Sunday, March 4, 2007

In Flew Enza

This is another piece I wrote for US Medicine, in August 2006. I have included it verbatim because very little has changed and 'Bird Flu' is just as likely to devastate northern Uganda today.

And In Flew Enza
By Robert Leitch

I had a little bird, Its name was Enza, I opened the window, And in-flu-enza.
-American Skipping Rhyme circa 1918

Life On Hold
Things have happened in northern Uganda, since last I wrote for this column. Peace-talks, to end the 20-year insurgency, have begun in Juba, southern Sudan. Given the complexity of the issues, it is not surprising they are proceeding in a faltering fashion. But there is real optimism these talks will succeed, not least because the Government of South Sudan (GOSS) instigated and are mediating the proceedings. The Lord's Resistance Army (LRA) has used southern Sudan as their main operating base for most of the conflict, and the Government of Uganda (GOU) is clearly committed to ending the war.

Whilst talks drag on, there are tentative moves by the people to leave the [Internally Displaced Persons, or IDP] camps [in northern Uganda] for their land. Thousands have returned, but life for the majority remains on hold. No one who visits a camp can fail to be moved by the plight of the people. The sight of hundreds of men and women, passively lining up to collect food from the back of the World Food Program (WFP) trucks, is both chilling and depressing. During the day, the camps resemble ant hills, with thousands of women and children carrying bundles of wood and whatever food they can cultivate locally. Most of the men seem to have succumbed to the misery of camp life. Producing alcohol is a major occupation and large amounts are consumed, contributing to the high levels of disease, crime and violence. Children in vast numbers swarm everywhere, unclothed, dirty, bellies swollen by malnutrition and disease, neglected by parents too worn down to care.

Aid, But Little Impact
Every day, battalions of aid workers foray into this sad milieu, offering a menu of aid and assistance, each in coded humanitarian argot-WATSAN (water and sanitation), SGBV (sexual and gender-based violence), NFI (non-food items), Psychosocial, Food Security, Child Protection, Human Rights and Protection, Mine Action, etc. Time and space preclude even an elaboration of the acronyms let alone description. Try Google.

Given the level of effort and the huge resources poured in over the past decade, it is depressing to see how little impact this aid has had on the lives of the recipients. Statistical indicators of quality of life and health show nary a dent in their appallingly high numbers [of death and disease]; some, such as HIV/AIDS, show an uptick. The reasons are many and complex, but two stand out.

First, the shameful level of government neglect of Northern Uganda, for decades. The essential infrastructure of society has been allowed to run into the ground. Local government lacks money to pay salaries. Roads, water and sanitation are much as they were 40 years ago, or worse. Education, overwhelmed by the huge numbers of children, is grossly under-resourced. The government health care system provides only rudimentary care for a small part of the population around the major towns. In addition to starving the north of resources, the government has failed to articulate a plan for managing the long-term humanitarian crisis-identifying needs and coordinating aid to meet clear goals.

Into this void, have stepped the international organizations (the United Nations and bilateral [and/or national] aid agencies, such as those funded by the United States Agency for International Development) and the NGOs (non- governmental organizations), the latter in bewildering numbers. Lacking a clear government plan to work to, all the players march to their own drum. The consequence is duplication of effort with its huge waste, and yawning gaps in the provision of aid, both in service and distribution. Despite a deluge of reports on the disparity between needs and services provided, the NGOs appear genetically incapable of coordinating their efforts and nowhere is there leadership to make them do so.

Given this level of dysfunction it is small wonder that the health of IDPs remains in desperate straits. A frightening array of infectious diseases are endemic to the camps. Access to clean water remains a survival skill and the figure for [pit] latrines is about one for 130 people. Government- and NGO-run clinics exist in many camps, but such is the disease burden, that they can offer little more than medical treatment to 'fix the broken.' Preventive health measures are no match for the health threats. Disease surveillance is mainly action taken after an outbreak, rather than a methodology to provide early warning.

Damning Indictment
This month has witnessed a damning indictment of current health care for IDPs, an outbreak of measles in a number of camps. Given the very high birthrate and the movement of people from southern Sudan where the disease is endemic, one would expect a number of cases annually, spread throughout the population. There have been over 400 cases in one cluster and 200 in another; this is a failure of a fundamental public health task-infant vaccination.

Local government health organizations (responsible for routine vaccination in the camps), WHO and UNICEF hurriedly rolled out a measles awareness and vaccination campaign, which will probably prevent a more serious epidemic, but it is a chilling indication of how vulnerable the population is and how unprotected [it is] in the face of even more terrible diseases that lurk in this part of the world. I am not inferring Ebola or Marburg, diseases for which Africa is infamous. The people have already witnessed and endured these horrors (there is even a local Ebola Survivors Group). My concern is something with apocalyptic potential, not only to devastate the region but to accelerate its global spread, avian influenza.

Farming Culture
Ugandans are agriculturalists, none more so than the northerners, long famous for their herds of cattle and farming land on which almost anything grows. Their farming culture has made their incarceration in camps, living off WFP handouts, ever the more cruel. But they are resourceful and have turned to what they can 'farm' in the camps, animals of all kinds. It is not unusual to see pigs and goats roaming freely between the crowded huts, feeding on the detritus of human squalor. There is even the odd cow tethered on the outskirts. But the most commonly found domestic creatures are fowl; chickens, ducks, turkeys and even pigeons are raised in huge numbers, to supplement WFP rations and as income generation.

Poultry raising is so successful and ubiquitous, it is impossible to even guess how many 'birds' are raised, eaten and sold in the camps and outside, every day. Some indication of the size of this 'cottage-industry' can be gained from the stream of vehicles-bicycles, pickups, trucks and buses-arriving into the major towns each morning, festooned with live poultry, destined for sale in the local markets. Many are transported further afield to the capital Kampala, usually under the seats of the over-crowded, over-speeding buses that hurtle to and from the north every day. Some of these are bartered for other goods, at the frequent stops on the 200-mile journey.

Giant Petri Dishes
It takes only a couple of visits to the camps, an awareness of [the] appalling state of the population's health and health care, some knowledge of the history of 'bird flu' and a little imagination, to see the huge potential danger they present. They are, in effect, 'giant Petri dishes' in which H5N1 could develop unnoticed, acting as a focus for the spread of the disease throughout Uganda and beyond. Perhaps even enabling that dreaded moment when the virus mutates from avian-to-human transmission, to human- to-human.

Some might consider these the scribblings of Chicken Little (obvious pun), noting that in many countries where H5N1 has appeared to date, notably Hong Kong, Viet Nam, Thailand, China and Indonesia, the environment was very similar-dense human populations living in close proximity with birds and other animals. In each case, the virus was contained with relatively few human fatalities and the disease has not yet 'crossed the Rubicon' to become a human-to-human disease. Where it has appeared in Africa-in Nigeria, Egypt and Sudan-it was swiftly identified and contained. Moreover, as every day passes we know more about the virus and are assured we are better prepared, even to the extent we have recently developed a vaccine.

But consider this. The population in my scenario is over one million people living in conditions that beggar description, many with their immune systems besieged by an array of endemic diseases, malaria, TB, HIV/AIDs, typhoid, cholera and almost the entire species of helminths. Their health care relies on an ad hoc arrangement of government and NGO clinics able to provide only rudimentary care. Preventive medicine and disease surveillance are no more than token gestures.

Moribund Veterinary System
To cap it all, despite being an overwhelmingly agricultural society, public veterinary services in Uganda are almost non-existent. Thanks to a raft of ill-conceived World Bank and IMF 'structural adjustment programs' (i.e., cut public spending in order to borrow WB money) in the 1980s, one of the best national veterinary services in Africa has over time been reduced to a crumbling skeleton, and the bones are thinnest in the north. That is not to say there are no vets; Makrere University in Kampala graduates about 40 a year, [and they are] well- trained. [But] half never find a job in veterinary medicine, [and] most of the remainder eke out a living in private medicine in the richer south, [while] a few get jobs with the government. The local government veterinary services are so under-resourced that they can only provide for the few farmers who keep large herds of cattle and goats in the region, and [provide] oversight of slaughterhouses. Despite being well aware of the amount of animals and birds being reared in the camps, the conditions in which they are farmed and the existence of a huge reservoir of zoonotic disease among these animals (particularly TB, brucellosis and helminthiasis), the local government veterinary services are powerless to intervene. They lack the resources even to provide day-to-day animal husbandry, let alone establish zoonotic disease surveillance.

Inept Government/UN Action
The government is well aware of the inevitable arrival of bird flu into the country, the huge damage it could do to the economy and the threat to life as well as livelihood. Together with the UN Food and Agriculture Organization (FAO) and WHO, they have, according to their public information blurb, "[e]stablished a National Task Force, bought a machine to test for the virus, begun a public awareness campaign and bought 1,000 doses of Tummy Flu" (sic). It would be funny if it were not for the pathetic scale of government reaction to an inevitable catastrophe. FAO, the smallest UN office in the north, has given $45,000 for the public awareness campaign, which has paid for a half-hearted radio and leaflet program. Given the poor penetration of these sorts of programs to the camps and the fact that bird flu is, to most [people], a dim and distant threat when they have to deal daily with a host of present dangers, I doubt its impact.

Moreover, disease afflicts animals in the camps every day, the normal practice is to kill and eat an ailing animal or bird, while it is still edible. It would require large scale bird deaths to create alarm, by which time, given the system of marketing birds I have described, the damage would be beyond control. It is also hard to imagine disease control by standard practice, culling the domestic poultry population. The logistics are formidable. Quite apart from the fact that there is an unknown number of birds, secreted in every nook and cranny of hundreds of camps with a million-plus people, who will compensate the people for their lost livelihood?

Left Hand, Right Hand
As an indicator of how little the international agencies and the government know about what their left and right hands are doing, consider the following. The government, using World Bank funds (therefore one assumes, with the agreement of WB) through an organization called the Northern Uganda Social Action Fund (NUSAF), funds a large number of small scale 'backyard' chicken rearing projects across the region, in towns and more developed camps. They are undertaken by community groups with little or no knowledge of industrial chicken rearing, yet they use the same methods scaled down-'day-old' chicks from a huge agro-industrial conglomerate, raised in a confined space, in large numbers (300 or more) using industrial feeds and antibiotics. However, the projects are not governed by any standards of industrial farming and lack expert [veterinary] oversight. To date, the bird attrition rate has been huge but they continue to be funded. One day, people as well as birds will get sick and die. These projects only compound the dangers of the 'free range' practices in the camps. It seems incredible that the [Ugandan government's] National Task Force (with the WHO and FAO) has not ended these dangerous projects.

Realism And Action
Having painted what I hope is a dark picture, what can and should be done to improve a dire situation? It requires a very candid examination and description of the true state of the threat and current efforts at mitigation, particularly in the north and specifically in the IDP camps, which I have argued present a real threat to the region and the world, as a breeding ground for bird flu. There are realistic measures that could be taken, rapidly and cost-effectively. The first is to develop coordinated preventive health measures in the camps. This would require expanding, resourcing and regulating the current ad hoc system of government/NGO health clinics to include education and disease surveillance. The second is to resurrect the moribund government veterinary service and provide it with the resources to work in coordination with the health services. First, to undertake routine animal husbandry services and education in the camps, which would be expanded to include zoonotic disease surveillance and provide an early warning system for bird flu.

Whatever action is taken to attempt to mitigate the potential catastrophe of bird flu in northern Uganda, it has to be based on more than a hope that it will not happen or it will not be too bad. In the words of my old friend and mentor, General Gordon Sullivan [who was chief of staff of the U.S. Army in the mid 1990s], "Hope is Not a Method."

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