The Elephant in the Sitting Room

Dark Clouds
My search for clues as to how the 20-year conflict in northern Uganda will end, has drawn me back again and again to the IDP camps and the countless children they contain. I have no doubt there will be an end to the LRA and it will be soon. I also think there will be a second and even more chaotic and probably bloody phase as people return to their lands and disputes over ownership lead to community conflict. But that too will eventually be resolved. A far darker and impenetrable cloud looms, not just over the north but the whole of Uganda; one that threatens Uganda’s stated goal, to emerge as a middle-income economy by 2025 and perhaps the very future of the nation: a population growing at a speed that almost beggars the imagination.

It seems counter-intuitive that a country ravaged by war and disease, particularly HIV/AIDS, on the scale that Uganda has suffered for 25 years, would be undergoing a population explosion. It is even less conceivable when viewed against a background of an infant mortality rate of over 70 per 1,000, a maternal mortality rate of almost 500 per 100,000 live births and a life expectancy at birth of around 50 years. But the population is increasing at a rate that should set alarm bells ringing in Kampala - it has doubled in the past 20 years - yet the subject doesn’t figure on the political agenda, academic debate or social discussion. It is the Elephant in the Sitting Room everyone is trying to ignore.

Lampposts
The facts are carefully and unemotionally laid out in a document, Uganda: Population, Reproductive Health and Development: 2005, by the Ugandan Ministry of Finance, Planning and Economic Development. It is a little-known publication, which Google failed to identify in the welter of online articles on youth, gender, HIV and other socio/economic subjects concerning Uganda. I am well aware of the saw, “Statistics is like a lamppost to a drunk. It's there more for support than illumination” but I offer some numbers from the book to underpin my argument.

The Fertility Rate in Uganda (numbers of babies each woman produces in her lifetime) is currently somewhere between 7 and 8, little changed over 30 years. The Replacement Rate (numbers of babies required to sustain a stable population) used in demographic science, is 2.1. All countries in the developed and many in the developing world are close to or below that rate. Neighboring Kenya is about 4 and falling. Nigeria, often cited as a country with a looming population problem is 5.5. The Ugandan population is currently estimated at 29m, if the Fertility Rate continues unchecked the population will double to 60m by 2025. If it halves to 3, the figure will still be a huge 45m by this date. I have found no evidence of a drop in the rate.

Young in a Slum
There is a school of thought that argues population growth on this scale is not all bad and that Africa has traditionally suffered from too small a population to grow a strong internal market. This may be so, but a combination of high birth rates and the ravages of HIV have skewed Uganda’s population. Over 55% of the population is under 16 years, the average age of Uganda is 14 years and a few months. This has short and long-term implications: the child dependency ratio (numbers of child dependents to adults) is 100:100 placing huge strain on working adults and social services, particularly schools and health services. In the long term these children will enter the workplace which currently cannot provide modern-economy jobs for even a fraction of its workforce, estimated as an annual need of 200k. At current predictions there will be a requirement for between 0.5m and 0.75m new jobs a year by 2025, an impossible goal to achieve.

As if this isn’t daunting enough, there is another distortion to the equation, urbanization. The population of the capital, Kampala was 450k in 1980, today its about 1.5m, small by African city standards, but it’s an overcrowded city with over 50% of the population in temporary housing (euphemism for slums). If the present rate of urbanization of 7% continues unchanged (the trend throughout Africa is upwards) at the current rate of population growth, Kampala will be a huge 3.5m by 2025 (and double its current size to 2.8m if this rate halves). Nationwide, the estimated increase in urbanization - to 18.5m by 2025 - will require another 12 “new Kampalas” to be built in less than two decades. Population growth halved will still need 9 “new Kampalas”. It is hard to imagine how the country could develop housing, infrastructure and power for 9 or more new cities in less than 20 years

Contraception and Culture
During my investigations, I discovered amongst all the troubling predictions, a startling fact: in Uganda, research shows 35% of married women currently want to space or limit their births but are not using contraceptives. There is no data on unmarried women who do not want to get pregnant but don’t use contraception but it would be a fair guess that the figure is even higher. The UNFPA estimates the overall ‘contraceptive prevalence’ as less than 20%. Why this unmet need exists is difficult to discern but appears to be a mixture of government complacency - it has not identified high population growth as a critical threat to development, traditional culture – family planning has never been a cultural practice, and the attitudes and moral teaching of religious organizations and faith-based groups, which fundamentally disapprove of contraception or believe that freely available contraceptives - particularly condoms for the unmarried - promotes promiscuity, with increased risk of unwanted pregnancies and HIV.

More recently the Government, led by the President and First Lady, have been overtly manipulating the long-standing A(bstinence) B(e faithful) C(ondoms) approach to HIV prevention by placing greater influence on AB and less on condom use. The result has included a nation-wide shortage of condoms, which must have impacted upon their availability for contraceptive use.

Marketplace Morality
There has been much talk about the undue influence of the US in this domestic turmoil, particularly condom availability. Matters came to a head when the UN Secretary General’s Special Envoy for HIV/AIDS in Africa, Stephen Lewis, told a world-wide teleconference on AIDS, Uganda’s policy shift has been influenced by the US government “which is now mainly promoting pro-abstinence programmes and less of condom use”. Dr. Mark Dybul, the US global AIDS co-coordinator, rebutted the charge, stating there was no change in US policy, current emphasis on abstinence is only to ensure a more balanced ABC strategy.

Research suggests Dr Dybul is being economical with the truth. USAID policy and procurement regulations for contraceptives, including condoms for HIV prevention, for foreign aid projects can be found at ADS 312.5.3d of the organization’s procurement manual. The key words amongst all the jargon are: “Source/Origin and Nationality - Contraceptive products shall meet the requirements for U.S. source, origin and nationality”. In other words recipients of US funding for both reproductive health and HIV prevention programs must buy American. Maybe the US government indeed has no hidden moral agenda for shaping Ugandan reproductive health policy, unless you count the morality of the marketplace. But the effect of such blatant trade protectionism can only be to limit availability of reproductive health resources to Uganda and elsewhere, by denying access to cheaper, equally high-standard generic contraceptives on the global market.

Rearranging the Deckchairs
Whereas Uganda, as a sovereign state, does not welcome overt outside interference in domestic policies, the very disturbing scenario I have described for Uganda’s population and development must surely impact upon national and, in turn, regional security. Given that the USA, as one of Uganda’s largest aid donors, has much influence on national issues, it seems sensible foreign policy for the US government to offer guidance and resources to help Uganda limit the worst effects of its rapid population growth. To do otherwise is to do no more than help the Ugandans rearrange the deckchairs on their personal Titanic.