to walk much further now to find suitable wetlands in which to fish, and the catfish habitat has been virtually eliminated in Pallisa district. And not only were the fish a good source of protein, they also ate the mosquito larvae. Now the area has many more mosquitoes than in the past.

To some members of the executive committee the walks on the second day were revelatory. In the morning the team clambered up to the rocky summit of the highest hill. From there they could see quite clearly how much their woods had shrunk. Dotted around the cultivated landscape were a few statuesque muvule trees. In the old days, said one of the more senior members of the committee, these trees were far more common.

The following morning the group of 13 attempted to introduce some order into the chaos of likes and dislikes which they had drawn up on the first day, also in the light of the subsequent walks and discussions. This was a lengthy process, occupying the best part of a day. By sunset, the group had ranked, in order of importance, the main areas of concern. At the top of the list came 'lack of knowledge', followed by 'population issue', 'income generation', 'water and sanitation', 'energy, transportation, and housing' and finally 'food security'. Although the categories were broad and the problems not exhaustively defined, there was a general consensus around the items that were included - and especially around the need for greater knowledge.

That evening the PACODET committee sent word around the area that on the following afternoon there would be a large meeting, open to everyone, to discuss Pallisa's environmental problems. Around 100 people turned up at the primary school and split into six groups. Each group had as chairperson and rapporteur two members of the PACODET committee and spent several hours discussing a topic of particular relevance for the priorities identified the day before. While one looked at the issue of pesticide use and abuse, another discussed the population issue, another the encroachment into swamps and forests, and another one the need to understand better what was happening in the area. Each group sat in a circle on the ground; Lawrence, in keeping with his role as schoolmaster, had wished to sit on a bench while chairing his small group, but others convinced him that it was better to be on the same level as the others. Afterwards, he said he was glad he had done that, as it helped to change his attitude. At the end of the group work, reports were given by the rapporteurs and then the women sang religious songs and some folk melodies.

Planning for action

On their last day in Kapuwai, John Arube-Wani and Tom Barton met with the executive team to discuss the results of the community-wide meeting the day before. It was now time to draw up a plan of action. Although there was a good deal of consensus on the problems to be addressed, the same could not be said for the actions that the group felt PACODET could or should take. There was still a good deal of confusion, not just about the nature of Pallisa's environmental problems, but about their severity and significance. Stanley began by saying that the conservation of the swamps was a priority, as was the protection of the woodlands from further encroachment. At present, he didn't think pesticide use was widespread enough to constitute a serious problem, though he acknowledged the need to gain more information about the extent of their use.

Everyone agreed that 'lack of knowledge' contributed to poor land-use practices, the mistreatment of women, the rapid population growth and many other perceived ills. A variety of income-generating activities were mooted. The idea of trying to gain an income while improving the environmental conditions was suggested; many found this appealing. Stanley and others expressed interest in fish farming as a possible alternative to growing rice in the swamps. Others mentioned setting up a grinding mill - they already had a suitable building - and the women in the committee discussed the local manufacture of mosquito nets and latrine slabs. There were some ventures, such as tree planting, which the villagers could undertake themselves at little or no cost. In fact, they had already set up a small nursery. There was talk too of setting up a vegetable garden at the primary school.

Yet again, 'lack of knowledge' was identified as a major problem. The villagers had no idea how to make mosquito nets, or where to get the materials; they had little experience in forestry matters, and none in fish farming. PACODET's Plan of Action was mostly devoted to gathering information about training opportunities, funding sources and a variety of technologies, as well as about themselves and their surroundings. Over the next few months they intended to map their resources and carry out a survey of agricultural practices; they hoped to find out who was taking trees and who was encroaching the swamps. They also intended to look at a range of concerns from family planning to household hygiene, from dietary habits to the use of pesticides. It was an ambitious program and the faces of those gathered beneath the mango tree expressed both excitement and apprehension. Time, they knew, would test their commitment, their ability and their luck.

Monitoring and assessing progress

Four months later the PACODET committee gathered once again in the shade of the mango tree to discuss progress towards implementing the Plan of Action. The participants in the January meeting were all there, but now they were joined by many new faces, among them several women. PACODET had become more structured in the past few months and various sub-committees had been formed to take charge of specific interests and activities; each was headed by a man and a woman. During the course of the day each committee reported on its progress.

James and Filder began by discussing family planning, the promotion of which had been virtually non-existent in this part of Uganda. Realizing that it was nearly impossible to get government services delivered locally, Filder and Ann had gone to Kampala in search of training and resources. For a few days they slogged around town, mostly on foot, visiting national and international agencies. They gathered huge amounts of information and ideas, and talked to many people. Gradually, they became more confident, not just in their dealings with officialdom but in discussing matters among themselves and with their families. Now they were working out plans to introduce a family planning program, plans which had been boosted by the recent news that Florence, one of PACODET's first health workers, was to receive midwifery training. This would undoubtedly help any family planning initiative, as would the expertise which Stanley was about to gain as a newly appointed short-term consultant to CARE-Uganda. His task was to assess family planning needs in three eastern districts, including Pallisa.

Amos was the next to speak and he presented to the gathering a small sample of the many maps which he and friends had made to illustrate the results of the health and environment surveys. The maps showing land-use patterns - swamps, forests, cultivated areas - were complemented by photographs taken by Tom Barton from the top of the rocky hill. Ann then discussed the preliminary results of the health and environment surveys, which had involved field visits, group meetings and questionnaire interviews with many families. It seemed, she said, that the immunization program was working well, that the incidence of diarrhea and other preventable diseases was low and that children were reasonably well nourished. However, the sub-committee was particularly concerned about the dangerous use of pesticides and PACODET planned to launch an education campaign to address this matter. The new regulation would limit the use of Dimicron pesticide, which was used for the control of insects and birds. Another measure to reduce pesticide use involved the purchase of a truck-load of disease-resistant cassava, which would be planted in a local plot and later distributed in the district. Some people had begun to use animal manure to fertilize their fields and to select seeds for their pest-resistant qualities. Finally, Vincent and Lawrence had set up a tree nursery in the school garden, and here the children would learn how to plant and tend trees.

Despite progress in these many areas, not everything was going well. Someone mentioned that monkeys had begun to steal chickens; as there was so little forest left for them to hunt in, no one was particularly surprised by this. One person complained about the increase in rats around villagers' homes, possibly due to the decrease in the number of herons preying on them. Several committee members wondered whether the widespread use of pesticides and the loss of wetlands habitat had led to the decline in herons. 'We're learning basic ecology the hard way,' said Amos, 'but we are surely learning it!' Recognizing the importance of wetlands' ecology, Stanley had had contacts with the Ugandan office of IUCN, which had proposed a pilot community project in wetlands management as part of the new wetlands policy in Uganda. Everyone got very excited learning about this.

Outsiders might find it odd that a poor rural community organization should turn down an offer of money, yet this is precisely what PACODET did. A couple of years before the 'PEC meetings' in Kapuwai, PACODET had sent in an application for the financing of a diesel grinding mill to the US Agency for International Development (USAID). During their visit to Kampala, Filder and Ann had discussed the proposal with USAID officials, who offered PACODET a considerable sum of money. At first, the women were delighted, but after they had discussed the matter with the PACODET committee, everyone began to have second thoughts. For one thing, they realized that there were now several mills in the area which were operating at a loss. There were also the environmental arguments against a diesel mill, which would emit noxious gases, fill the air with dust and introduce an unappealingly noisy element into an otherwise peaceful and largely machineless setting.

The PACODET committee eventually decided to ask USAID to shift the grant from the mill project to another one which would establish a sewing and carpentry workshop. "So far we have no commitment from USAID," Filder told the committee, "but they've agreed to hold on to the money until we present more detailed plans for the workshop. Perhaps they'll help us to get the tools we need to start working." The women were eager to produce quilts, mosquito nets and clothes, and they wanted to use scraps of fabric, unwoven cotton and anything else they could find. The workshop would also become a useful meeting place for their association.

It was now late afternoon and an orange sun was sinking in the west. A group of teenagers arrived to play music under the tree. It was a warm, humid night; fireflies blinked in the darkness and the smell of wood smoke drifted over the gathering crowd. People ate, chatted and laughed a lot, still excited by the news of the day. As soon as the music started, many began to dance. Others came close to the players and sang. They sang religious songs, songs about AIDS, about past tragedies and future hopes. The people of Kapuwai had come a long way since their region was plundered by the Karimojong in the late 1980s. They had every reason to celebrate.

The story of PACODET is abridged from Pye-Smith and Borrini-Feyerabend, 1994.