Mars and Aesculapius

Appropriate Medical Monitoring

2010-06-08T03:43:00.000-07:00

I see that today's ( 8th June 2010) New York Times has an editorial on the involvement of medical personnel in torture. Physicians for Human Rights has issued a report concerning the alleged involvement of doctors and other medical professionals in harsh interrogation by the US military and other government agencies. Back in 2004, I wrote a piece for US Medicine on just this subject. Sadly, when the magazine changed hands they ditched the website on which the original article was published. I thought for posterity's sake I would republish the piece here. I like to think that the medical profession has learned its lesson from the debacle of Guantanamo and 'extraordinary rendition' but sometimes I worry.

Appropriate Medical Monitoring (published July 2004)

‘If nothing can protect the nation against itself, neither its traditions nor its loyalties nor its laws…then its behaviour is no more than a matter of opportunity and occasion. Anybody, at any time, may equally find himself victim or executioner’ – Jean-Paul Sartre

The Prisoner
He lay very still with his eyes closed, feigning unconsciousness. He was a big man and had put up a fight. He had a large gash over his left eye and his knuckles were bloodied and torn. The head X-rays were negative and the ‘doc’ completed his exam. He told the medic to clean him up and up and stitch the eyebrow.

They were alone in the cubicle, the medic, the prisoner and the sergeant who brought him in. “He is one bad b…..d,” the sergeant told the medic, “killed six of my soldiers this month.” He pushed the pistol further into the prisoner’s neck. “ On three I knock you over and he gets it. We say he tried to escape. OK?” The medic froze. The sergeant’s eyes were scary. The cubicle door opened, “Need any help stitching him up?” said the nurse. “Yes please,” replied the medic and the moment was past. Not Baghdad 2004 but Belfast 1970. The medic was me and, to this day, I do not know what I would have done had the nurse not opened the door.

Worried
In thirty years of service as military ‘medic’ this was not my last ethical crisis or moment of self-doubt. Safe in retirement I can say more often than not a combination of good luck and leaders wiser than me, saved the day. I am therefore well aware of the minefield I am about to negotiate, but I am worried for my friends in the US military medical services.

It begins with the Congressional hearings on the debacle at Abu Ghraib. I, like most of the world, sat transfixed throughout, angry as the catalogue of events unfolded but aware war is terrible and once good people are often brutalized into committing unspeakable acts. The more I heard the more concerned I became. Whether, as seems increasingly unlikely, this was an isolated incident perpetrated by a group of ill-trained and poorly led junior ranks, or the tip of a sinister iceberg of systemic abuse of prisoners, the damage to the reputation of the US military is huge.

But as I listened to the unrelenting and incisive questioning of lawmakers, I felt better. Whatever wrong had been committed, this was American democracy in action. The truth would come out. Justice would be done. I was reminded of Churchill’s observation, “America always does the right thing, but only after it has explored every alternative.”

Coercive Interrogation
The debate spread wider than Iraq, to Afghanistan and Guantanamo. Details emerged about interrogation described as “coercive interrogation practices”. It seems for some time the Pentagon has authorized the use of a number of techniques, including sleep deprivation, sensory deprivation and forced prolonged positioning as part of interrogation. Lawmakers were assured that these coercive techniques were only used under very limited circumstances. “Every case required the approval of senior Pentagon officials -- and in some cases, of the Defense Secretary. Once approved, the harsher treatment must be accompanied by appropriate medical monitoring”. A red flag went up. I wondered who was doing this ‘medical monitoring’ and what was involved.

Over the past weeks I have scoured every available source from the New York Times to the Army Times. Meanwhile increasingly graphic detail has appeared in the media and it is clear there is more to this than the macabre theatre at Abu Ghraib. A catalogue of events, accusations and allegations would be a pointless exercise. Moreover, many investigations are in train and I am in no position to know all the facts. I can however, offer a couple of comments on the most contentious issues. First, did those at Abu Ghraib act without authority? Answers might lie with the senior officer at Guantanamo who in his inspection report of Abu Ghraib stated, “Detention operations must act as an enabler for interrogation.”

Torture?
Second, do “coercive interrogation practices” amount to torture or cruel and inhumane treatment? It seems to depend upon where you ask the question. The Pentagon is emphatic it does not [use torture]. When questioned as to whether the techniques listed as authorized for ‘coercive interrogation’ (apparently there are 24 interrogation techniques approved by the Secretary of Defense in a classified directive in April 2003) a Pentagon spokesperson offered, “… The techniques on the list are consistent with international law and contain appropriate safeguards such as legal and medical monitoring. "

This position appears at odds with the US State Department. Its annual Country Reports on Human Rights Practices routinely acknowledges the following practices as torture and/or ill treatment:
· sleep deprivation
· forced/prolonged positioning
· forced nakedness and sexual threats and humiliations
· blindfolding or hooding
· isolation, loud music, witnessing or hearing torture
· mock executions, threats to family and insults

This debate is far from over. The Wall Street Journal and the Washington Post have begun a public dissection of a number of Department of Justice, Pentagon and Whitehouse memos from 2002 and 2003, dealing with the legal definitions of torture and the limitations of the Geneva Conventions as applied to US Forces. I smell Pulitzer. The recent decision by the senior military commander in Iraq to ban all forms of harsh treatment of prisoners, suggests there are also serious concerns in the Pentagon regarding both the interpretation and practice of the laws of war in recent years. But I digress; my concern here is not with specific ill-treatment but with aspects of medical involvement.

Medics and Interrogation
I have found no evidence that any individual US military healthcare professional has been directly involved in the torture or ill treatment of prisoners – in Abu Ghraib or elsewhere. However, it is clear that healthcare professionals have been complicit to varying degrees in what I will refer to as ‘coercive interrogation practices’ – the clue is in that odious term ‘appropriate medical monitoring’. There are further indications in the Congressional evidence referring to procedures for interrogation, “The guidelines were the product of three months of discussion between military lawyers, medical personnel and psychologists, and followed several incidents of abuse of prisoners at Guantanamo”.
In a May 13,2004 article in Stars and Stripes, Major General Geoffrey Miller [Commanding General at Guantanamo] implied direct medical involvement at least in Guantanamo interrogations, in his quote “keeping prisoners hungry must be supervised by medical personnel. Also, wounded or medically burdened detainees must be medically cleared prior to interrogation.”

Culpability
Is the involvement of healthcare professionals in the interrogation of prisoners, whether - defined as ‘coercive’, ill treatment or torture – always wrong? Unequivocally, yes. I would go further; healthcare professionals even where they don’t directly participate but advise and train others, facilitate ill treatment or torture and are as culpable as the perpetrator.

I make such sweeping statements with the confidence that history and international law are on my side. The first support I offer is that of the World Medical Association (WMA) (a global institution formed under the aegis of the USA after World War II to address the issues raised by the medical atrocities committed by Nazi doctors). In 1975 the WMA issued the Declaration of Tokyo, which laid down basic precepts for the medical profession and human rights:
The doctor shall not countenance, condone or participate in the practice of torture or other forms of cruel, inhuman or degrading procedures, whatever the offence of which the victim of such procedures is suspected, accused or guilty, and whatever the victim’s beliefs or motives and in all situations, including armed conflict and civil strife
The doctor shall not provide premises instruments substances or knowledge to facilitate the practice of torture or other forms of cruel, inhuman or degrading treatment or to diminish the ability of the victim to resist such treatment
The doctor shall not be present during any procedure during which torture or other forms of cruel, inhuman or degrading treatment are used or threatened
The doctor’s fundamental role is to alleviate the distress of his or her fellow man, and no motive, whether personal, collective or political shall prevail against this higher purpose

Contravening Medical Ethics
The second justification for my argument comes from the UN, which has specifically addressed the ethical obligations of doctors and other health professionals in its clumsily titled document, The Principles of Medical Ethics Relevant to the Role of Health Personnel, Particularly Physicians, in the Protection of Prisoners and Detainees Against
Torture and Other Cruel, Inhuman, or Degrading Treatment or Punishment (1982).
The document states unequivocally ‘It is a gross contravention of medical ethics, as well as an offence under applicable instruments… to engage, actively or passively, in acts which constitute participation in, complicity in incitement to or attempts to commit torture or other cruel, inhuman or degrading treatment and punishment.’
It also states:
Health professionals may not participate, actively or passively, in torture or condone it in any way.
"Participation" in torture includes evaluating an individual’s capacity to withstand ill treatment; being present at, supervising or inflicting maltreatment; resuscitating individuals for the purposes of further maltreatment or providing medical treatment immediately before, during or after torture on the instructions of those likely to be responsible for it; providing professional knowledge or individuals’ personal health information to torturers; intentionally neglecting evidence and falsifying reports, such as autopsy reports and death certificates.

Medically Approved
What might make a healthcare professional get involved in ill treatment or torture of prisoners? Some may attempt to justify their complicity by contending they are obliged to obey orders. Others may claim their presence was necessary to protect the patient in situations where interrogation might go too far. Both are morally bankrupt arguments. Healthcare professionals must recognise that in using medical skills and knowledge to further the aims of the interrogators by making their job easier or reducing risk, they are complicit in any actions deemed to be inhumane. This is all the more insidious when it appears to stem from a concern for the welfare of the detainee. The repulsive expression “appropriate medical monitoring” illustrates the point. It suggests that techniques used will be subjected to medical professional scrutiny and approval. Thereby making them safer and humane?

Poor Training
Experience leads me to believe deliberate involvement of medical professionals in ill treatment of prisoners is rare. Most healthcare professionals err as a result of poor training. Many have scant awareness of prisoner’s rights or their own responsibilities to prisoners. Many too are ill-equipped to deal with moral dilemmas and ethical risks they face. They may have to decide for example whether loyalty to colleagues is more important than the interests of a detainee alleged to be a dangerous terrorist. If, as seems probable, US military healthcare professionals have been involved in “coercive interrogation practices” in Iraq, Guantanamo or elsewhere, I want to believe it was out of poor training and ignorance.

Urgent Action
All the signs are that in the near future the US government and armed forces will be severely censured by the international community, not only for events in Abu Ghraib but also for its general treatment of prisoners, particularly the use of harsh interrogation techniques. There is little doubt that ‘medical monitoring’ of such treatment will be condemned. There is an urgent need for action. First, medical participation in any form of interrogation must stop immediately. Second, the Pentagon should issue an unequivocal ban [on medical involvement] and clear directions for the future. Third, a thorough investigation should take place, of all military medical involvement, active or passive, in alleged prisoner abuse and in ‘coercive interrogation’. Finally, there should be a detailed review of current training of military healthcare professionals in the Geneva Conventions and Human Rights law. An improved training curriculum must be quickly implemented. Absent such urgent action, I am convinced there is grave risk to the ethical reputation of the US medical services. We [in military healthcare] have been teaching and practicing the Geneva Conventions unambiguously for over 50 years, they are our laws. Once you tell people its OK to break the law, there is no telling where they might stop

As a postscript, the reader might wish to know the prisoner I treated was released from detention a few days later, ‘for lack of evidence’. He continued to kill British soldiers for another ten years. The last I heard he was running a used car business and doing nicely.

My Magnificent Octopus

2008-09-23T01:42:00.000-07:00

“ Black Adder: “What have you got there Baldrick?” Baldrick, “I have written a story. My Magnificent Octopus.” Blackadder: “I think you mean Magnum Opus”.

Baseline Study

We are in our last month in Uganda and will shortly be returning to the US. The end of an era, we will have done six years in East Africa. It has been an experience I would not have missed for the world. I have been back at school for all this time.

My final task has been to undertake a Baseline Study on Malaria, AIDS and TB grouped under the latest aid acronym (MAT) in Luwero and Kiboga Districts, in Central Uganda, for a major NGO. In many ways the results summarize what I have discovered about health and healthcare in this part of the world over the past years and I think it might be worthwhile sharing them.

Just to give some context, the two districts are archetypal Uganda, rural, heavily agricultural, poor infrastructure and communications and little disposable income. There are almost three-quarters of a million people living in the area. The burden of disease, particularly malaria, HIV/AIDS and TB is very high, malaria overwhelms the healthcare system the whole year round.

The Study was designed in three parts: first a detailed survey of every health facility in both Districts, from hospital down to Health Facility Level II - the clinics that serve Parishes, which contain a number of villages - about 75 health facilities in all. Second, a household Knowledge, Attitude and Practice (KAP) sampling survey covering about 100 households in each District, rural and urban, total population over 200 households comprising about 1500 people. Third, a detailed examination of the information systems.

It was great fun and hugely educational. I visited and talked with healthcare workers and the people they serve, many miles from the nearest town or paved road. I saw up close the results of the millions of dollars of aid that the USA and other countries pour into development in Uganda and other African countries annually

A Perfect Storm

In summary, the study identified a ‘perfect storm’ resulting from the concatenation of number of events: a rapidly increasing population ( the Total Fertility Rate is 6.9) with a concurrent huge increase in the incidence of infectious disease, particularly malaria; rising expectations amongst the population, resulting from increased awareness and education; Uganda’s healthcare workforce crisis, there are severe shortages of trained healthcare workers at every level; de-centralization of healthcare, which has spread healthcare resources even more thinly, and chronic under-resourcing and neglect of the national healthcare system. The result is two Districts whose healthcare systems are in crisis. My experience suggests that they are indicative of the rest of the country.

In order to give my story a little more life than a turgid Study Report, I have decided to use the format of a [very lengthy] email I wrote to a long-suffering friend, describing my findings and thoughts on the issues. It may not follow the rules of grammar but I hope it makes the subject less dense

Malaria

Everyone [we interviewed] knows what causes it and where ‘mozzies’ live and breed. Everyone knows who is at greatest danger, moms and babies. Everyone knows how best to protect themselves and families, Insecticide Treated Nets (ITNs)
Yet less than 40% of the population has an ITN in their houses, very few have two. If you read the newspapers and the advertising of the UN and big NGOs, you would imagine the entire country draped in the ‘things’. Despite the imploring of Bob Geldorf and the rest, the promise of ‘nets for all’ is a myth, we found one facility with a dozen
nets available for hand out in over 75 facilities we surveyed. Almost all [ITNs] are bought and at large cost to families with little disposable income.

Healthcare workers complain constantly about advising moms at ante-natal clinics (ANC) to use a net and yet don't have any to hand out. It is really bad for morale.
Uganda needs to flood the market with free nets to the point where they have no retail value, and there are enough spare to decorate wedding venues and to use for fishing nets, both common practices here

About 60% of all patients visiting health facilities at every level, are diagnosed with malaria. 97% are diagnosed symptomatically. About 60% are diagnosed by nursing or health assistants, with very little training or experience. About 30% are diagnosed by volunteer Village Health Team (VHT) or Community Medicine Distributors (CMDs)
workers, with a couple of weeks training on an array of diseases. About 90% of suspected malaria patients are treated with Artemisinin Combination Therapy (ACT). The drug is handed out by formal health workers and volunteers, like M&Ms.

ACT has rapidly become the most sought- after drug in the Ministry of Health (MOH)
inventory. MOH offer it free of charge. It has become a source of alternative income for many healthcare workers who either sell it to their patients or to businessmen who shift it to DRC and Sudan. The result is an erratic and unreliable supply of ACT. Patients worried about availability, take the drug for 2 of the 3 days prescribed
and then horde the rest, for the next attack on them or their children. It does not take a PhD to know what constant and widespread subclinical exposure of any drug does to its efficacy I think we are on a fast track to ACT resistance, which I believe will be quicker and more terrible than the Chloroquine/Fansidar debacle

60% welcomed Internal Residual Spraying with DDT, 20% opposed the
idea, 20% didn't care. IRS has started in the North, Apac and Oyam Districts, with very good results It has now been stopped thanks to a court injunction lead by British American Tobacco (BAT(U)) and Dunavant Cotton Int. They worry that DDT will leach from the homes and contaminate their crops. The idea of organic tobacco beggars my imagination and vocabulary.

The strategy of providing intermittent preventive treatment (IPT) with sulfadoxine-pyrimethamine (SP) to pregnant women, though great in theory ( it offers considerable protection to pregnant mums when they are their most vulnerable) is hugely flawed. Most women only come to a health center once during pregnancy,
so they only get IPT1, they need the second dose, IPT2, for better protection, few get the latter. Only 30% of Ugandan women deliver in a health facility.

My general comment about Uganda's Roll Back Malaria plan is it might more aptly be named Operation Sisyphus.

HIV/AIDS

Everyone knows how it [HIV] is spread, 'sex and needles'. Everyone knows how to prevent infection, condoms, faithfulness and abstinence, in that order of import
Knowledge appears to impact little upon behavior. Condoms are available free, even in the most remote locations. Few men use them consistently. Fertility rates in both Districts are estimated at 7. Multiple sexual partnerships, particularly males fathering children with more than one woman, are commonplace.

Prevention of Mother To Child Transmission (PMTCT) is less well known about and the practice very poorly organized. Only 10% of interviewees knew the details. Again, the problem is that PMTCT relies upon regular ANC attendance and subsequent delivery in a health facility. I cannot see the current 30/70% balance changing in the near future. The healthcare system could not cope

Everyone knows about Anti Retro-Virals (ARVs). Everyone knows about HIV testing. Many women test, usually at ANC but often too at outreach clinics now known as HIV Testing and Counseling (HCT): note the change from ‘Voluntary’. Few men test. It seems they don't want to face the truth. HIV testing remains difficult to find in rural areas. HIV testing is scary for all and still carries much stigma. There is a distinct lack of national leadership in testing. The Tanzanian model, the President and First Lady testing in public, is one that. should be copied here. My conversation with the local Anglican bishop, that he might lead a local public HIV testing ‘fair’, fell on stony ground.

ARVs are limited in distribution and erratic in supply. The nearest supply point for a rural villager is Health Center III, at the sub-county level a two day round-trip for many people. Long gaps in ARV treatment are commonplace. HIV treatment in general, is threatened by inept and corrupt national management of medicines and medical equipment by the National Medical Stores (NMS). The term 'Stocks Out' ( medicines have run out) has been incorporated into the national languages. The number of new cases of HIV is increasing faster than the number being put on ARVs
Current methods of prevention appear to be having little impact. There is a dearth of new ideas in prevention

Tuberculosis (TB)

Pulmonary TB is reaching epidemic proportions in both districts. An alarmingly small number know how TB is spread. If you don't know how a disease is spread how can you protect yourself? Few make the connection between HIV and TB. Many TB patients are HIV +. The data is too erratic and poor to give an accurate picture of the % of TB/HIV. Almost 50% of TB patients we found in our survey remained positive at the end of treatment with first-line drugs and had to begin second-line treatment. Directly Observed Treatment Strategy (DOTS) therapy is taken seriously but is undermined by the erratic supply of drugs from MOH. I have had a cough since half-way through the survey

Health Facilities and Staff

Morale in the healthcare system is at an all-time low. MOH is viewed as incompetent and corrupt, by staff and patients. Government is viewed as uncaring and mean-minded with regard to funding healthcare. Salaries and conditions of service for all healthcare workers are so poor as to encourage corruption and neglect.
Kiboga District hospital can fill only 28 out of 88 established nursing posts. Most Level II facilities have about 25% of staff, about two healthcare workers. The quality and experience of staff is as much a concern as the numbers. Many posts are filled by individuals who lack the required qualifications, training and experience. The result is a high level of [symptomatic] diagnosis and treatment, well above the level of staff competency. Less than twenty of the sixty five healthcare units surveyed have working laboratories, it is little wonder that symptomatic diagnosis is the norm.

Housing and accommodation for staff is as big a problem as pay, it stymies recruiting and undermines morale. Continuing professional education is jealously guarded as the prerogative of the most senior staff. Many healthcare workers run private clinics and shops selling medicines, resourcing them with misappropriated medical supplies.
Without this option they would merely subsist.

Very few facilities have any form of power supply and most close at night Few have running water, the staff carry it in jerry cans from the nearest well. Disposal of medical waste is totally ad hoc and quite frankly dangerous. The only hospital in Kiboga hospital has not had running water in 21/2years and has no incinerator either. The daily bonfires are nauseatingly smelly.

The NMS has a contract with a private company to remove out of date medicines. it has never visited the hospital. Out of date medicines are stacked outside next to the hospital kitchen. There is not one functioning ambulance in the entire Kiboga District.
The total annual drug budget for Kiboga is UGSH 200m. Given a population of 280,000, this allows UGSH 770 (50c) ppa.

Some Suggestions

Given the extent of the problems I have detailed in the report, it would be of little value for me to leave it all hanging in the air. As a soldier, I was taught to argue to a decision rather. than simply a conclusion. So I have a few suggestions to offer.

I think we should enhance malaria diagnosis at HC II level through a Malaria Rapid Test and increase community-based oversight of malaria treatment with ACT through a DOTS approach. I think we could increase IPT2 provision by delivery through CMDs and VHTs and increase the availability of ITNS by the same method. There is an urgent need to initiate regional Preventive Education programs for PMTCT and also for TB. There is a vital and urgent need to refurbish clinical laboratories if we are to have any hope of improving diagnosis and treatment.

Finally, and again to quote Baldrick, “I have a cunning plan” to increase the number of men who test for HIV. It involves Corporate Social Responsibility and the 2010 Football World Cup. I will resist the temptation to elaborate further and save the details for my future essay

The Culture of Co-Dependence

Well! That is my "Magnificent Octopus" . Six years in Africa has convinced me the only way we will break the 'Culture of Co-dependence' we call Aid but should properly call Charity, is to find some new ideas. We must centre our thinking around business development and job creation. The dignity of a job is vital for the future stability of Africa's ever-growing and youthful population.

I frequently upset my fellow travelers with what I offer as new ideas, and they consider to be unfair sniping at the Aid Industry. I am currently proposing a six-month moratorium on workshops and conferences. I am informed it would do untold damage to the hotel and catering industries as well as Coca Cola and numerous
Chinese tee shirt and baseball cap manufacturers.

I have also developed an irrational antipathy to certain aid industry jargon; its use has the same effect on me as dragging fingernails down a blackboard. To name a few: sensitization, holistic, gender-based, participatory and most irritating of all ….. youth-friendly! A more patronizing expression is difficult to imagine, it suggests that the young are incapable of understanding the same information as adults, whereas the truth in my experience, is the opposite. Perhaps it is time to take a break.

More Frantz Fanon Than Xenophobia

2008-05-24T00:43:00.000-07:00

I watch with sadness, but no great surprise, the horrors being played out in the townships of South Africa: they were inevitable. Overnight, the arcane term xenophobia has become part of African discourse, describing seemingly incomprehensible, irrational violent acts by a section of South African society.

The extent of African leaders’ cognitive dissonance over this issue is exemplified by the Kenyan Foreign Minister Moses Wetangula in a recent comment, "[A]long its bumpy road to independence, South Africans were scattered all over the continent, including Kenya. "We gave them tremendous and admirable hospitality (...) The last country anybody would imagine would engage in xenophobia is South Africa."

The Minister has lost the plot. This tragedy is not a manifestation of racial or ethnic hatred. It is about economics in its crudest form. Outsiders, legal or illegal, Zimbabwean or Ugandan are hated because they are competing, often successfully, with poor South Africans for jobs and wealth. Despite the rosy picture of South Africa as the economic engine of the Continent, social and economic inequality is institutional. The gap between rich and poor is a chasm, at its deepest in the townships around the big cities, where the majority of the population are young, poor and uneducated. The nation has an unemployment rate about 40%, much higher in the townships and the majority are young men. South Africa has an unenviable reputation for violent crime, mostly perpetrated by the poor on the poor

Over the past decade, despite expansive promises from the government, little has been done to improve the lot of the urban poor. Their seething anger has finally exploded into awful violence against the nearest and most vulnerable, poor immigrants.

It is ironic that a Kenyan political leader would announce, he was perplexed by South Africa’s crisis. His inability to draw parallels with recent events in Kenya is depressing. The trouble in South Africa has similar echoes. I was not surprised then either.

The Kenyan crisis was a long time coming, but the factors have been in place many years; ever-increasing population pressure with over 80% of the population squeezed onto less than 10% of the land. Kenya has a very young population (average age, 18 years) and an economy unable to keep pace with population growth, rapid urbanization and the ever rising expectations of the poor urban young. There is a yawning chasm between the rich and the poor, a leadership shamelessly misappropriating the nation's resource and endemic corruption at every level of society.

The result is a vast number of young men without jobs in Kenya. I contend the most dangerous creature on Earth is a young man without a job. This is as true of Newcastle, New Orleans and Najaf as it is Nairobi. Young men without jobs view themselves as outside of society, disenfranchised and owing nothing to their communities.

Not only do they [young Kenyans] not have a job; there is little hope of the majority finding one. Moreover, and here there are clear echoes in South Africa, though tourism is a vital part of the economy it also enables poor Kenyans who come in contact with relatively affluent tourists, to see 'how the other half live' and to contrast their own lives and prospects.

These angry young men are fertile ground for the seeds of anarchy. The portent to the recent storm had long been obvious in the high levels of violent crime endemic to the country, not for nothing is Nairobi known as 'Nairobbery’ and comparisons made with Johannesburg. The rise of the secret and violent Kikuyu sect Mungiki, and its mirror organization, the Kalenjin Warriors, were also harbingers of terror to come.
Even through the narrow prism of the TV camera, it was clear that the majority of those committing violence were young men; their common denominators, anger, frustration and poverty. They had nothing; so having nothing to lose, focused on destroying all and everything. The gangs on camera in Kisumu looked and behaved exactly like the ones in Gauteng.

For those who still cannot see the writing on the wall, I suggest Frantz Fanon's, The Wretched of the Earth. What we see in Gauteng today and Kibera months ago, he describes as 'catharsis through violence’.

Those who prefer their logic on a bumper-sticker will continue to cluck and prattle about tribalism and xenophobia. What we are witness to in Africa today, is much more; the concatenation of three irresistible social forces: the unequal distribution of wealth, population pressure and the revolution in rising expectations.

The ‘have-nots’, particularly the urban poor, can see how little they have, measured at first hand against the urban ‘haves’. They want a share. If anyone wants to know what comes next, try A Tale of Two Cities by Charles Dickens.

So what of the future? The violence in South Africa will simmer down much as it has in Kenya. The young unemployed, will return to violent crime, mostly robbing the poor, occasionally the rich, and the anger will slowly build up until it explodes, more violently, in the future.

Spinoza offered, "There is no hope without fear and no fear without hope". Maybe the fear created by this current bout violence will galvanize South Africans and Kenyans into radical change. It will take much moral courage and huge effort. In practical terms, there must be a more equitable distribution of the nations’ wealth, mainly through the creation of jobs, lots and lots of them.

A word to the wise; Uganda must draw lessons from both these crises. I see the same dark clouds on the horizon. Corruption is endemic, the gap between the rich and the poor, huge. The population is growing at a frightening rate and the nation's leadership is in an advanced state of denial on this issue. It is even younger than Kenya’s at less than 15 years. As optimistic as I am about Uganda and its wonderful people, it is plain to see that current economic growth is an order of magnitude behind the population boom and the people’s ever rising expectations.

Moreover, the young are rapidly rejecting traditional lives as agriculturalists and urbanization is almost as rapid as population growth. Not because there is no land to work, but because the young envision more than what they see as life in a hut, with a paraffin lamp and hoeing a row of maize, far from friends and the Premier League on GTV. Yet many who migrate to the towns and cities fail to make a living. The ever-rising crime rates across the nation and the recent terrible spate of violent crime in Kampala are testament to the growing anger and frustration of the urban poor

Prediction is no more than entertainment, but without radical new thinking and bold action, I am gloomy about the future of South Africa, Kenya and indeed Uganda. I offer only this from a man much cleverer than I.
“A world of this magnitude of inequality is inherently unstable. Peace is in the palm of the devil” - Fouad Ajami

Now For Something Completely Different

2008-05-13T07:58:00.000-07:00

“Insanity: doing the same thing over and over again and expecting different results.”  Albert Einstein

Back in 2005, I wrote a piece for a US healthcare magazine with the hugely pretentious title, ‘Of Hamlet and Per Diem’, I am now embarrased about the name, but article itself attracted considerable email flak, which was fun, It began as a discussion of Uganda’s long battle against HIV/AIDS and went on to describe how the focus had been lost, through a mixture of corruption, ideology and above all, a lack of original thinking, particularly in the hugely lucrative arena of HIV/AIDS Prevention. As a finale, I offered what I considered to be an original idea. Here it is in its in edited form:

“If, as I have argued, Uganda’s HIV/AIDS strategy is dysfunctional, what is to be done? Well, we cannot continue doing what we have always done and when it shows not to be working, try harder and throw more money at it. The time has come for original thinking and novel approaches. The key must be to reduce the opportunities for misappropriation, get more of every dollar donated, to land on the final target and develop long-term independence by making individual Ugandans responsible for their own health and future.”

“Here is my ‘out of the box’ idea. Somebody out there give me $1m, no strings attached. I will put it in a Ugandan Bank. I will then advertise for 1,000 volunteers from the next intake of Freshers at Makerere University. All will be required to undergo an HIV test. The first 1,000 ‘negatives’ will have a bank account opened in their name, a ‘health savings account’, containing $900.”

The contract will be they remain negative until they graduate. Immediately before graduation, they will be tested again and those still negative will have unrestricted access to their savings account, to do whatever they please with both the original sum and the interest accrued. How individuals stay healthy - ABC or any variation thereof - is a personal and private concern. If the project is a success, it will be repeated and widened, dependent on donor interest and funding ( if I had access to the $200m from the Global Fund I could impact on 200,000 people). This may seem a lot of money for a relatively small number of people, but in my time in Africa I have seen much more spent for much less impact.”

“I can hear the howls of indignation from the politically correct. ‘This concept smacks of bribery, it has no place in respectable social science’ etc. I offer the following for consideration:
Many more than 1,000 will volunteer; the ‘Positives’ will be able to seek treatment and long-term care, the ‘Negatives’ will know their status and adjust their lives accordingly
1,000 ‘at risk’ individuals will be trying to stay out of the ‘risk pool’ for three years
Money spent on administration will be minimal (much less than most current prevention programs).
Opportunities for misappropriation and mismanagement of funds will be negligible
On successful graduation, the capital sum plus interest accrued, will go directly to the individual, without caveat.
The money will probably be spent in-country on an individual basis.
Each individual will be incentivized to make personal decisions regarding their current and future health status.
Individuals will recognize that they are capable of determining their own future.”

“I doubt that, at first blush, I have convinced many that this idea is anything more than the crude use of financial reward to manipulate social behaviour. That might be true, but is it any more odious than many current schemes? At least it has no moral or ideological strings attached, requires minimum administration and does not lend itself easily to misappropriation. Has anyone out there got a better idea?”

Now why have I reprised this piece of public health apostasy “bordering on the immoral” (as one critic described it) at this time?
Well it seems that not everyone thinks it’s nonsense, the World Bank appears to have at least one person who inhabits the same parallel universe as me. This report by the Financial Times in late April 2008 outlines a program that aims to provide a financial incentive to encourage people in Tanzania to ‘avoid unsafe sex’:

[T]housands of people in Africa will be paid to avoid unsafe sex, under a groundbreaking World Bank- backed experiment aimed at halting the spread of Aids. The $1.8m trial – to be launched this year – will counsel 3,000 men and women aged 15-30 in southern
rural Tanzania over three years, paying them on condition that periodic laboratory test results prove they have not contracted sexually transmitted infections.
The proposed payments of $45 equate to a quarter of annual income for some participants. The programme, jointly funded by the World Bank, the William and Flora Hewlett Foundation, the Population Reference Bureau and the Spanish Impact Evaluation Fund, marks an important step in the fight to tackle Aids, which claims 2m lives a year.
In spite of billions of dollars spent annually on treatment and prevention worldwide, there were about 2.5m new HIV infections in 2007, predominantly in Africa. Carol Medlin from the University of California, San Francisco, one of the researchers, said: “We hope
this ‘reverse prostitution’ will make people think hard about the long-term consequences of their short- term behaviour.”
The Tanzanian experiment is a big advance in efforts to test public health ideas more rigorously, with some participants placed in a control arm not offered payment in order to track the effects of the
programme precisely.
“Conditional cash transfers” have already been used in Latin America to motivate poor parents to attend health clinics, and have their children vaccinated and schooled. The designers of the Tanzanian programme believe that payments of $45 when combined with careful counselling could play an important role in reducing HIV infection, especially for vulnerable young women.

The study will be conducted by the Ifakara Health Research and Development Centre in Tanzania, in conjunction with researchers from the University of California, Berkeley, the University of California, San Francisco and the World Bank. The Tanzanian trial programme, which is still subject to fine-tuning and ethical approval, will not specifically test for HIV, which is costly and already widely conducted in the country. It will use proxies , including gonorrhoea, and guarantees any participant found to be infected receives state treatment.
By Andrew Jack in London
Published: April 25 2008
The Financial Times Limited 2008

Whilst I am not yet saying, “I told you so!” I am encouraged that the HIV/AIDS industry might at last , after 20 years and countless billions of dollars, be trying to find alternatives to wornout and anemic ‘prevention’ activities encapsulated in meaningless jargon like, ‘sensitization’, ‘community mobilization’, ‘user-friendly youth services’ and ‘behavioral change’. Prevention strategies that are rarely if ever rigorously evaluated and yet judging by the numbers ( 2.5 m new cases in 2007) appear to be as effective as African road-signs.

In researching this article I came across one of the key architects of this concept of ‘conditional cash transfers, a chap with the splendid name of Meade Over., a Senior Fellow at the Center for Global Development, where he works on issues related to the economics of efficient, effective and cost-effective health interventions in developing countries. And his work is very impressive. His thinking is refreshingly original. Anyone who has an interest in HIV/AIDS would do well to visit his blogsite at: http://blogs.cgdev.org/globalhealth/2008/04/pay_for_prevention_a_1.php

I recommend not only the short article on ‘Pay for Prevention’ but also his working paper on the failure of Prevention and its future impact on the President’s Emergency Plan for AIDS Relief (PEPFAR)

After six years in East Africa peering closely at a disease that has killed millions, brought out the best and the worst in people and made many of the latter wealthy, I know I am at risk of incurable cynicsm. This glimmer of new thinking gives me fresh hope. I am still looking for a donor!

World Malaria Day

2008-04-27T04:24:00.000-07:00

This past week has seen World Malaria Day, aimed at focusing the world's resources on irradicating this ancient and terrible disease. On Sunday I caught and article in the Washington Post, 'Eradicating Malaria Worldwide Seen As a Distant Goal at Best'
The article, well written and compelling, stirred me to write down my thoughts on the subject.

I live in a place that has the highest number of infected mosquitoes in the world, a District in northern Uganda. That's what the Ministry of Health and WHO tell me. It also has the third highest fertility rate, 1.2m babies born each year. Average age of population 14.9yrs. Put the two together and you get a huge infection rate that without radical action will continue to grow with the population explosion. Most deaths from malaria are babies, kids under five and pregnant women. It is not just deaths either, my town has a huge number of disabled children, their brains damaged by being boiled by malaria fevers or by being directly infected by the parasite

There is no silver bullet solution. My current work, a baseline study on malaria/HIV/TB gives me a close up view of the reality of malaria. The people tell me they cannot live 24/7 under an ITN, they often get bitten in the evening, eating supper or doing homework. They tell me too I should try sleeping under a net in a 12' hut crammed full of people on a red hot airless night. I can imagine. I have a big net in a 12' bedroom and a fan on all night. When the electricity fails (often) I sweat buckets and find it hard to sleep. I understand why, despite the risks, the people don't use them every night.

Moreover, most people here view malaria the way people in the US or Europe view a bad cold, and sometimes thats how it affects fit, healthy adults with partial immunity. So data on the disease is hugely inaccurate. There are already reports of ACT resistance, though no confirmed data. . I am not surprised, ACT like other antimalarials, is frequently used without firm clinical diagnosis. If the symptoms disappear after ACT treatment, it must have been malaria. ACT is costly; the stuff, now given free by MOH, it is often stolen, repacked and ends up for sale in village shops and even in neighboring countries. Health centers in my District, which have no ACT, direct patients to buy from the 'chemist shops', often supplied by the same healthcare workers. Selling medicines is often justified as the only means of subsidizing very poor salaries.

The nation's healthcare system is overwhelmed by population pressure and the burden of disease and under-mined by shameless corruption. The brain drain of healthcare workers, migrating to the US, Europe and other developed countries, to escape the appalling conditions of work and pitiful salaries, is accelerating the dissolution of the national health service.
There is no history of any nation with a ruined healthcare system ever successfully conquering any infectious disease, least of all one as old and complex as malaria

IRS, using DDT, the cheapest, most effective agent, has just begun here. It remains to be seen whether the expansion of the malaria campaign into a coherent, focused effort to include IRS, ITNs, ACT and education will have lasting impact on the disease, but I am pessimistic, without a vaccine.

As expected the campaign to use IRS is being dogged by the pious ranting of the self-appointed guardians of Africa's ecosystem, as if Africans were too stupid to understand the arguments and reach their own decisions. I have little time for such organizations as Beyond Pesticides. One would do well to remember that its staff earn a comfortable living through this NGO, lobbying on behalf of poor Africans. They have very comfortable offices, alongside the the lobbyists of E Street in DC. Their office rent would buy a huge number of ITNs.

They know the scientific evidence they quote is based upon massive use of DDT as a pesticide in US agriculture in the 1960s, when planes were used to dump tons of DDT per acre on cotton fields and fruit orchards. Even with this massive industrial overuse, the evidence, after 50 years of scientific scrutiny, connecting DDT with diseases in humans is thin indeed. IRS will use less DDT in a year across the entire country, than was dumped on a few acres of US cotton in the 60s

My advice to anyone who wants a credible voice at the table, is to come and live here, out in the countryside, away from the Cities, for a couple of years. To live without expensive Malarone prophylactics and designer insect repellants and about 200 miles from the nearest capable hospital

They are welcome to come with me to the villages to convince people they need to use an ITN all the time. They could also try and explain their version of the facts regarding IRS and DDT; tell mothers that "DDT can be passed on in breast milk". For many it will be an irrelevance, they will not be feeding their dead babies.
4/27/2008 7:15:09 AM

The Global Health Workforce Crisis

2008-04-26T06:12:00.000-07:00

‘Over several decades, a global health-workforce crisis has developed before our eyes. The crisis is characterized by widespread global shortages, maldistribution of personnel within and between countries, migration of local health workers,
and poor working conditions.’ - World Health Organization. World health report 2006

There Were Reports
In late February I was surprised to find our home-town, Lira in northern Uganda, in the international news. And it wasn’t a 60 word paragraph by Reuters. Lira made it all the way to the hallowed ground of the Lancet Editorial; fame indeed! Actually one might better describe it as infamy.
Now I for one know the temptation of purple prose, but I expected more of the Lancet. Given our remoteness from London, or for that matter, anywhere on Earth, I can only surmise the Editor got his information from the Ugandan ‘Dailies’, which delight in hyperbole. The result was an opening paragraph that read:

“Earlier this month, medical workers at Lira Hospital in northern Uganda went on strike to demand unpaid allowances promised by the government for working in this war-torn area. Seven patients died. There were reports of bodies decomposing in wards and women in the maternity ward assisting with each other’s deliveries. “

Let’s set the record straight. I was there when it happened. The lady that keeps our house went into labor; I took her to the hospital, witnessed the chaos and took her to a private clinic. I wrote a blog about it called ‘Super Tuesday’. I followed events very closely for the next few days.

The healthcare workers went on strike because they had exhausted every other option. They had been promised the money for almost a year, every other healthcare worker in the Region had received an ‘allowance’ and they had been stone-walled. This is not uncommon. Teachers commonly go for months without being paid their tiny salaries of about $100 a month. It usually happens because some bureaucrat has ‘eaten the money’, a local euphemism for stolen it.

The brave but naïve District Medical Officer of Health, was publicly derided when he suggested that the ‘seven patients who died’ would have died with or without healthcare workers present. Knowing the resources available to the hospital, I do not doubt him. ‘Women assisting each other with their deliveries’ is another hyperbole. Most Ugandan women come to deliver in hospital with droves of mothers, aunts and sisters; some with their own village birth attendant. That’s how the deliveries were done. As for, ‘bodies decomposing in wards’; this a hot place, there are no undertakers. Funerals take place pretty quickly.

Global Forum
The irony of this strike is that it took place a few weeks before the first WHO Global Forum on Human Resources for Health, hosted in Kampala. That, I suppose is why Lira made the Editorial, coincidence. I did not attend the Forum; no report has yet been published. I have however, received anecdotes aplenty. Given the scale and political complexity of the [healthcare workforce] crisis, it is not surprising that the meeting produced a lot of heat but little light.

Exploitation
What happened in Lira was a reflection of events played out every day across Africa, which has 25% of the world’s disease burden and only 3% of the world’s health workers. The reasons as to why this imbalance exists are manifold, but the political heat centers around one argument, the migration of healthcare workers, trained in Africa, at African expense. The accusation is they are lured away by unscrupulous recruiters with promises of huge salaries, to meet the ever-rising demands of caring for the aging population of the developed world, leaving their own countries bereft and in crisis.

In the eyes of many, this is yet another example of predatory exploitation of African resources by the developed world. In condemnation, the Lancet editorial ends with a pious flourish, “[R]icher countries can no longer be allowed to exploit and plunder the future of-resource poor nations” . Such sanctimony suggests migrating doctors and nurses are victims of a modern slave trade. Nothing could be further from the truth. Many leave because it is in their nature to explore and seek advancement; but for the majority it is because working in healthcare at home is under-paid and overwhelming. Moreover, despite the promises of the international community and the proclamations of African governments, in most countries, there are no signs of things improving, rather they are getting worse.

Distortion
Responsibility for the distortion in the healthcare workforce can as easily be laid at the feet of the huge numbers of Non Government Organizations and International Agencies as it can ‘malign foreign recruiting agencies’. It is they (INGOs) who recruit the cream of the public sector, offering in-country salaries and employment opportunities that cannot be matched by governments. It is the dream of many of my medical friends to get permanent employment with ‘a big international NGO’ or better still the ‘Holy Grail” of international healthcare employment, the WHO.

The extent of this distortion is evinced by the number of surgeons and surgical staff in Africa. Uganda for example, has about 75 general surgeons and ten physician anesthetists for a population of 30 million people. Most live and work in Kampala. The majority of surgery is performed in rural hospitals by the equivalent of family physicians. Why this dearth of surgical capability? In part because the public sector pays poorly, private surgery is limited and few INGOs are into surgery, so rarely hire surgeons. Better by far to enter a career in public health and specialize in HIV, TB and Malaria, that’s where the [NGO] money is. To emphasize the point, Makerere University recently restricted entry into its Masters in Public Health program to physicians.

The reasons for Africa’s healthcare worker crisis are too many and complex for reasoned debate in this essay. They will no doubt be the subject of many future PhD theses. I will offer a few comments about two factors, using Uganda as an example; few countries on the continent are markedly different.

Overburdened
The first is that of population pressure. Uganda is undergoing a population explosion. The national Total Fertility Rate - about 7 - is the third highest in the world. As a result, despite the ravages of war, disease and staggeringly high maternal and infant mortality rates, the population has leapt from 6m in 1962 to about 27m in 2007. Moreover, average life expectancy has dropped, mainly due to HIV/AIDS, producing a skewed population with a mean average of 14.9 years. Barring some apocalyptic event, Uganda’s population will reach 60m by 2025. Economic growth is nowhere near keeping up with this massive and rapid population increase; every aspect of national infrastructure is overburdened. Electrical power is rationed, schools are overwhelmed with pupils and have pitiful resources, roads are falling to pieces as fast as they are built and emergency services non-existent in most of the country. Uganda has for example, ten fire trucks; four are in Kampala. Nowhere is this overburdening more obvious than in healthcare.

I offer a few anecdotes in illustration; first in the arena of mother and child care. I am currently working on a project in Luwero District, central Uganda. Recently I visited the largest healthcare unit in the District, called a Level Four health center; there is no Referral Hospital, though there are about a million people in the District. The unit is small, old and in disrepair. The maternity unit has ten beds and one delivery room with one table. When I looked in, there were 15 women who had delivered in the past 12 hours, five were on the floor. The overworked but dedicated midwife told me they averaged 450 deliveries a month. She added that other smaller District health centers were similarly overstretched. This is in an area where about 60% of women deliver at home.

My next-door neighbor is the only surgeon in Lira hospital. He was away during the strike, but some weeks before he had experienced an incident that exemplified the sheer weight of his work and the paucity of resources. Late one evening a truck loaded with worshippers returning from a ‘Revival’, overturned about ten miles from town. The town has no emergency services; the casualties arrived in traditional fashion, in the back of private vehicles, usually pickup trucks co-opted by the police as ‘Good Samaritans’. By the end of the night he had 90 casualties; seven had died instantly or en route. His only assistants were a family doctor doing Ob/Gyn, an Anesthetics Officer and a handful of nurses. Help, in the form of one doctor arrived the following day. It took him three days and nights to complete the surgical care for his 90 patients.

A few weeks ago, in a town not far from here, a furor erupted over the town mortuary. Plans to refurbish the unit had run out of money. However, the doors at least were fixed. This, according to the town council was major improvement. Prior to that, dogs had chewed of parts of bodies and local ‘thugs’ had used the place to skin stolen goats and cows that would end up in public butchers. The council stated that hygiene remained a problem however. “The mortuary has neither a refrigerator nor is connected to electricity and given there are no drugs for preservation of bodies, some end up rotting”.

As I was preparing to write this article I glanced at a short byline in a national daily. I offer it verbatim. “Close to 200 health centres across the country can no longer offer immunisation services after they ran out of gas for the refrigerators in which the vaccines are preserved. In a] survey done in 22 districts by a concerned party within the Ministry of Health, out of 534 health centers sampled, 198 had stopped offering the services by the beginning of March. There has been no delivery of gas to the centres since January
15. Vaccine shortage poses grave risks to pregnant mothers and their babies who risk missing the tetanus immunity at the time of delivery. Uganda has at least 1.2 million children born every year countrywide”.

Corrupt and Inept
The second issue is that of Corruption and Ineptitude, so inextricably linked I consider them as one. Corruption has permeated every facet of public healthcare in Uganda, from the very top to the remotest health center. The reasons range from shameless greed at the top to survival at the bottom. But at root the problem is OPM (Other Peoples Money, a euphemism for foreign aid). Ugandan healthcare attracts huge amounts, too much for an inept bureaucracy to manage. The temptation to ‘eat it’ or miss-use it are huge, the results glaringly obvious. Headquarters MOH in Kampala has so many SUVs in its parking lots it has earned the sobriquet ‘Ministry of Land Cruisers’. Few of these vehicles ever leave Kampala city limits.

The previous Minister of Health and his immediate staff, currently face charges of misappropriating millions of dollars of Global Fund monies. Funds meant to buy and distribute anti-retroviral drugs, drugs for TB and antimalarials. A glance at the inquiry findings shows it was done with breath-taking impunity. My favorite anecdote concerned evidence given to the initial inquiry. The judge was shown a receipt for fuel for an MOH vehicle traveling thousands of kilometers around the country on “HIV sensitization duties”. The vehicle registration on the receipt belonged to a Caterpillar tractor. My friends were not amused; they called it ‘stealing from the dying’.

The upper-mid level of the Ministry has followed their leader’s example and the new Minister is not strong enough to break their stranglehold. The National Medical Stores (NMS) an autonomous governmental organization is so riddled with theft and ineptitude it has become a national scandal. The current Minister has publicly stated he wants the boss sacked, as yet to no avail. The NMS is the only means of supply and distribution of medicines and medical equipment to the public healthcare system. Its reputation for incompetence is all-pervading. The project I am currently working on has a caveat in the proposal regarding the availability of medicines and medical materials for HIV/AIDS, TB and Malaria, one line reads, “[N]MS itself has systemic problems that lead to stocks out”. That is a huge understatement.

Lira District health centers currently have no AARVs and have not had for months. Neither do they have the new antimalarial, Artemesin Combined Therapy (ACT) but I know at least four ‘chemist shops’ in town where I can buy them and just about anything else. Where and how they got them, the traders will not say. The same would probably be true in most of the country.
At the bottom of the food chain, a District Medical Officer of Health has just been charged with stealing a refrigerator and gas bottle from one of his health centers. It was found in his quarters, filled with beer. There is no word of the vaccines.

Ineptitude is not the sole prerogative of the MOH. Some of its INGO partners appear to have either given up their Sisyphean task or in some cases let the rock roll downhill. You will remember the anecdote about the maternity wing in Luwero. Directly across compound from this building there stands a brand new construction, built by one of the most renowned INGOs. Locked and never opened, it was built as a ‘center for acutely-malnourished children’. A laudable purpose, but acutely-malnourished children seem to be in short supply locally. The building would make a great new maternity unit.

About 10 miles out of town, down a very long muddy track, with a few small villages, there is a brand-new maternity unit, built by the same INGO. It dwarfs the Level Three healthcare center it serves, has about 50 beds and all the equipment required outside of emergency surgery. The problem is nobody uses it. Well; about 5 women a month have given birth in it since it opened, which is probably a good thing because it does not have one toilet, bath or shower. The midwives have dug a latrine outside. I just cannot figure out how it came to be built there, but there is a huge new house a little further down the track.

In conclusion, I admit to only touching the margins of the crisis Africa faces in healthcare and its healthcare workers but I hope I have provided some light and thought for debate. I will add one more comment. I consider the idea that doctors, nurses and other health workers born and trained in Africa should be prevented from working abroad to be abject sanctimonious nonsense. Why stop at healthcare workers? Why not ICT workers? University professors?

We should ask young doctors and nurses why they leave this beautiful, tropical country, their families and cultures, for the cold rain of Manchester, England or the frigid plains of North Dakota.
When we have listened to the answer, we will be some way to fixing the problem.

Bloody Hands and Bleeding Hearts

2008-03-24T22:40:00.000-07:00

“[h]umanitarian agencies don’t mind coordinating with the military but they don’t like being coordinated by the military” ….Hugo Slim
Medical Diplomacy
It is almost a year ago today that I rather foolishly volunteered, without a second thought, to join a Project HOPE mission as the leader of a contingent of medical volunteers aboard the USNS COMFORT. The plan was for the hospital ship to visit twelve countries in Latin America and the Caribbean. Project HOPE would provide a group of about twenty five volunteers at any one time.
During this Odyssey, I wrote a couple or articles. In one I described the mission as an exercise in what had become known as ‘Medical Diplomacy’ and promised I would examine the issue in depth at a later date. The key issues, it seemed to me, centered around the relationship between NGOs, in this case Project HOPE, and the US military and the US Navy in particular. Is this a good model for future humanitarian operations? What does the US Navy get from it? What do NGOs like Project HOPE get from it? Is this a flag waving exercise or does it provide long-term good for the recipient countries and their people? I have procrastinated for almost four months since the end of the COMFORT mission; herewith my observations.
Nothing New
My first contention is that what Project HOPE did on the COMFORT was neither new nor innovative. They and a number of other NGOs had deployed on the USNS MERCY the previous year, on a similar mission in SE Asia. Whilst the COMFORT was sailing noisily around the Panama Canal, the USS Peleleu, with a contingent of HOPE volunteers, was quietly reprising the MERCY mission in SE Asia. Currently, a group of HOPE volunteers is aboard a USN ‘grey-hull’ off the coast of West Africa and the USNS MERCY prepares to sail, with HOPE volunteers and other NGOs for SE Asia in June.
Moreover, whilst relationships between the military and civilian humanitarians have certainly intensified over the last two decades, they are by no means new. As Hugo Slim notes in a series of excellent articles The Stretcher and the Drum: Civil—Military Relations in Peace Support Operations. The ICRC was born in 1863 out of the Battle of Solferino, the Save the Children Fund (SCF) in 1919 out of the First World War, and OXFAM and the US Committee for Aid and Relief Everywhere (CARE) out of the Second World War in 1942 and 1945 respectively. He points out that, to a large degree, “Militarism and humanitarianism have represented two sides of the same coin – humankind’s inability to manage conflict peacefully”.

The Birth of CIMIC
Perhaps the defining moment in recent NGO/military relationships was Operation PROVIDE COMFORT in northern Iraq in 1991. I think even the most hardened critics of civil/military cooperation (CIMIC) would agree that a great deal of good was done and many lessons learned. It’s a shame they were not remembered in the frequent man-made and natural disasters of the following decade; Bosnia, Rwanda, Kosovo to name but three, saw the CIMIC relationship as exercises in re-inventing the wheel. To misquote Santayana, ‘History repeats itself. It has to because nobody listens.”
More recently, conflict in Afghanistan, Iraq, the Tsunami and the Pakistan Earthquake have seen ever-increasing cooperation between INGOs (UN etc), NGOs and the military. With each experience the relationship has improved and the results too. But it has been a fraught and imperfect gestation.
New Tools
My second contention is that like it or not, the CIMIC approach to disasters either man-made or natural; is the model of the future, particularly and most contentiously with the aftermath of conflict known as Peace Support Operations Why? Because there is a growing revolution in thinking amongst the militaries of the world, that questions the utility of force. It argues that most modern conflict is so complex; militaries have only a limited role in their resolution, creating the conditions for a political solution. In other words creating and enforcing a secure environment.
The problem is, to butcher a quote from Maslow, ‘If the only tool you have in your toolbox is a hammer, all the world’s problems are nails’. The argument goes that the military needs new tools, new methods, new training to meet the demands of modern conflict. Like Colossus it moves and changes slowly, but the change is inexorable. We can already seeing US Army Artillery Regiments putting away their field guns and learning about peace support, civil affairs and COIN. But the military has so much to learn and little time to learn it in. Moreover, there are skills and expertise it finds difficult to obtain and impossible to retain; skills essential to Disaster Relief and Peace Support Operations. For example how many veterinary officers does the Navy have? It must therefore form alliances with the UN and with NGOs of every shape and size, local and international, to provide this expertise in order to achieve what it calls, ‘winning the battle for hearts and minds’..
So the first point I would make about Medical Diplomacy, I have in part, made before; it is an experiment, an honest attempt to explore ideas old and new to meet demands that appear to be inescapable. The people of America and indeed the world, want conflicts, where they are inevitable, to be resolved in ways other than bombing cities until the rubble bounces. This will require the military and civilian humanitarian agencies to work in very close concert from the outset. This in turn will require them to think, plan and train together.
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Pre-Planned Humanitarian Missions
You might ask why this discussion has focused so far, on disasters and conflict, when the organization at the center of my argument, Project HOPE, has historically not been involved with the military post-conflict, in what are fashionably called Peace Support Operations. In fact it has only been involved with the military on one recent Disaster Relief operation, the Tsunami. All of HOPE’s other sojourns with the military were and are to date, archetypal preplanned ‘cold’ Humanitarian Assistance operations.
So I must return to the original questions. Why would HOPE want to be involved in these sorts of missions? What does it get from them? What does it contribute? How does it justify such a close working relationship with the military?
Pragmatism
The answer to the first question is pragmatic and banal. HOPE used to have its own ship. In fact it started using it 50 years ago this year, beginning in SE Asia and then moving along the Pacific coast of Central and South America. It got too old and expensive; HOPE let it go and became land-lubbers with long-term capacity building programs. There are many such HOPE programs around the world, some conventional healthcare and development programs; others very out of the ordinary. HOPE is currently completing the building and staffing of a Children’s Hospital in Basrah, Iraq. It has even taken on the training of nurses and other clinical staff, in what I consider to be a model method; the subject of a future article.
Project HOPE has always had a hankering to return to its seaborne roots and the US Navy has provided the means and much more. They provide what an NGO needs to survive and work in a hostile environment, security, logistics and communications. Much the same as the military provides NGOs in CIMIC operations the world over.
Given the essential political/military nature of these missions, NGOs like HOPE don’t get much of a voice at the table when it comes to deciding where to go or for how long to stay. But that need not be a deterrent to joining. With planning and forethought, NGOs with long-term interests in a specific geographic area can capitalize on the Navy’s presence. Operation SMILE used the COMFORT mission in Latin America to obtain logistic support, communications and clinical resources for surgery and post operative care in a number of countries. The US Navy shared in the kudos of this unique service and a number of Navy medical staff both learned and taught local healthcare workers.
Project HOPE used the journey for similar purposes; to conform to military argot, I called it ‘armed reconnaissance’. We deployed teams of healthcare Volunteers who undertook an array of clinical and teaching roles in concert with their Navy counterparts. At the same time we used this work to create relationships with the MOHs, local NGOs and civil society and to identify new long-term capacity building training and education projects for HOPE. We have potential new projects in Panama and a number of other Latin American countries at this time.
The preplanned, ‘cold’ Humanitarian Affairs mission of the COMFORT/MERCY type, also provides a medium for the thousands of volunteers from all over the US and beyond, who want contribute their time and there expertise but only have a little of the first. Many are willing to give a few weeks of their time to provide what HOPE is looking for, expert teaching and training of healthcare skills in under-served regions of the world. The HOPE/US Navy partnership provides a relatively uncomplicated means for these individuals to serve. Vitally, in an era of the All-Volunteer Military, it also offers a chance for civilians to experience and perhaps understand a little of military life.
Experience as Value-Added
The case for HOPE’s contribution to this aspect of CIMIC is a little more complex and I need to tread carefully for fear of sounding like the archetypal arrogant NGO. Military medicine in general and Navy medicine in particular have much to learn about Humanitarian Assistance and Disaster Relief. The average Navy doctor, nurse and medic is a very busy person working in a peacetime facility. Their customers are fit health young men and women with mainly fit healthy families, who leave before they get old and sick. Moreover, many of the navy medics are young and inexperienced and have been trained according to rigid protocols with state of the art, resources. When they are suddenly thrust into an environment where every affliction known to man is common-place, resources are minimal and people ‘wing’ the protocols, it is a chastening experience and a tight learning curve.
It is in this environment that the HOPE volunteers provide the value-added. Most are experienced in working in austere environments; HOPE deliberately seeks and selects those with previous NGO, volunteer, missionary experience. The Volunteers become the teachers and trainers, often at the behest of the Navy medics. It is this role, of education, training and expertise that HOPE promotes as its contribution to these missions. Whether the ‘student’ is an indigenous, doctor, nurse, community midwife, or a US Navy corpsman or nurse, really is not the issue. It is about capacity building through education and training. That is HOPE’s contribution
Continuity Factor
There is another aspect, the continuity factor. When the COMFORT sailed on her 12 country mission last year, she had a complement of about 850 souls, from the Navy, AF, Army, USHPS, Coast Guard, Canadian Defense Forces and NGO volunteers. Most had never previously met and many had never been to sea before. It is not hard to imagine what the first few weeks were like. If we had been called upon to deal with a DR mission before week 4, I think we would have had real problems. The first month was a training exercise for all on board.
By the time the COMFORT sails on a future mission, almost everyone who sailed last year will be dispersed to the four winds, The CO and the leadership will be starting almost from scratch. The Mercy when she leaves for SE Asia in June will have exactly the same issues. These are the facts of life in the modern US Navy. Here again there is a role for NGOs who have access to experienced people who have ‘been there and got the tee shirt’.
Underpinning CIMIC
Finally, I want to try and bridge the gap between preplanned ‘cold Humanitarian Assistance missions and Peace Support Operations or whatever term the jargoneers in the five-cornered building are using this week.
Every, mission involving UN/NGOs/military (US and Coalition) I have served in or analyzed has labored at the beginning. It’s to be expected, it is the fog of war. But there are some deeper intrinsic reasons for this initial dysfunctional relationship. They might best be examined under the general rubric of communications. This is not a reference to ITC or radio communications, though they are always a bone of contention. The key is how to forge a working relationship, CIMIC, rapidly and efficiently, in a time of great stress. How to weld together a number of organizations often multi-national and multi-cultural in nature and with deeply differing views as to how to achieve a successful outcome.
Creating Understanding and Trust
The key principals of humanitarian agencies are impartiality and independence, luxuries rarely afforded the military – Bob Leitch
From 1991 in northern Iraq through to today in Helmand Province, the secret of a successful CIMIC operation has been how well the players worked as a team. The military generally knows what it has to do, the Commander’s Intent. How they get there is always a dynamic process, depending on the changing political environment and the actions of those who would thwart them. INGOs and NGOs too, normally have a pretty clear idea of what they intend to do and although they aim at impartiality, neutrality and independence their very presence shapes day to day events and the endgame. To achieve a common goal, the end of conflict, suffering and a return to normalcy, all parties have to know each other, know what that endgame is and how each team member intends to contribute. They have to know each others strengths and weaknesses, cultures and customs. Above all they have to trust each other, more often than not with their lives.
If, through projects such as the routine HA missions of the MERCY,COMFORT and ‘grey-hulls’, and focused interagency training courses, like the Army’s at Ft Polk, we could begin this process of understanding and building trust, this might shorten the time and ease the difficulties in establishing future CIMIC structures. We might, in turn, go into the next crisis better prepared and more rapidly produce a favorable outcome
This is my most defensible justification for ‘Health Diplomacy’ missions; in the manner Project HOPE and other NGOs are conducting them with the military, particularly the Navy. Both are developing and encouraging an ever closer relationship. The aim: to build a bridge, intellectual, institutional and above all cultural, between two organizations which as Hugo Slim says ‘represent two sides of the same coin.

Super Tuesday

2008-02-10T04:34:00.000-08:00

It is Super Tuesday here
and Sue and I have been glued to the SatTV. since early morning
At 1pm almost on the dot, there is a knock on the door.
It is Evelyn. She is the lady that looks after the house, cleans, dusts and does all the washing except our underwear, culture forbids.
Evelyn is a really nice young woman. She is 23 years old and has two girls, both at school, aged 6 and 7 years.
Her husband is a nice chap too. He has no formal education, no land, no skills and has recently finished DOTS for TB. So she looks after him too
Evelyn is the sole wage earner and is great at her job so gets spoilt. She now has a bike and a mobile telephone and new clothes, Sue dotes on her.
When I arrived back from the COMFORT mission, I found out that Evelyn was pregnant again. She had been on "the Injection for seven years and had been told to stop for a while".
Back to the knock on the door. Evelyn, looking exceeding uncomfortable, announces she "having pains". She is 7 months pregnant by her calculations.
I ask her a few questions, yes she is 'spotting'. Yes the pains are regular etc.
her kids are at school and her husband miles away.
I put her into my truck and we crawl down to the town's Referral Hospital.
i am feeling a bit like a Grandad to be.
When we arrive we are met by pandemonium
The entire hospital staff are out on strike. Not a medic of any shade to be found in the hospital. Chaos, crying wailing, its like something out of Dante, only hotter.
Inside the 'maternity unit' the scene is like the set of a Angelina Jollie movie. The dads, grandads grandmas and mums come at me like a wave, 'Muzungu help us!"
By now I am used to African theater so I shout back and smile.
As it calms down, Evelyn is getting distressed and I am thinking what next. I hear a scream and then groans.
I walk into the delivery room[s] and there on one bed is a kid of about 15, she is naked, sweating and in agony, her mum is holding her down.
i find an English speaker, a brand new dad, nothing to do with the girl in agony, he looks 18.
He translates, the girl has been in labor since the previous evening ( the nurses walked out at 10am today)
I gird my lions and examine her, she is about 6/7cm dilated baby's moving a little and i can hear a heartbeat.
I know i cannot do anything here. I am not credentialed for Uganda, the nurses are on strike, its an MOH hospital. I could end up in a law court
So think. I find out there is a private medical clinic some 5 miles away. The nearest city, Kampala is 200 miles away.
So i load preganant child with mum and grandma into my truck. Evelyn, now really uncomfortable is in the front.
As we were trying to leave, i am suddenly surrounded by people who need help.
At first I say no I must go and point at the girl, but they and I know i am lying, i am simply overwhelmed.
The young guy who speaks English and translated for me asks me to look at his wife. I push through the crowd to her bed.
She is so young, sweating and out of it. I think she is a problem about to happen, lift her sheet to find she had had a Caesarian within the last 24hrs. He points at an empty IV attached to the window frame and pulls out from under the bed a box with 9 remaining 500ml units of Normal Saline." Fix for me please mzee!" At this point I see a bundle of rags under the bed, "whats that?" "My son Mzee! A strong new son!"
I pick up this tiny newborn from the filth and flies on the floor and put him next to mum. She smiles. I say, "ask if she has had a drink, is she thirsty?" "I am so thirsty and hungry too".
I tell the dad no more IVI ( I risk getting in deep trouble even changing an IV) "plenty by mouth" . I leave both smiling
Outside a woman and a man meet me with a baby, it is no more than 6 months, a twin they tell me. "But this one will not suckle"
I take one look at the baby, feel its little head and chest watch its eyes roll and back arch and know why. "How long has your baby had malaria?'
"Oh three days mzee." i pinch his paper dry skin he doesnt flicker, I open an unseeing eye and search for a thready heartbeat that is almost exhausted. His back has lost its arch and he is flaccid, deeply unconscious.
I get back in the car and say I cannot help, I know the baby is doomed. I have to get the two pregnant women to a private clinic quickly
We set off. A word to the wise. Africans do not travel often in closed vehicles, they throw up. God bless mum, she opened up her handbag, a fake crocodile-skin, and her daughter threw up in it.
When we arrive, the chaos is similar but less intense
Dr Pamela examines them both.
The young girl is 7cm but making heavy weather of it, she is 16 and a PG, small in pelvis and been at it 10 hours, odds on for a Caeser'.
Evelyn, acting in sympathy gets a spurt on and starts to do it for real. The nurse tells me she is 5/6cm and moving along nicely.
At that point I tell the young woman who came with us, the child mother's mother, she is about to be a Grandma, she must be 30.
I ask what next and the hospital staff say come back in the morning and pay the bill please.
I drive home slowly thinking about the dozens I had done nothing for still waiting for the nurses to come back to the hospital, knowing that it will not be tonight
Wondering if the the baby is still alive
Trying to convince myself there was nothing i could for it
(done this a few times with babies with fulminating cerebral malaria)
We have phoned Evelyn's family, given them money for their telephones
and food and water for Evelyn
Food and water for the kids' family, I don't even know their names
And now i am going to have a beer and watch CNN
And try and forget about my Super Tuesday

Reservoir Dogs

2008-01-21T11:20:00.000-08:00

Outbreak
One morning, just before Christmas, I was startled by the banner headlines of my local newspaper, which read, ‘Uganda Hit By Epidemics!’ Closer inspection revealed that apart from the ‘usual suspects’, cholera and meningococcal meningitis which have plagued the parts of country recently, two new pestilences are stalking the land, Bubonic Plague in Nebbi, West Nile and Ebola in Bundibugyo, western Uganda.

The outbreak of Bubonic Plague is the latest in a series of epidemics of yersinia pestis that periodically afflicts the border between northwestern Uganda and eastern Democratic Republic of Congo (DRC). The catalyst is exceptionally heavy rains; this past year has seen widespread flooding of the region. The rats, the primary reservoir, meal-ticket and main means of transport for the fleas, the key vector, move into human habitation to avoid drowning. The disease kills the rats, the fleas jump hosts and off we go; ‘The Black Death’ on a miniature scale. As usual, the local health service’s reactions were slow, medicines in short supply and a few hundred caught the disease; about 20, mainly women, have died to date.

The outbreak has been contained in the major towns along the Border but has certainly not been extinguished. It is hardly surprising; the populations are huge, over-crowded and grindingly poor. Healthcare resources are minimal and it’s a long way from Kampala. Central government’s attitude to the epidemic is exemplified by the statements made to the press by the Minister of State for Primary Healthcare, Dr Otaala and the Director General of Health Services, Dr Zaramba. At the press conference Dr Otaala attributed, “the recurrence of [P]lague in Nebbi…….is due to the primitive culture of indigenous people, where men sleep in beds and women on the floor. The people mainly affected are women because in Nebbi women only come up on the bed for sex.” Dr Zaramba, obviously seeking to clarify his Boss’s offensively patronizing statement elaborated, “The flea that causes the Plague can only jump six inches high, if everybody was sleeping on a bed, there would be no Plague in the country.” Now why didn’t someone in CDC think of that!

Ebola
‘The Plague’ has deep historical connotations for many but it no longer frightens the way it did our forefathers. Not so Ebola Hemorrhagic Fever (EHF). Thanks to Richard Preston’s not-bad account of Ebola-Reston in a government laboratory and the hysterical film ‘Outbreak’ in 1995, Ebola has a truly frightening global reputation; to be fair, not without cause. It has an impressive mortality rate of between 50% and 80%. The last time it visited Uganda was 2000/1; it sickened about 450 people in three towns, spread across the north and west, and killed 250. This time it seems to be contained in western Uganda, in a region surrounded by national parks. To date over one hundred people have been diagnosed with EHF and about 40 have died.

What makes this outbreak as interesting as it is scary, is its relatively slow progression. The estimate is it began in September 2007 and was not officially recognized until December. This may in part be to the paucity of healthcare resources in the region but skeptics also suggest that the Government kept it quiet because they did not want to frighten away the Commonwealth Heads of Government Meeting, a huge international junket held in Kampala in late November. The disease became international news in early December.

The second issue is the relatively low mortality of this outbreak compared to others. It seems that the pathogen is a new subtype (the three known to date are Ebola Sudan, Ebola Zaire and Ebola Reston). Paradoxically, the slow progression and low mortality could be very bad for us humans. Scientific opinion holds that humans are ‘dead-end hosts’ for EHF and the speed at which the virus kills us limits its ability to propagate; slowing down the process may enable it to spread more efficiently.

Finally, the so-called index case, the first known casualty, seems to have been a hunter who killed and ate a monkey (primates of all types are common food source in the region). The Government and wildlife organizations are warning locals not to eat monkeys (or chimpanzees or gorillas) which is good for the primate population but primates are just as susceptible to the disease as humans, an outbreak in 2000 in DRC is estimated to have killed 5,000 lowland gorillas. They [primates] are not the reservoir host, which normally carries the disease asymptomatically. The monkey that was killed was probably sick, this week a number of dead monkeys were found in the nearby national park.

Bats
“At this point you are entitled to ask: Damn, what is it about bats?’ David Quammen .
This outbreak comes at a key moment in the study of Ebola and growing array of viruses such as Marburg, Hendra, Nipah and the corona-viruses of SARS, which are producing new and frighteningly lethal human diseases. Virologists collaborating on international research have strong scientific evidence the reservoirs for these and other pathogens, are bats. This should come as no surprise. They have been around a long time, are hugely adaptable and can be found almost everywhere on the planet. It seems the reservoir for Ebola might be a fruit bat. There are lots of them in the forests of western Uganda and the DRC. Moreover, as human population pressure mounts, people increasingly encroach on the natural habitat of the bat and every other wild animal.

Zoonoses
This brings me to the point of my argument. Both of ‘Uganda’s Epidemics’ are zoonotic diseases: Infectious diseases that can be transmitted from animals, wild and domestic, to humans. The really surprising issue (for me at least) is how many zoonotic diseases there are and the burden of disease for which they are responsible. A recent study by the University of Edinburgh calculates that of the 1,710 pathogens afflicting humans, 832 are zoonotic (49%). Among the so-called new and emerging diseases 75% occurred first in animals.

A cursory ‘Google’ produces a veritable avalanche of information on Zoonoses. To study zoonotic disease is to study the path of human history. A couple of examples might serve to illustrate. Yellow Fever, the scourge of the New World for much of the 18th, 19th and early 20th Centuries, that almost stopped the building of the Panama Canal, probably originated in west Africa and traveled to the Americas in the mosquito larvae living in the water barrels of slave ships.

West Nile Virus, a mosquito-borne virus, appeared in the USA in 1999 attacking and killing birds, horses and humans and is now considered enzootic/endemic to the USA. It was first identified in West Nile District Uganda, the setting of my Bubonic Plague story, in 1937. How it got from Nebbi to Nebraska in 70 years is a mystery almost certainly as related to human movement as the migration of Yellow Fever.

Sleeping Sickness or Trypanosomiasis is another disease with an odious reputation. There are two types. African Trypanosomiasis is transmitted by the tse-tse fly from wild animals to domestic cattle and dogs and humans. Data on the disease is sparse; it affects mainly the rural poor who are ill-served by modern healthcare and is an appalling way to die. New World Trypanosomiasis or Chagas Disease is transmitted the Reduviid or “kissing bug”. Chagas Disease infects about 18m people every year in Central and South America, about 50,000 die. Charles Darwin is believed to have succumbed to the disease. The principal reservoir for Chagas is the domestic dog. A recent study found that people could significantly reduce the risk of infection by excluding dogs from bedrooms.

Reservoir Dogs
It seems that ‘man’s best friend’ is a reservoir for a significant number of zoonotic diseases. ‘Fido’ is host to an array of worms, which regularly infest our children, sometimes with awful results like Ocular Larva Migrans, where worms migrate to the child’s eye, and to adults, particularly a tapeworm, which migrates to the liver and causes chronic inflammation known as Hydatid Disease. In Sudan, the domestic dog is the principal reservoir for a terrible disease known as Kala Azar or Visceral Leishmaniasis. Domestic dogs are also the principal reservoir for rabies, in Africa. About 55,000 people, mainly children, die of Rabies every year.

Adapted to Travel
Despite Ebola’s fearsome reputation, it and other exotically-named viruses are seen as diseases of primitive far away places, unlikely to be encountered in the average American ER. That may be true today, Ebola has not yet adapted to distant travel, but if history is any judge, it will soon, and the results could be ghastly. Consider the evolution of the perfectly adapted virus, HIV. It almost certainly jumped to humans from primates in the same way as Ebola and probably the same part of the world. But it kills so slowly it has managed to become a global pandemic, killing millions within 50 years. Even more worrying SARS, a corona-virus which probably spilled over from horseshoe bats and which infected many thousands and killed over 700 people on its first world tour, has disappeared from our radar but will probably return with a vengeance soon, its vector, the international traveler. Finally, there is Avian Influenza, the boogey man of the infectious diseases. One of its ancestors scythed the human race less than one hundred years ago, when the world’s population was much smaller and travel slower. I shudder to think what havoc it would reap in over-crowded poverty stricken Africa or Latin America.

One Medicine
When I began examining the issue of zoonotic disease what puzzled me the most was why, given that zoonoses contribute hugely to the burden of disease and the very clear and intimate relationship between human health, animal health and the ecosystem in which both exist; their respective sciences are so stove-piped. I am not sure they always were. Where we are now seems to be the result of the narrowing of our scientific viewpoints and the specialization of our professions, driven partly by the sheer volume of what we have to know. The history of human health is replete with accounts of men and women who took a broader view of human health than simply the absence of disease; individuals who described, promoted and practiced what has been called ‘One Medicine’ or latterly ‘One Health’.

Amongst the most famous proponents of ‘One Health’, three deserve special mention. Rudolph Virchow, a 19th Century German physician and statesman, often cited as the Founder of Modern Medicine, wrote extensively about the link between human and animal diseases and coined the term zoonosis. William Osler, a Canadian physician and former pupil of Virchow who became one of the four ‘Founding Fathers’ of Johns Hopkins School of Medicine, began his scientific life as a veterinarian and is credited with creating the term ‘One Medicine’. Ironically, whilst at Oxford in 1919, Osler fell victim to the great zoonotic disease of the era, the Influenza Pandemic. Finally, no account of the One Medicine movement would be complete without mention of Calvin Schwabe, the legendry epidemiologist from UC Davis School of Veterinary Medicine, who until his death in 2006, was the leading proponent of a unified approach to human and animal health. His monograph, ‘Veterinary Medicine and Human Health’ remains a classic.

One Health Now and the Future
So where are we now? ‘One Medicine’ is unquestionably a resurgent concept, growing in strength as the public and the scientific communities become increasingly aware of global ecological disturbance directly attributable to human population pressure. The growth of One Medicine ( I prefer One Health) is evinced by the creation of organizations like the Consortium of Conservation Medicine (see www.conservationmedicine.org) and One World, One Health (see www.oneworldonehealth.org) The most recent conference, the Fifth Annual ‘One Medicine’ Symposium, held at the University of North Carolina In December 2007, provided clear directions for future collaboration between scientists involved in the entire spectrum of human, animal and ecological health. I also strongly recommend the excellent article I quoted by David Quammen in National Geographic October 2007.

One Health and the Community
I confess to some reservations regarding how ‘One Health’ is developing, essentially as the academic pursuit of elite scientists. I believe there is an urgent need to include the ‘foot soldiers’ of human and animal healthcare in the debate and in the action, particularly in the developing world where most of the action and interaction is taking place. My experience in Africa and Latin America leads me to believe that the community healthcare workers, who form the backbone of healthcare in most developing countries, know little about zoonotic disease, the inter-relationship between human and animal health, (their domestic animals or wildlife) and even less about their environment and ecology. Yet, as the Ebola story indicates, it is the community healthcare worker who comes first in contact with infectious disease outbreaks, ancient or emerging. Invariably community healthcare providers are so ill-prepared they are amongst the first victims.

I am advocating a fundamental review of what is taught and practiced as community health and healthcare in the developing world. I believe I have illustrated the vital importance of zoonotic disease in the health of people, particularly the rural poor. Most rural peoples are agriculturalists and own domestic animals; healthy animals add to the wealth of their owners, sick animals increase their poverty. The more rural people encroach upon wildlife habitats, the greater the risk that diseases which live relatively innocuously in the wild, will spill over into domestic animals and humans, Uganda’s Ebola outbreak is a good example. I offer an idea. Train two types of community healthcare worker under the same roof; one in human health and one in veterinary health and deploy them to work in teams together in the community. Maybe that’s a concept worthy of a trial project somewhere in Latin America, soon.

Dude Where's My Landcruiser?

2008-01-14T23:51:00.000-08:00

I wrote this back in late October 2006 and have no idea why I did not post it at the time. Still, as a synopsis of events in Uganda at that time, it covers most issues and, perhaps tragically, events are little changed today. We still have no peace accord with the LRA, we still struggle with malaria, electricity remains rationed and erratic and there is an acute fuel shortage. This time because of civil unrest in Kenya but also because the government gave away its strategic fuel reserve to its friends and forgot to ask for it back. But, thanks to a bulk buy of top-of-the-range SUVs for the Commonwealth Heads of Government Meeting last November [07] we have many more Landcruisers, Hummers, BMWs etc. The roads remain awful. The population continues to increase at an exponential rate, urged on by a Government which believes that Uganda's future development hinges upon 'growing a population large enough to create its own internal market'. As far as we are aware, we have not yet been stricken by Bird Flu, but who cares. We have Ebola Fever again.

Interesting Times
"May you live in interesting times" is popularly believed to be a Chinese curse but more likely owes its origins to a speech by Robert F. Kennedy in Cape Town, South Africa, on June 7, 1966. Nevertheless, it resonates with life in Uganda today.

The 20-year conflict in the north of the country is slowly but surely drawing to a close. An agreement called a Cessation of Hostilities has been in place for a month and the Lord's Resistance Army (LRA) has moved the bulk of its 'fighters' into agreed safe areas in southern Sudan under the aegis of the army of south Sudan, the Sudanese People's Liberation Army (SPLA). The next step will be for the LRA to agree to the release of 'non-combatants'-women and children. This will probably happen within a few days.

The political center of gravity of the final stages of the conflict has now shifted to the Hague in the Netherlands and has become far more complex. At issue are matters of international law and the outcome of the debate will have global ramifications. A synopsis of events is essential to understanding the current crisis. In 1999, in order to inject fresh political initiative into ending the war in the north, the government passed into Ugandan law, an Amnesty Act, in effect offering amnesty to all LRA insurgents who surrendered. From 2000 to early 2004 many LRA members sought and received amnesty. The senior leadership did not. In 2004 the newly formed International Criminal Court (ICC) in the Hague intervened publicly in the conflict, announcing that the Ugandan government intended to amend the national Amnesty law to exclude the senior leadership of the LRA and had [also] asked the Chief Prosecutor [of] ICC to investigate charges of 'crimes against humanity.' The amnesty law was amended and in late 2005 the ICC issued arrest warrants for Joseph Kony and the top leadership of the LRA on charges of war crimes.

From the outset, there was heated debate over the perceived 'outside interference' of the ICC (even though their involvement was at the request of the Ugandan government). Many northern Ugandans believed it threatened the short-term quest for an end to the war and prospects for long-term peace, which would have to be based upon reconciliation rather than retributive justice. Many, too, saw the ICC as the 'international community' meddling in sovereign issues.

Now matters have come to a head. When peace talks began, the Ugandan government stated publicly their wish for greater flexibility over the ICC arrest warrants, even suggesting they be dropped if there was a conclusive peace deal. The LRA have repeatedly stated they will not accept any deal that includes arrest and trial by the ICC. The ICC remains implacable, insisting that the warrants be enforced and those indicted brought to trial. The result is a complicated impasse with serious implications for the future of international law. In my opinion, fault lies with the ICC, which failed to appreciate the complexities of the Uganda conflict and acted precipitously. It will be fascinating to see who backs down and how.

The Pale Horseman
Even as the peace talks in Juba began to show promising results, a scary shadow was cast over them. Pestilence appeared in the town, in the form of confirmed H5N1 'Bird Flu.' An unknown number of local domestic poultry were found dead and dying of the disease and an unknown number have since been slaughtered. There have been no confirmed cases of the disease in humans. Given my last missive to this magazine, which dealt with H5N1 in northern Uganda, I feel like Jeremiah.

Juba, the capital-city-in-the-making of south Sudan, is about 200 miles from Gulu. The road between the two towns is a constant stream of vehicles carrying every animal, vegetable and mineral that can be bought in Uganda and sold to satisfy Juba's rapidly growing appetite. The outbreak was first reported there on Sept. 6. Since that date, information has been scarce and direction from Uganda's Avian Influenza Task Force has been of the 'don't panic' variety. No attempt has been made to stop the flow of domestic poultry in and out of the towns or to map the 'backyard chicken projects' spread across the north, so that when the disease arrives, swift intervention will be possible. There are so few resources available and so little planning and preparation has been undertaken, I suspect that when the disease breaks out in the IDP [internationally displaced person] camps, the government will have little alternative but to send in the Army to supervise the culling of birds. Given that domestic fowl are a vital cash crop in the camps, this move will further alienate the Army from the IDPs. We wait with bated breath and try not to cross the line between alert and alarm.

Re-Thinking Silent Spring
On Sept. 15, the World Health Organization (WHO) made an announcement forcefully endorsing the wider use of the insecticide DDT to combat malaria across Africa. In one sweep, the WHO reversed a 30-year old policy of ambiguity on the issue of DDT and poured gasoline on a fire that has burned in Uganda for years; the argument between health professionals fighting an uphill battle against the disease, agricultural businesses that worry about the threat to their markets, particularly in Europe, and ecological activist groups, mainly international.

The data on malaria in Uganda are mind-numbing. It is the single biggest killer of children under five, accounting for about 100,000 child deaths country-wide annually. The country's maternal mortality rate is about 550 for every 100,000 pregnancies, [and] malaria is a key factor in the majority of these deaths. But the figures mean nothing unless viewed in the context of day-to-day life in the country. Whereas a kid's sick note to school in the U.S. may read, "Johnny has had a cold," in Uganda it will more likely read, "Samuel has had malaria." It is the single biggest cause of [lost work] days; nobody bats an eyelid when Fred comes back to work, looking gray and thin after a week off. They assume malaria. It is quite simply a part of life here and always has been.

In the 1980s, HIV/AIDS hijacked the public health agenda in Uganda. Interest in malaria as a disease threat waned. In the past few years, as HIV/AIDS rates dropped and public fear diminished, malaria came back on the agenda. The problem was how best to tackle disease prevention. The optimum method, proven successful in the [United States] and southern Europe in the 20th century, was by attrition of the vector, the mosquito. There is too much water in Uganda to contemplate 'draining the swamp.' Most insecticides are ineffective or too expensive for large-scale use. The most effective and cheapest, DDT, was essentially banned by international opprobrium. Many donors wouldn't fund malaria programs that contemplated using DDT. Fresh flower and vegetable markets, particularly in Europe, threatened embargoes on products originating from regions using DDT. The only tool left in the box was insecticide-treated nets (ITNs).

They (ITNs) have not proved to be the 'silver bullet.' The science has yet to be done to prove why they have not had a significant impact. I can offer a [firsthand] observation. They work for me at home [in Gulu] because we live in a spacious house with a big, well-ventilated bedroom. It is relatively cool at night, even under a mosquito net. I have spent nights in small dark windowless huts and boiled under my net. I can imagine, but only just, what it would be like to try and keep the average Ugandan family of two adults and seven kids, living in a 12-foot diameter hut, under mosquito nets all night. The number of nets distributed is no indicator of use.

So the debate has turned again to insecticides and to DDT. This is neither the time nor the place to debate the detailed science of DDT but it seems clear that the infamous reputation it gained in the '70s owes much to the amounts and methods of use. The WHO, in reversing its policy, is advocating small concentrations of DDT be sprayed in emulsions onto the walls of huts, houses and other buildings, and only [up] to a few feet above the ground. [DDT is used in a form called 'internal residual spray,' indoors only and low down toward the ground. Mosquitoes usually rest about one to three feet above the ground.]

This form of precision use, in conjunction with ITNs, is another saga in the long war against malaria and seems eminently sensible. It is already used in 10 countries in Africa. But the battle has multiple fronts and the most intractable is the political. I can understand the reticence of the Ugandan Ministers of Agriculture and Export. They worry about the fickle markets of Europe and the potential impact on a shaky economy. The decision should be a national one, made by the government, weighing the economical, health and social risks. What I cannot accept is interference from international activist groups such as Beyond Pesticides, which campaigns against the use of DDT in Africa from the comfort of its mosquito-free moral high ground on E Street in [Washington], D.C. Particularly when they rationalize their position with platitudes of the caliber of, "[W]e should be advocating for a just world where we no longer treat poverty and development with poisonous band-aids, but join together to address the root causes of insect-borne disease..." I have a piece of advice for them. If you want a credible voice in the fray, come and live in Gulu for a year. And leave behind your unaffordable Malarone [an antimalarial drug that costs $33 a week] and designer packs of insect-repellent 'wipes.'

Demography And Destiny
This month has also seen the publication of the government's State of Uganda Population Report (SUPRE). It was a damp squib, meriting only brief mention in the middle pages of the national newspapers and not a whisper of national debate. The report's most hard-hitting line is to warn of the "[m]is-match between a population growth of 3.2 per cent and economic development." Closer examination shows what a 3.2 per cent growth means: the current population of 28 million will double to 56 million in less than 20 years and double again to over 100 million by 2050. The most staggering statistic: there will be 28 million 'job seekers' in 20 years time. This is set against an economy-already struggling to keep up with a rapidly growing population with ever-rising expectations-pole-axed by a catastrophic hydro-electric power-shortage, resulting from the drop in the levels of Lake Victoria. Plans to rebuild the power industry to get back to the levels of two years ago are estimated to mature in five years, [and] to get ahead of the game will take another five years [after that]. The best advice the authors of the report can offer is "[P]lan, plan, plan."

The level of debate in the media has bordered on the fatuous. It has included celebrating 'Uganda's natural fertility as gifted by Nature,' to blaming current economic woes on colonization, [and] to dire examples of economic crises in European countries with low population growth. If 'demography is destiny' was ever true, then it is so in Uganda. And the people are ignoring it.

Dude, Where's My Land Cruiser?
You would imagine with all these momentous events in train or just over the horizon, Uganda's leaders would be consumed with affairs of state, Parliament would be conducting all-night sessions on the future of northern Uganda, bird flu, DDT and plans for economic recovery. Not so. The most contentious current issue among Uganda's lawmakers is official cars for Members of Parliament (MP). This august body of individuals, totaling 300, is debating the necessity of each having an official car to travel to their constituencies. Moreover, given the appalling state of the roads and the huge numbers of road accidents, the MPs believe it vital that their cars be SUVs (Land Cruiser size) to give them better protection in an accident. Never mind the poor constituent who has to travel the same roads crammed on the back of open pick-ups. The cost of this essential 'perk' to the taxpayer? Uganda 20 billion shillings, about $10 million, and that does not take into account fuel and maintenance. [There are about 2 million shillings to $1,000 U.S.]

But this pales into insignificance when compared to the government's spending on official vehicles. A recent government report showed that it maintains a fleet of 11,000 'luxury cars,' mostly SUVs and double-body pick-ups. The total annual cost of fuel and maintenance is 54 billion shillings, about $27 million. There is no mention of capital costs, but at $40,000 per vehicle, I estimate the total at nearly half a billion dollars.

The Ministry of Health has almost 3,000, the Ministries of Education and Agriculture over 1,000 each. The most damning indictment is that few of these vehicles ever leave Kampala or the big towns, [and] most drivers reported they had never used four-wheel drive. They are used to ferry officials from home to office and meetings. The [State of Uganda Population] Report notes that the excessive number of SUVs in the Health and Education ministries was probably the result of the large number of donor projects they are required to run. That statement is worthy of further detailed examination and I intend to do just that. The other question that nags me is how much money comes from the Ugandan taxpayer to fund this obscene display of bureaucratic excess and how much comes from taxpayers in other nations?

The Turbo Effect

2008-01-14T23:27:00.000-08:00

Last month, December 07 to be precise, I wrote that in order to mark World Aids Day 2007, I would resurrect a number of articles I had written in the dim and distant past, on the subject of HIV/AIDS and plonk them on this site. It seems to date I have only posted one. Keeping my promise and because i think this piece remains relevant today, I have another offering, The Turbo Effect. Here it is essentially unedited from its original, published in US Medicine in 2002. It may, one day, be of interest to some wandering soul.

Cognitive Dissonance
In 1957 a Stanford University social psychologist Leon Festinger published his theory on behaviour called cognitive dissonance. In simple terms it is the distressing mental state in which [in Festinger’s words] people "find themselves doing things that don’t fit with what they know, or having opinions that do not fit with other opinions they hold”.
Festinger considered the human need to avoid dissonance as basic as the need for safety or to satisfy hunger. It is a drive to be consistent, so strong it can make us change our belief in an effort to avoid a distressing feeling. The more important the issue and the greater the discrepancy between behavior and belief, the higher the magnitude of dissonance that we will feel. In extreme cases cognitive dissonance is like our cringing response to fingernails being scraped on a blackboard—we’ll do anything to get away from the awful sound. After a year of near total immersion in HIV/AIDS in sub-Saharan Africa, I am struggling with an acute bout of “the CDs”.

Hard Talk
The source of my discomfit is a series of review articles in the International Journal of STD and AIDS 2003: 14. The authors are a group of international scientists whose principal author has a rather catchy name, David Gisselquist PhD. The articles address the factors that account for the rapid spread of HIV/AIDS in Africa. I admit that when I first read them, although my interest was piqued I was most influenced by the opinions of ‘my elders and betters’ in the world of HIV/AIDS and public health who abound in Nairobi. They almost unanimously dismissed the articles and the studies that underpin them as “flawed science”. About ten days ago I sat down to watch a current affairs program on BBC World satellite TV called “Hard Talk”, which specializes in the contentious and the topical; grilling those brave enough to subject themselves to inquisition. On this occasion, to my surprise and delight it was the aforementioned Gisselquist and some luminary from the London School of Tropical Medicine and UNAIDS. The ensuing battle was short sharp and painful, for my money Gisselquist came out on top and I once again set about the rather turgid prose and dense tables that epidemiologists deem as the only fitting means to publicize their science. The “CDs” set in after the first iteration.

Sex Central
The authors’ thesis is that almost from the outset of the pandemic, the consensus amongst influential AIDS experts has been that heterosexual transmission accounts for the overwhelming majority of adult HIV infections in Africa, yet the scientific evidence to support such a belief is questionable. They argue that the conventional wisdom regarding adult HIV infections in Africa emerged as a consensus in 1988. In that year,
the World Health Organization’s (WHO) Global Program on AIDS circulated estimates that 80% of HIV infections in Africa was due to heterosexual transmission, 10.8% from mother-to-child transmission, 6% from blood transfusions, 1.6% from contaminated medical injections and other health care procedures, and 1.6% from men who have sex with men (MSM) and injection drug use (IDU). Estimates for heterosexual transmission have inched upwards since. According to the World Health Organization’s 2002 World Health Report, ‘current estimates suggest more than 99% of HIV infections prevalent in Africa in 2001 are attributable to unsafe sex’.

They further argue that if experts had treated the consensus as an hypothesis—which it was and still is—and had used it to guide research to test competing hypotheses, it could have played a constructive role. Unfortunately, many experts have accepted the consensus as fact and not seen the need for further research to test its estimates. The result has been that the consensus has suppressed inquiry and dissent as researchers in Africa—and in Asia and the Caribbean—have often assumed sexual transmission without testing partners, without asking about health care exposures, and when conflicting evidence nevertheless emerges—such as infected adults who deny sexual exposures to HIV—routinely rejecting it.

Turbo Charge
The key to the Gisselquist et al argument is that studies in Africa show that sexual activity levels in the general population are comparable to those reported elsewhere, especially North America and Europe. Moreover, transmission efficiency studies amongst African couples produce estimates remarkably similar to studies of couples in the developed world. So, their argument goes, if African sexual behaviour is comparable to North American and the virus moves between heterosexual couples with the same efficiency north or south of the equator, why has the disease moved so much faster in Africa than in the developed world and why has heterosexual sex been more effective as a means of transmission in Africa than the developed world? What additional factors cause the so-called “turbo effect” that has enabled the disease to spread so rapidly compared with other regions of the world?

Quality of Care
The authors examine the history of AIDS in Africa from 1983 to 1988. Through extensive literature searches and studies they demonstrate that during the period there was considerable debate about the role of healthcare in the spread of the disease. They produce both anecdotal and science-based evidence to demonstrate that during this time, poor healthcare practices had a considerable impact on the spread of HIV/AIDS. Contaminated blood products and the use of unsterile needles for the administration of drugs and vaccines were acknowledged as key factors in the spread of the disease in certain regions of the Continent. This was recognized by experts but considered of secondary import to sexual activity.

They go on to argue there is evidence to show that in those early years of the spread of the disease, health care exposures caused more HIV than sexual transmission in some regions of Africa; suggesting that as much as half of all adult infections during that time were related to healthcare exposures.

Interests, Assumptions and Opportunism
Why was this evidence ignored? The authors argue that papers published around 1988 reveal a number of considerations that might have encouraged a mindset prepared to see heterosexual transmission as the driving force in Africa’s HIV epidemic. First, it was in the interests of AIDS researchers in developed countries—where HIV seemed confined to MSMs, IDUs, and their partners— social groups outside of general society - to present AIDS in Africa as a heterosexual epidemic devastating “ordinary people”. In a prominent 1988 article in Science, Piot and colleagues argued that ‘Studies in Africa have demonstrated that HIV-1 is primarily a heterosexually transmitted disease and that the main risk factor for acquisition is the degree of sexual activity with multiple partners, not sexual orientation’ .
Second, there may have been an inclination to emphasize sexual transmission as an argument for condom promotion, coinciding with pre-existing reproductive health programmes and efforts to curb Africa’s rapid population growth. Third, the role of sexual promiscuity in the spread of AIDS in Africa appears to have evolved in part out of prior assumptions about the sexuality of Africans. Fourth, health professionals in WHO and elsewhere worried that public discussion of HIV risks during health care might lead people to avoid immunizations. A 1990 letter to the Lancet, for example, speculated that ‘a health message—e.g., to avoid contaminated injection materials—will be misunderstood and that immunization programmes will be adversely affected’ .
In summary, peripheral and opportunistic considerations combined with an increasing display of cognitive dissonance amongst the cognoscenti to cause the evidence to be misinterpreted or completely ignored.

Yesterday’s News
Some might argue, “so what?” Even if its all true, these were events of nearly 20 years ago. Even if the quality of healthcare was a significant factor in the spread of HIV/AIDS in the 1980’s it no longer holds true. Across Africa basic healthcare has considerably improved and healthcare providers are well aware of and take precautions against the spread of HIV through faulty practices. Moreover, few would doubt that today heterosexual sex is by far the most likely means of transmission.

Trust Me I’m a Doctor
There are a number of reasons to be concerned about these studies. First, they raise genuine questions about the fidelity of scientific thought 20 years ago and do little to persuade the reader that things have changed for the better. Why should Africans trust those [predominantly from the rich developed world] who promised so much and yet have had little impact on the disease? Second, the image of African sexuality and promiscuity as the almost exclusive cause of the disease and the major focus for intervention tends to a patronizing even racist attitude towards the problem. Third, there is a growing body of opinion that circumstances and vested interest are driving those who manage HIV/AIDS in Africa to deal with it in a vertical or stove-piped manner, independent of other health issues; to view it as one scientist described as “HIV exceptionalism” . If we fail to realize that HIV/AIDS is yet another [albeit terrible] infectious disease to add to the many that plague Africa, there is a danger that we will fail to strengthen our public health and health services. The result will be a resurgence of poor healthcare services and practices as a significant factor in the continuing spread of the disease, a complete loss of trust in healthcare systems and an increase in disease of all kinds in Africa.

The Gisselquist writings bother me. I commend them to anyone interested in HIV/AIDS in the developing world. Flawed science or not, they raise questions about the blind faith we seem to place in science and our ability to accept conventional wisdom without demure. The problem is we have in turn asked millions of helpless people to trust us and if we lose that trust the battle against HIV/AIDS will receive a serious setback. The least we can do is re-examine the evidence and re-open the debate. Africans deserve the truth. As to whether I believe in the “turbo effect”, yes. Though I very much doubt that I will ever be able to identify it. I have one consolation; writing this has eased my cognitive dissonance.

Kleptocracy in Crisis

2008-01-08T03:18:00.000-08:00

Kleptocracy in Crisis
Three of the happiest years of my life were spent living and working
in Kenya. Today I sit in the relative calm of northern Uganda and
view, with great sadness but no great surprise, the events of recent
weeks. I would have kept my counsel had I not read three articles on
the subject in recent days, one really irritated me and the other two
inspired me to scribble this piece. The first article was in the
Washington Post, by Caroline Elkins, a Harvard professor and author of
a history of the end of colonial rule in Kenya, Britain's Gulag. I
have read the book, along with the much better, Histories of the
Hanged by David Anderson. Sadly her thesis degenerated into an
anti-British tirade within a few chapters and never recovered. As one
critic offered, "I shudder for those of her students who expect
academic rigour: Elkins doesn't let facts stand in the way of a good
rant". Her WP article, followed the same trajectory.

I much preferred the latest two essays by Richard Dowden on the Royal
African Society's website, http://www.royalafricansociety.org/
But it was the excellent Op-Ed piece in today's [ 08 Jan] Nation, a
Kenyan daily newspaper, that really galvanized me into type. It is at
http://www.nationmedia.com/dailynation/nmgcontententry.asp?category_id=25&newsid=114132

Like the author of the op-ed piece, Macharia Gaitho, I am not surprised at the crisis in Kenya, its
been a long time coming, but the factors have been in place for many years.
What we are witnessing is a concatenation of events, most beyond the
control of Kibaki, Odinga or any current leader: Here are a few:

Ever-increasing population pressure ( 9m to 30m in 45 years)
Over 80% of the population squeezed onto less than 10% of the land ( 80% of Kenya is arid or semi-arid land)
A very young population (the average age is just 18 years)
An economy that cannot keep pace with population growth
Or the
Rising expectations of the rural and urban young and poor
Ever-increasing Urbanization
A yawning chasm between the rich and the poor
A leadership that shamelessly misappropriates the nation's resources
and exploits the poor, primarily through promoting tribal differences
Endemic corruption at every level of society

The result, a huge population of young people whose relatively simple
expectations, the dignity of a job and some disposable income to buy
the odd Tusker beer, watch the Premier League on TV and maybe one day buy an old
Toyota, appear to be receding with each passing day. Long-term
sustainable improvement in the quality of their lives, is no more than
development jargon

There is an unknown number of young men without jobs in Kenya. Thirty
years of military experience and six years in humanitarian aid work in
Africa has convinced me the most dangerous creature on Earth is a
young man without a job. This is as true of Newcastle, New Orleans and
Najaf as it is Nairobi. It is the dignity and sense of purpose that is
as important as the salary. Men without jobs view themselves as
outside society, disenfranchised and owing nothing to their community
or society in general.

Not only do they not have a job, there is little hope of ever finding
one. They do their best to find some means of 'income generation'
-selling puppies, songbirds, sunglasses and mobile telephone
paraphernalia, filling in potholes [and then digging them out again]
and general panhandling - only to have their noses rubbed in the mud
daily by sneering Wabenzi and patronizing Muzungu in their SUVs.
Moreover, though tourism is a vital part of the economy it also
enables poor Kenyans who come in contact with tourists ( and for that
matter immigrant Europeans and Asians, expats in NGOs, missionaries
and the UN) to see 'how the other half live' and to contrast their own
lives and prospects. These hugely angry young men [and some women] are
fertile ground for the seeds of anarchy and social upheaval. The
portent to this storm has long been obvious in the high levels of
violent crime endemic to the country, not for nothing is Nairobi known
as 'Nairobbery'. The rise of the secret and violent Kikuyu sect,
Mungiki and its mirror organization, the Kalenjin Warriors, was also a
harbinger of terror to come.

Complacent, comfortable institutions like the UN, other International
Organizations and NGOs have ignored the gathering clouds and offered
no more than to help Kenya rearrange the deckchairs on their Titanic.
Who knows how many millions have been spent on sensitization workshops
and 'income generating activities'. Even when disaster happens, the
first into the breach are the UN and NGOs. Where are the government
institutions, where is the Corporate Social Responsibility of Kenya's
big businesses and the donations of Kenya's super-rich?

What we are witnessing is the culture of co-dependency. The Kenyan
government is doing the minimum to help the urban and rural poor, the
victims of current violence. The 'aid industry' critically dependent
upon such disasters to justify their existence, jobs and fundraising,
are again vying for time on CNN. In some respects, the 'aid industry'
is complicit in the disaster, refusing to tell the truth to power, for
fear they be PNGd and jumping into the breach at the first opportunity
and without caveat. In their actions and attitudes I can hear echoes
of 'The Whiteman's Burden' – 'we [Westerners] have to save the poor
Kenyans because their Government and civil society cannot'

Even through the narrow prism of the TV camera, it is clear to see
that the majority of those committing acts of violence in this civil
upheaval, are young men, of every and any tribal and political
affiliation. Their only common denominators are anger, frustration and
poverty. They have nothing so they have nothing to lose and are
focused on destroying all and everything, I suggest this is classic
nihilism. I would make Frantz Fanon's, in The Wretched of the Earth,
mandatory reading for every would-be Kenyan leader. What we are
witnessing in Kibera and Eldoret he describes as 'catharsis through
violence'.
It is mendacious and misleading for observers to imply that this
social conflict is primarily about Kikuyu- Luo tribal enmity. Though
tribal differences are a strong feature of Kenyan society and a factor
in this crisis, it ignores the fact that Ex-President Moi, one of
Kibaki's closest advisers and both Moi's sons and the long-time
enforcer for the for the Mount Kenya mafia, Simon Biwot, all deposed
from their Parliamentary seats, in this election, are of the Kalenjin
tribe. It is groups of young Kalenjin men, the so-called Kalenjin
Warriors who have been putting the Kikuyu to the sword. If this was
simply tribalism, Kibaki would surely have pressured Moi and the Kalenjin leaders to intervene.

Blaming yesterday's colonialism and today's tribalism is to suggest that Kenyan's, both the leadership and the people, have no responsibility for current events and no control over their futures, that it is their inexorable destiny. No amount of blaming the past can excuse the appalling leadership of today. This is the soft bigotry of low expectations.

In his excellent book on Command in Battle, Rick Atkinson describes
how every night, the then Commander of the 101st Airborne Division in
the Gulf War, General Patraeus, asked the same trenchant question,
"Tell me how this ends". Here are my offerings.

I concur with Macharia Gaitho, the Genie is out of the Bottle. At best
we will have slow return to simmering discontent. A government of
compromise, presided over by an uncomfortable partnership of Odinga
and Kibaki will maintain power, using the crude tools of patronage and
tribalism. Neither man has much to offer that is radically new or
different. Both are aged, as rich as Croesus, hugely self-absorbed and
remote from the people, though Odinga casts himself as a populist.
Either or both will fight for the status quo and will use the tools of
state to crush any resistance.

The young, unemployed and disenfranchised, will return to violent
crime, mostly robbing the poor but occasionally the rich, and the
pressure will slowly build up until it explodes again in the future.
Spinoza offered, "There is no hope without fear and no fear without
hope". Maybe he is right, maybe the fear created by this current bout
of violence will galvanize Kenyans into radical change. It will take
much courage and huge effort. The biggest hurdle will be to break down
the 'culture of the Mzee', a veneration of the elderly, particularly
old men, a deeply entrenched taboo that suffocates, original thought
and innovation, the prerogative of the young.

In practical terms, there must be a more equitable distribution of the
nation's wealth, mainly through the creation of jobs, lots and lots of
them. Building a modern national infrastructure, roads, railways,
electrical grids and water and sewage systems would employ a lot of
people for a very long time. It would also be a far more useful way to
spend foreign aid than 'workshops on sensitization, income generation
activities, IECs' and the usual paraphernalia of the 'aid industry'.

I am making these comments as a Muzungu, living [ relatively]
comfortably in northern Uganda. I am however,
not a fool, I can see the same dark clouds on the horizon as I saw in
Kenya, perhaps bigger and more ominous. The population is growing at a
frightening rate and the nation's leadership is in an advanced state
of cognitive dissonance. Corruption is pandemic and the leadership
presides over another shameless kleptocracy. To watch Ugandan society
up close and personal is to observe Darwinism in action, only the
strong survive.

But the young, and they are huge in number, want more than a life of
subsistence. Urbanization is almost as rapid as population growth. Not
so much because there is no land to work, there is more than in Kenya,
but because the young want more than a life in a hut, with a parafin
lamp and to hoe a row of maize. Among their many aspirations, they too
want at least to be able to watch the Permier League on TV at the
weekends. Those few hours in front of the TV are used for far more than supporting a favorite team (though the support borders on the fanatical) It provides the [predominantly] young men with a meeting place to discuss the issues of the moment, including politics and also gives them a window on a wider world, one with seemingly endless opportunities and wealth. Here's a thought: Is football a revolutionary force which will shape Africa's future?

Predicting the future is no more than entertainment but without the
sort of radical action I have suggested, I am pessimistic for the
future of Kenya, Uganda and indeed much of Africa. I offer only this
quote from a man much cleverer than I.
A world of this magnitude of inequality is inherently unstable. Peace
is in the palm of the devil - Fouad Ajami

The Lord's Gift and Flying Toilets

2007-12-09T01:55:00.000-08:00

Living With Corruption
It is 9th December 2007 and I have just watched, for the third time in two days, a CNN special program entitiled, ‘Living With Corruption’, yet another first rate documentary on Africa by the incomparable Sorious Samora. Maybe it is just because I live in Africa and have great interest in the subjects he covers of maybe it his totally unpretentious manner, but I find him one of the best documentary producers around today.

As the title suggests, ‘Living With Corruption’ takes a hard look at corruption in Africa. Some might ask, so what’s new, it’s a subject well chewed over by the media on an almost daily basis. This film gives a new slant, it looks at how corruption rules the lives of the ordinary man and woman in the street. It demonstrates all too horribly and clearly how corruption pervades every level of society, and Samora suggests the entire Continent.
This at times infuriating film depressed and angered me on a number of levels; first because it reminds me of what I have witnessed almost every day of my past six years in east Africa and second because in many ways, Samora is ‘preaching to the choir’, the people most likely to see this film will be people who already know and have an interest in the subject. These are the same people who have witnessed the issue for years and have failed singularly to do anything to change it, I count myself amongst this group.

I doubt that the USA’s domestic CNN channel will make room in its twittering vacuous 24 hour ‘news cycle’ for a program as sober as this. Not least because CNN’s Directors have long since assumed [ or indeed created] an American audience with the attention span of a humming bird, that simply could not concentrate for almost an hour.

Of the many scenes that angered me, the shots of Samora walking at night down narrow alleys of Kibera slum in Nairobi ranked pretty high. His camera pans to the streams of raw sewage and describes the plastic bags under foot as being filled with human waste. There is such a dearth of pit latrines in Kibera, (as in most urban African slums) that the people have solved the problem by shitting in plastic bags and then hurling them as far away from their own dwellings as they can. The practice is called “The Flying Toilet”.

When I lived in Nairobi some years ago, I wrote a piece in early 2003, about HIV/AIDS and public health, essentially criticising the then ‘new’ PEPFAR initiative as being too narrow in its focus. My argument then and now is that attempting to stem the tide of AIDS by offering medicines to those in need is in many ways a pointless task. Giving medicines to people whose living conditions are so appalling they cannot find clean water with which to swallow their medications and cannot find food enough to re-generate their lost body weight, seems an exercise in futility that does no more than make the donor community feel good in the short term.

I entitled that piece The Lord’s Gift and Flying Toilets. Watching Samora’s film prompte me to revisit the piece, it is depressing to see that almost five years on so little has changed for the better and most for the worst.
I have reprised the article below…………..

Medicines for the Hungry
Even if it all comes together and “the Feds” get the money and resources to do what the President has directed, I have serious doubts about the [plan’s] overall impact on the disease, at least in East Africa, because it takes too narrow an approach to the issue and offers a single templated solution. The Harvard economist Jeffrey Sachs recently commented: “…the US administration has latched on to a simplistic vision of what to do, based on a single example, Uganda. It knows little of measures in place in other parts of the world, and that each country needs to shape the best local response”.

I think he’s right. My brief sojourn into HIV/AIDS in this part of the world has taught me that there is no template: even communities abutting each other need different plans of attack. But above all else it has taught me that it is a disease of poverty and that no plan will work unless it deals directly with the underlying social causes of poverty as key objective. A Kenyan friend puts it more bluntly. “Giving medicines to the hungry that live in shacks with no heating, lighting or toilets, consume dirty water and are illiterate will not reverse the scourge.” Another commented: “No community or government can tackle disease when its people are barely surviving on $1 a day.”

This Hecate’s brew of hunger and AIDS is impacting upon Kenya in a multitude of ways. The Country has a population of about 30 million, around 80% live in rural areas and could be broadly considered as farmers. But the demographics are changing rapidly. Farmers who once grew cash crops such as cotton and peanuts cannot find enough healthy members of their family to harvest so they have turned to subsistence crops like maize. But when disease stalks the land on a biblical scale even subsistence farming fails. So the people, particularly the young move to the cities to find security and work. HIV/AIDS is accelerating the pace of urbanization in Kenya and in doing so it is creating another dimension of social problems, which in turn must shape the way HIV/AIDS is managed in those communities.

Living in a Ditch
Kenya’s capital, Nairobi, is a city of approximately 2.2 million and growing daily. Over 60% of the population lives in slums euphemistically called temporary settlements and the numbers are growing at an unstoppable rate. The most infamous is slum is called Kibera. It has the dubious distinction of being the biggest in Africa, with about three quarters of a million people occupying 226 hectares – three-square meters per person. It was most trenchantly described by the BBC’s East Africa correspondent, Andrew Harding as, “Wood fires, fried fish, excrement, and rubbish – the rich stench of 800,000 people living in a ditch…six hundred acres of mud and filth with a brown stream dribbling in the middle…and at least one third of Nairobi lives there.”

The majority of Kibera’s residents work in and around the city, in light industry and the service sector. Most live in tin-roofed shacks connected by mud tracks, which usually double as open sewers. There is an erratic electricity supply for those who can afford it. It is a dangerous place to live. Robbery and violence is commonplace. Drugs, prostitution and heavy drinking of an illegal and potent homebrew called Chang’aa are common recreational activities. The police rarely patrol; vigilantes provide security for a price and sometimes exact terrible punishments: ‘necklacing’ is not uncommon for theft

Lord’s Gift
TB and dysentery are endemic and there are frequent outbreaks of virulent infectious diseases such as meningitis and hepatitis. Rats and other vermin are constant health risk. The HIV prevalence is estimated to be 20% (5% above the national level) but I have failed to find out how this figure was determined). Public health standards would shame a refugee camp. There is little or no running water; contractors bring in most in aging water trucks with logos such as “the Lords Gift” painted down the side. It is sold at exorbitant prices and carried home every day by women and children. Only a hardened Kibera dweller would drink it without boiling. The sewage system is a combination of open sewer and pit latrine. But as numbers multiply there are not enough latrines and in desperation, people resort to the “the Flying Toilet”. In simple terms those with no access to a latrine evacuate into plastic supermarket shopping bags and hurl them as far away from their own shack as they can. The result needs no description.

Reality Check
Now: against this medieval background lets remember our clear and simple mission is to reduce the number of new HIV infections, treat a number infected with Anti Retroviral Therapy (ART) and a considerable number more for the opportunistic diseases of AIDS. In this scenario prevention through education and behavioral change is an uphill struggle. Clinical diagnosis and medication are overshadowed by the need for clean water an adequate diet. How effective will ART be when the patient drinks water laden with cryptosporidia and eats one meal of porridge a day? For those who will never receive ART and who will spend their last days in their shacks in what is euphemistically called Home Based Care, the greatest need is a clean place to lie, a caring nurse, relief from pain and a death with dignity.

This is the reality that our “Emergency Plan for Aids Relief” must deal with. It can only succeed by a broad approach, socio-economic, educational and health. Each country stricken by this plague has unique problems and each must deal with them in an individual fashion. It requires the complete involvement of the people, communities and government. Solutions cannot be designed and imposed by even the most clever, generous and wealthy outsiders. America cannot solve this problem alone and in a way of its own choosing. To have any hope of success, we must act now, the numbers are growing inexorably. It needs huge sums of money, focused, trained human resources and a ‘coalition of the willing’.

This last cliché raises another spectre. If by the time this reaches print we are at war in Iraq, then war will eclipse every other international human priority, HIV/AIDS included. Wars divert attention; wars consume resources. Will America still be able to meet its promises?

George and the Dragon

2007-12-01T10:09:00.001-08:00

Today is World AIDS Day 2007
I decided my contribution would be to dig up all the old pieces i have written on the subject and dump them on this 'Blogsite', if for no other reason than to enable me to track my life against the progress of the disease. I am not happy about where we are but have not yet lost hope.
Here is a piece written back in July 2003. Plus ca change.

George and the Dragon
“But overall the passage of HIV around the world has continued roughly as if we had done nothing” – Richard Feachem, Executive Director of the Global Fund. January 2003

George
George is a good doctor. He has been practicing internal medicine for almost 5 years, works about 60 hours a week and gets paid about $1,000 a month (his government salary doubled this year). In his free time he is studying for a Masters in Public Health. He is a man with a mission, to save his country from HIV/AIDS. It is an uphill struggle; most of his patients present with the range of opportunistic infections that signal full blown AIDS. He counsels them, tests those who consent to testing, treats what he can, keeps them in hospital until they are fit to walk (60% of the beds in the hospital are taken up by HIV/AIDS patients) counsels them again about diet, clean water and avoiding infection and sends them home. Every day a half dozen join the 700 or so who die from AIDS-related diseases in Kenya.

Today George is very angry. He has just been asked to speak to a man who attended the Voluntary Counseling and Testing (VCT) centre adjacent to the hospital. The man has received his HIV test result. After an hour of patient explanation and guidance he is intransigent, adamantly refusing to inform his sexual partners of his HIV status. In pre-test counseling he disclosed that he was married and that his wife and year-old daughter were living with her parents in Busia, Western Province. He admitted to having a “regular girlfriend” who is pregnant. Smoldering with anger, George heads back to the wards. He tells me. “Even if I could find his wife or girlfriend and get them to counseling and testing, without his consent I am breaking legal and ethical guidelines and could be out of a job. How did we get to the point whereby some foolish law prevents me from telling a household that help is needed and death is on the way?”

HIV Exceptionalism
How indeed? The answer lies in part in the genesis of HIV/AIDS as an epidemic in the USA and its perception as a “homosexual” problem. Randy Shilts in his definitive social history of the disease, ‘And the Band Played On’, exquisitely catalogues the epidemic and its management in the early years. Fear of an unknown, incurable and deadly disease combined with a set of social and moral values loosely known as “homophobia” to create a level of discrimination and stigmatization so powerful that the needs of disease management and public health were overwhelmed by social imperatives. HIV/AIDS was no longer a disease it was a political movement. Out of the turmoil rose the phenomenon of ‘gay rights’, which were designed to protect, at first those suffering from HIV/AIDS and eventually all homosexual men and women from the worst excesses of stigmatization.

A unique coalition formed between the gay community, public health practitioners and civil liberty proponents to avoid prevention measures that might “drive the epidemic underground”. The traditional tried and tested public health measures of disease notification and contact tracing used for diseases such as typhoid, TB and syphilis were abandoned, and medical confidentiality was replaced by anonymity. The new strategy, based upon voluntarism, stressed mass education, counseling and the respect for privacy. This special approach to HIV/AIDS, as opposed to other infectious diseases, dubbed “HIV Exceptionalism” became the norm in the USA. The focus on voluntarism and what had transmogrified from ‘gay rights’ to ‘human rights’, shaped the policies of the Global Program on AIDS at the World Health Organization, which in turn informed the policies of nations around the world, in particular, Sub-Saharan Africa. George’s ability to use the standard tools of disease management to deal with a pandemic which threatens to overwhelm Kenya today is constrained by the peculiar political imperatives of a nation thousands of miles away and two decades ago.

Stigmatization
“The public policy challenge is to fight the discrimination at the same time that we fight the virus, not to assume the permanence of the discrimination, exalt it, and argue backwards from there against effective disease control” – Chandler Burr, The Atlantic Monthly June 1997
While no cure exists for HIV/AIDS, we do know enough about the virus to prevent its spread. But after almost 20 years of effort and countless millions of dollars we have signally failed to do so. Why? The more I stare at the problem the more convinced I become that the single biggest hurdle to overcome is stigmatization. It is all-pervasive. The developed world stigmatizes the developing world; Africa in particular it seems has only itself to blame for HIV/AIDS, the issue cursorily dismissed by one commentator as “over-population and over-copulation”.

Within Africa the perception of HIV/AIDS is still shaped by ignorance, misinformation, myth and superstition. Fears of becoming a social outcast deter many from seeking advice and help. Those living with the disease, though often showing little signs of illness, are shunned by their communities and discriminated in every aspect of their lives, even healthcare. Those who seek medical help frequently receive scant care because of discrimination by healthcare workers. The terminally ill, are left to the care of friends and family who rarely have the medical skills to cope and whose own fears result in stigmatization and even neglect. Above all, women are the most stigmatized, often forced into sex to survive and abandoned or brutalized when they become ill from the results.

Although human rights laws can and do protect against discrimination in employment, education and healthcare they can do little to protect against stigmatization which is far more pernicious but less easily defined and identified. In their ground-breaking article in the Lancet in 2002, De Cock et al argue that the real irony is treating HIV/AIDS differently from other infectious diseases almost certainly enhances the stigma surrounding it. Replacing the well-tested precepts of confidentiality with anonymity has created a cult of secrecy, which as the disease progresses, is impossible to maintain. Nevertheless, secrecy remains the orthodoxy despite the fact that promotes rather than breaks the destructive silence surrounding the disease and divides the known infected from the undiagnosed and uninfected. We will never beat the disease unless we get it out in the open

Normalization
“People will not agree to be tested until the results provide them with more than just a death sentence’ – William J Clinton. February 2003

There is a growing body of opinion within the healthcare professions that HIV exceptionalism, whether for principal or pragmatism, has broken nearly every tenet of infectious disease control and public health management and has failed to prevent the spread of the disease and to protect society at large. Richard Feachem’s comment chillingly echoes the result. In Africa the most obvious result is a complete lack of accurate data on the disease. Most prevalence rates are obtained by complex extrapolation of data obtained anonymously from antenatal clinics designated sentinel sites. HIV/AIDS is rarely entered in death certificates and yet treatment decisions are based upon the assumption that a patient is infected. Truth to tell, we simply don’t know the size of the problem. We can only judge it by the numbers who get sick and die on a daily basis. But why should we be surprised? In the USA and Europe today it’s estimated only half of those infected by HIV are aware of it.

So what is to be done? It is hardly likely that we could return to the authoritarian practices of yesteryear (although Canada’s experience with SARS shows that even “liberal” countries set limits on human rights). Five years ago De Cock and Johnson lead the debate to re-examine current practices; they termed it “normalization.” The concept is further enlarged in the 2002 Lancet article. De Cock describes a new model expanding considerably the practice of HIV testing backed up by enhanced access to care. As Anti-Retroviral (ARV) drugs become more widely available there will be an increased need for testing and more to offer than “just a death sentence”. He discusses four contexts for HIV testing: mandatory testing, VCT for prevention; routine testing for delivery of specific healthcare interventions and diagnostic testing in individual medical care.

Mandatory testing has little utility outside specific situations such as military service. VCT is to be developed as a means of prevention by testing people who are well rather than sick; in universal know-your-status campaigns. The idea being to use VCT as a tool to reduce secrecy and stigmatization. Each test site would be linked to institutions offering care for the infected. Routine HIV testing, which differs from mandatory testing in that it implies a default policy of testing unless an individual specifically elects not to, would be become standard practice in antenatal obstetrics and the management of all sexually transmitted diseases. Finally, diagnostic testing would become routine management for those diseases currently recognized as opportunistic infections such as tuberculosis. Although this does not sound too radical it is a major departure from current practice

I would add to this concept social marketing campaigns of a scale never before attempted. Analogies between the war on disease and terrorism are hackneyed but just as terrorism can only be tackled by addressing the social issues in which breed it, the same is true of HIV/AIDS. It is much more than a simple “bug kills host” argument. Social change on the scale necessary to combat HIV is critically dependent upon an informed public with rising expectations, eventually creating demand. Most of the social marketing campaigns I have seen to date have been to say the least, amateur. I want to see the guys who sell Budweiser at the Superbowl sell HIV prevention to the world.

The Dragon
Whilst researching this article I came across a book in the AMREF library, by an old friend, the former New York City Health Commissioner and Assistant Secretary of Defense (Health Affairs) Doctor Steve Joseph. I confess that I had never read the book “Dragon Within The Gates” until now. It is a fascinating read and eerily prescient. His description of attempting to use the standard tools of public health in particular contact tracing and being thwarted by vested interest echoes down the years. But the greatest resonance came from his accounts of conservative opposition to condom distribution and the fury resulting from his halving the original estimates of HIV infections in the city, which he argued were based on shaky extrapolation of shaky data; thereby threatening research funding. Plus ca change! I have loaned the book to George.

XTB and Mandatory Volunteering

2007-10-08T05:40:00.000-07:00

Consumption
Her name is Maria. Her eyes staring at me over the blue paper face-mask are clouded with fatigue. She sits in silent surrender as the conversation, in English and Spanish, ricochets past. Her entire being concentrates upon lifting rail thin shoulders and pulling in tiny gasps of air into a concave chest. Maria is a beautiful 17 year- old girl and she has Pulmonary Tuberculosis (PTB). The clinical notes tell us it is of a type, resistant to almost every medication available to treat the disease. Maria has what the denizens of international health call Extensively Resistant Tuberculosis. Shortened to the acronym, XTB, it sounds like the name of a new sportscar. Without a miracle, Maria will not live to see her eighteenth birthday, she has what in the old days, before the advent of antibiotics, they called Consumption, virulent TB that is consuming her lungs and there are no longer drugs to cure her, she weighs 70lbs.

Maria is one of a dozen patients lined up quietly, trying to find shade from the stunning heat, outside the back door of the Coliseum Sports Stadium in Buena Ventura, a port city on the northwest coast of Columbia. They are at the back door to avoid the mass of people queueing at the front entrance. Those people are here to see the primary health care teams deployed from the USNHS COMFORT on this its eighth stop in its four month odyssey around the littoral of South America and the Carribean. Our small group of patients all has TB and each has a form of the disease resistant to many or all the medications known as first and second line TB drugs. At best they have Multi-Drug Resistant TB (MDR) at worst, XTB.

They have come to see us because…well because we are here and they have exhausted every other option. To be precise, a microbiologist from the local office of the Ministry of Health (MOH) responsible for the scientific work to determine the level of resistance amongst TB patients in the city, has identified and gathered together over two dozen patients in dire straits. Stricken by MRD TB they are unable to find or afford the expensive options. She has brought them along to get whatever help we can offer. In terms of immediate relief, it is not a great deal.

I am an observer, assistant to a quietly professional Infectious Disease physician, Lieutenant Commander Todd Gleeson, as expertly conducts a detailed examination of each patient and confers through his interpreter with the microbiologist, patient and relatives. Masked up, we escort each in turn to the portable xray machine where a masked technician quickly takes a chest xray and we confirm the extent of the damage through and instant image on a laptop screen. Only a couple of those we assess show any sign of improvement since their last examination. What more is to be done? We are somber when we consider the options. The dozen we have assessed are, we are told, only a few of many more.

When we consult with our collegues, including local medical practitioners, conducting the general primary care clinics, it is apparent that TB is a common disease in the City and in the Region. Equally worrying, conversations with the local practitioners and the symptomatic evidence of our patients suggest that HIV is very present in the community and increasing in frequency. What we are witnessing is a public health crisis in the making and there is little we can do other than sound the alarm.

Finally it is agreed that the COMFORT can provide some limited medication for the most needy and less resistant. A meeting is held with the local MOH authorities exhorting them to sound an urgent warning to the Columbian Government and to seek help from the NGO ‘Partners in Health’ – an organization with great experience and expertise in TB in Latin America. The MOH is also urged to ask for help from the CDC and the Pan-American Health Organization, an agency of the World Health Organization that deals with health issues in Latin America. Gleeson and I muse about the future and the very obvious re-emergence of TB as a global health threat. I offer that we might yet see the return of the Sanitorium as a key means of controlling the disease. We are both silent.

Challenging Travel
Columbia has been the most challenging and in many ways the most rewarding of COMFORT’s ports of call to date and not just because of the burden of disease. The Ship has not been able to reach its intended rendezvous, alongside at Buena Ventura and has anchored off the coast, some miles from the secondry destination Bahia Malaga. Though the latter provides demanding and rewarding medical work, the population is small. The weather has been awful, with heavy rain showers and low cloud.

Getting to and from Buena Ventura has been an adventure for most and a serious challenge for some. It has required us to leave the ship early in the morning, around 6am, travel by small boat to the Columbian naval base of Bahia Mallaga and there transfer to a US Army Blackhawk for a twentyfive minute flight into the City. At the end of a long, hot and damp day, the journey has been most times repeated in reverse, though by late in the afternoon the seas are often much much more lively and the return boat journey long, wet, stomach-churning and exhausting.

Occasionally the lucky few have been picked up from Bahia Malaga or even Buena Ventura, by the tireless and intrepid ship’s helicopters. On a couple of occasions the weather has been bad enough to strand medical staff in Buena Ventura. Thanks to the outstanding work of the US Embassy’s military contingent, known as the MILGP, being stranded has been a far from uncomfortable experience, which I for one, have very much enjoyed. It might have been better from the outset to plan for at least a cadre of medical and administrative staff to stay ashore throughout. Much valuable time, which could have been spent with patients, was consumed travelling.

Rewarding Moments
There have been many rewarding moments during the mission so far. Sometimes I have been lucky to observe the COMFORT’s crew when they happen. Often they have been found in the camaraderie generated by overcoming the challenges of difficult journeys, long demanding days, seemingly endless flows of patients and cooperation to determine a particular diagnosis and a plan of care. Other times they have been found in an individual heart-felt offer of thanks for a kindly ear, expert advice and medications where needed. Sometimes too, through the pride of a successful intervention that alters a life and the uninhibited gratitude of a patient.

One of my favorite moments occurred in Buena Ventura. It concerned a man who was brought to see us in a wheelchair, having been shot in the back some six months previously. He was a fit-looking fifty-year old with a young wife and son. His clinical notes indicated he had a ‘paralyzed left leg’ with a lower leg brace to prevent foot drop. He had been unable to move his leg and confined to the wheelchair since the attack. He has come to the COMFORT convinced we could remove a bullet purportedly lodged in his back and with that enable him to walk again. When he was told that was not possible (an old x-ray showed a small-calibre bullet resting against a lumbar vertebra but not near the spinal column) his face crumpled and the whole family began to cry.

Nonplussed by this sad display we began a detailed physical examination. This showed, other than his wasting left leg, a very fit man with a ‘fully functional physiology’. Yet he had been in the wheelchair from the moment he had left his hospital bed, almost immediately after surgery. Asked if he had ever been encouraged to stand on his ‘good leg’ he shook his head. As luck would have it, the COMFORT’s Physical Therapy Department had deployed a comprensive capability in the Coliseum. Expert advice was sought, from the USAF and Candanian Medical Services PTs.

In short shrift our patient was gently but firmlycajoled and assisted to stand up from his chair and offered a pair of crutches. After some basic instruction he took a faltering step. The first in six months. To his obvious delight and with the encouragement of all around him he soon was able not only to bear weight on and move his ‘good leg’ but also to push his ‘paralyzed leg’ past the good one. In the expert opinion of the physical therapists, our patient would walk, probably unaided within weeks, given intensive therapy. A physician from the local hospital promised the therapy. The family cried again, this time because they were happy.

Volunteering Not Compulsory
No better story exemplifies the challenges of the Columbia Mission and the character of the ship’s crew, military and civilian, than the saga of our last day ashore. It began in the usual way, staggering out of our ‘racks’ (bunk beds) at 4:30am. Shower, shave, coffee, breakfast for those with cast-iron constitutions and muster in the CASREC (Casualty Receiving Department and the launching point for every move ashore) by 5:30am.
It did not take long to determine today was going to be a dificult day. The seas were choppy, the mist was dense and there was a continous drizzling rain. We adopted the usual posture, known to paratroopers as “hurry-up and wait”.

After an hour, the weather was little changed and it was pretty certain the ship’s helicopters would not fly, but at least one of the ship’s small utlity boats, known as hospitality boats, was prepared to make a run for Bahia Malaga where the weather was better and the Army Blackhawks would ferry us to Buena Ventura. Twentyfive volunteers were asked for. It was important we go because we had made commitments to patients from the day before and we had a great deal of medical equipment still in the Coliseum. Of the twentyfive who stood up to go, most were what I called ‘the usual suspects’ the same group of doctors, nurses and medics who seemed to be in every difficult mission, four were Project HOPE Volunteers, two doctors, two nurses, all younger than me - just. I had no choice but be the fifth.

Almost the moment we crossed from the lowered lifeboat to the hospitality boat, the rain began in ernest. As soon as we rounded the Ship from the sheltered leeward side, the boat began to rock and roll. Trying hard to avoid the rain and the sea spray we eyed the waves and held on to the boat, some including me, chattering away to settle the nerves. It wasn’t the choppy seas that bothered us, we trusted the Mariners piloting the boat; it was being seasick.

Half an hour into the journey the boat really began to bounce about, caught by increasing cross-winds and a rip-tide running up the river, a river we had to enter. Our craft began to buck so alarmingly, I would not have been surprised to see Captain Ahab on the prow with a harpoon and a big whale to port. Finally, after many more exciting and drenching moments, the boat made the relatively calm waters of the estuary and from there chugged quietly up to the pier in Bahia Malaga.

There we found to our dismay that the weather had beaten us ashore and the helicopters would not be flying until the rain and very dense low cloud cleared. Not to be defeated, we regrouped, cared for those who were seasick, found shelter and food and hunkered down to to wait out the weather. I wandered to the water’s edge with a couple of the boat crew, seasoned sailors; they were in no hurry to fight the tides and the seas back to the ship. Their advice was we all get some rest. I took it, determined I would not rush to take the boat back, I advised the four Volunteers to do the same. I was sure the weather would clear and the ship’s helicopters would pick us up, eventually. I was going to wait for them; they agreed to do the same.

I scrounged some old mats and a piece of plastic and was soon snoring; only to be woken by the boat’s coxwain who quietly informed me he was, “about to make a run back for the Ship and that much to his dismay, the four, the ‘HOPIES’ were volunteering to accompany him.” More than a little grouchy I found my intrepid comrades and crossly demanded to know what on earth they were thinking, the journey back would be as miserable as the one in and it was poor judgment to make the boat crew responsible for them. My final admonishment was, “Just because you are HOPE Volunteers, it doesn’t mean that *@##* Volunteering is Mandatory!” Chastened, the four settled down to wait. Two hours later the weather began to clear and the air was soon filled with the welcome thump of helicopter blades. We were on our way ‘home’.

As a young army officer, I once had a Commanding Officer who told me, “Your job is to give your soldiers tales to tell without getting them killed”. I think its fair comment that COMFORT’s time in Columbia gave many of its crew, civilian and military, tales to tell. Tales they will enjoy for years to come and which set them apart from the people who were not here with us.

Health Diplomacy - Tales from the USNHS COMFORT

2007-09-09T17:48:00.001-07:00

Leviathan
The MH60 Knighthawk describes a graceful anti-clockwise arc, suddenly to our left a huge red cross looms out of the grey sea. The aircraft turns its nose to the cross, levels up, utters a long shudder as it bleeds away airspeed and lowers itself to the ships deck. The moment the wheels are firm, a host of ground crew in colored jackets descend on the helicopter, in seconds it is secured to the deck, doors opened and we are ushered through the roaring wind of the blades, to the sanctuary of ‘Flight Ops’. As I remove my life-vest and helmet the Knighthawk’s engine tone becomes more urgent and it slowly lifts away, headed back to the shore to collect patients. I am home from teaching at the local medical school.

Home is a white-painted leviathan known as the USNHS T-AH 20 COMFORT; its official title is a hospital ship but its actual presence beggars description. It is almost one thousand feet long, eight floors high and weighs 69,000tons. It has a complement of over 800 souls and carries enough food and water to feed them for a month. It has twelve operating rooms, an enormous ER known as CASREC, cutting edge ICU and post-op capability, state-of-the-art laboratories and a radiology department that would be the envy of any mid-sized American hospital. It has the capacity to manage up to one thousand patients and bring them on and off by air or sea. It is a fully capable trauma hospital at sea, and it is huge!

The COMFORT has been my home for over two months. We have sailed together from Norfolk Virginia to Belize, Guatemala, and Panama, through the Canal, Nicaragua, El Salvador and most recently Peru. As I write, we are heading north again towards the coast of Ecuador, the seventh country in a planned twelve nation tour that began in early June and will finish in October in Suriname.

Health Diplomacy
I am part of an experiment. The brain-child of the Under Secretary of State for Public Diplomacy and Public Affairs, Karen Hughes, it’s called ‘health diplomacy’, the use of national healthcare assets, military and civilian volunteers, to ‘win the hearts and minds’ in strategically important parts of the world, in our case, Central and Latin America. The US Navy has long held it has a vital global role in providing humanitarian relief in natural and man-made disasters and has used assets, including the COMFORT’s west-coast sister-ship the MERCY, in previous operations. The MERCY responded to the Asian Tsunami and the COMFORT to Hurricane Katrina. Recently the US Navy has sought to expand this role to more deliberate, planned humanitarian operations, specifically the provision of healthcare support in under-served areas of the world. In 2007, there are two such missions underway, the COMFORT is operating in Latin America and the USS Peleliu, a helicopter carrier, is working in Southeast Asia. This congruency of international policy and US Navy doctrine has produced a new and fascinating turn of events.

The experiment is novel not only because it is a new role for the Navy and particularly Navy medicine, but also because it deliberately includes contingents from the US Public Health Service and, more contentiously, civilian Non Government Organizations (NGOs) two in particular. Operation Smile, an NGO specializing in reconstructive surgery for cleft lips and pallets, and Project HOPE, a Virginia-based NGO with a long history of working aboard ships to deliver healthcare to under-served areas of the world. Both NGOs feature volunteers, individual doctors, nurses and other healthcare specialists who give their time and expertise for weeks at a time to serve on the ship and ashore in various countries.

Some will raise their eyebrows at the concept of NGOs working so closely with the military. I reserve my judgment; it is too early in the experiment to draw definitive conclusions. I view the Mission as a form of ‘armed reconnaissance’, the Navy is using its reach and power to identify needs in various countries, addressing the immediate needs where it can. The NGOs in turn use their expertise to determine the numbers and types of long-term capacity building projects that are feasible and begin work with the host countries to establish them. One thing is for certain; at the end of this Mission I will have a more informed position than most of my NGO friends. I will most definitely let them know.

Project HOPE
As a HOPE volunteer, I am the COMFORT mission medical director and will serve on the ship for four months. I manage the Volunteers during their stay on the ship. They come aboard in four waves, each of about 20 Volunteers and stay three missions each time. The twelve missions will see almost 100 Volunteers serve on the ship. They provide general surgery, primary healthcare and education, with a heavy emphasis on the latter. HOPE seeks volunteers with specific expertise, experience working in austere environments, good education skills and a strong streak of independence. The independence is an essential attribute for balanced living in a powerful Navy culture but it can cause the odd headache. I describe my job as ‘Manager of the La Scala Opera House’ I have more than one Diva to deal with daily. I nevertheless am in awe of the experience and sheer dedication of the average HOPE Volunteer.

In addition to the Volunteers, HOPE provides what it calls ‘Gifts in Kind’. The HOPE Regional Director for Latin America gathers from the country MOHs, ‘shopping lists’ of medical equipment and medications which individual countries need and find difficult to acquire. HOPE HQ approaches the US manufacturers and businesses in general to donate or buy these resources. They are delivered to their final destinations aboard the COMFORT and presented to the MOH for distribution. This huge generosity of US businesses amounts to millions of dollars annually and is another example of the private face of American altruism.

Tales to Tell
Each country we have visited has presented a uniquely different environment, cultural and working. Advanced teams visited each country months ago and plans were instituted by the US Embassies and the Governments, particularly the MOHs. On arrival the COMFORT either anchors off the coast or [preferably] comes alongside in a port. Up to three teams deploy to undertake primary healthcare missions in separate locations, a fourth to teach. In addition the surgeons deploy in the first few days to triage patients for surgery on board the ship. There is a substantial complement of SEABEES aboard; these redoubtable engineers turn their hand to any construction and repairs that they can accomplish within the ships stay in the country.

There are sufficient tales to tell from the journey so far, to fill this magazine and I will save them for a future date. They range from bouncing down the Guatemalan coast in a storm, the ship is a converted oil tanker and too light for its size so rolls around in a disconcerting [and sickly] fashion, to passing through the Panama Canal (a modern Wonder of the World), through ending up in Nicaragua at the same time as President Hugo Chavez and on Sandinista Day, to the trials of the Crossing the Equator Ceremony. We have seen all manner of people and all manner of illness, fixed some and not others but made many friends.

Emerging Themes
We are now in the second half of our Odyssey and though it is too early to draw absolute conclusions I have some pretty firm ideas about both the good and the not-so-good of the Mission to date. The first point I think it vital to make is that this is a training mission. We set off on the 15th of June over 800 souls from the US Navy, Army, Air Force, US Public Health Service, Canadian Defense Forces and NGO volunteers. Few if any had ever seen each other before let alone worked together. Most, including the majority of the Navy medical staffs had never been to sea before. It was only to be expected that the learning curve for all would be vertical and life would be difficult. It was, and at times painfully so. It is hard to reconcile learning a task and practicing for real at the same time. But this is the reality of the modern Navy, constant turbulence.

We learned quickly and by Panama had grasped the main lessons and were beginning to work together. Peru has witnessed that truly military phenomenon, ‘the Team’, forming in almost every department of the ship. These tight little groups have cultures developed around shared experience and a vernacular that is impenetrable to the outsider. Though we may not appreciate it now, the often painful learning process we went through in each hot and dusty medical site, every frustrating encounter with a creaky communications system, was necessary to produce this very essence of the military culture, the ‘Band of Brothers’.

Competing Imperatives
We have learned too that it is difficult to reconcile two competing imperatives, to visit our ‘medical diplomacy’ on a large number of countries in a relatively short period, and provide substantive medical care in each target country. The latter takes time and the former does not allow it. The result at times has been the disappointment of unmet expectations, frustration amongst clinicians who felt their medical abilities constrained by time and resentment from indigenous medical staffs who felt excluded from events. It could be argued that no matter how long we stayed we would only be ‘scratching the surface’ and that is true, but longer would have been better. We are learning to compensate by making our procedures slicker, using our advance teams to set tighter, more achievable schedules and focusing in on what we do best. Still, the lines at the main primary care site in Trujillo Peru would have put a football match to shame. I contend that future missions would benefit from a more targeted approach, less countries and longer stays.

Trojan Horses
At the tactical level we have learned valuable lessons which we will continue to expand and exploit. The first and by far and away my favorite is what I have nicknamed ‘the Trojan Horse’ approach. The countries we have visited and will visit are overwhelmingly agricultural; animals are an essential element of Everyman’s wealth. It therefore follows that healthy animals mean wealthy owners and wealthy people are healthy people. Yet we did not grasp the full import of this until Nicaragua. Given the current political environment of the Country, we not surprisingly met resentment and disinterest in our offers of primary healthcare. A decision was made at one site, to lead with the USPHS Veterinary Medicine team offering healthcare to animals, principally horses, Nicaragua abounds in horses and they are an essential part of society. The effect was a sudden huge interest in all we were doing including human health. The ‘Vets’ had provided the catalyst to our primary care program. I believe this approach, combining animal and human healthcare in coordinated teams at the community level is a vital lesson learned and key model for future humanitarian operations.

Cabbage Patch Dolls
The second lesson concerns training and education, which should underpin our capacity building in every target country. We must expand our education initiatives and include them in every aspect of our healthcare delivery, from surgery to health promotion, dental care to veterinary care. The first tenet is that all training and education should be through the MOH and the medical teaching institutions and should include host nation teachers and interpreters. This takes a great deal of preparation and planning.

Training and education should be both culturally relevant and shaped to suit the needs and technology of the recipients. To this end we have instituted what I have called ‘come-as-you-are’ first aid at the community level. Rather than teach using the sophisticated technology of the US military, we have shown the Navy Corpsmen how use materials commonly found around households and workplaces as first aid appliances. Even more innovatively, the HOPE midwives teach the management of obstetric emergencies using a cardboard MRE box, Cabbage-Patch doll and a length of parachute cord. With these simple tools they can teach an array of techniques to manage deliveries. The local health workers are enthralled, both with its simplicity and the fact that ‘if it’s good enough for Americans, it’s good enough for us’.

The COMFORT of Home
The COMFORT is the center of our World and though we often complain about the food, the smells, the noise and lack of privacy (I like most ‘officers’ share a small cabin with seven other men) we know it is our safe haven, cool in the tropical heat, with familiar routines and friendly faces and the best hot showers I have experienced in my life. It also houses some wonderful technology and great people. I am fascinated by the Radiology Department which houses a CAT-Scan and is so sophisticated I view it as the modern Anatomists Laboratory. We no longer cut up bodies to see how they work, we map them from top to bottom, inside and out and travel their three dimensional digital images like modern explorers.

I am in awe too of our helicopters and their crew, who never seem to stop working. They fly tirelessly from dawn to dusk and whilst the rest of us are snoring they lovingly take their machines apart and reassemble them under the night sky. Without them and the redoubtable ‘pirates’ of the Military Sealift Command who ferry us faithfully to and from the ship like modern Charons, in almost all weather, we would most times be able to do little more than stare at distant shores.

So here I am for another two months. Some days I feel a little like the character that shot the albatross in the Rime of the Ancient Mariner. Others I am as excited as a latter-day Walter Raleigh. I have already learned much, seen a great deal and met some wonderful people, on both ship and ashore. I look forward to writing more tales and thoughts from our medical Odyssey.

Trout Fishing in Africa

2007-05-28T02:11:00.000-07:00

Friendly Fire
Some time ago, I wrote an article for a US magazine, the basic premise of which was that technology has the potential to bring about a revolution in post-conflict southern Sudanese society, particularly in healthcare. I thought that my arguments, though a little thin, were basically well founded and would meet with a sympathetic audience. Not so, I received a deluge of criticsm. What stung me a little was the amount of ‘friendly fire’ I attracted from my colleagues who described my line of reasoning as little more than a hackneyed and naïve view of the power of Western technology that failed to recognize the realities of health and development in southern Sudan and in Africa generally. Chastened but recognizing my discussion was a bit superficial, I pondered the question more seriously, expanded my research and offered a ‘new improved version’ for scrutiny. I have reitereated the argument in this piece.

Bridging the Digital Divide
My contention was that building a new healthcare system for southern Sudan lends itself perfectly to the technologies and techniques of telemedicine. The distance, terrain and climate (8 million people living almost entirely in rural areas of a region one and half times the size of Iraq, where for six months of the year the rains make travel nearly impossible) dictate that resources be concentrated at the primary healthcare level, the point where most patients might reach, despite the constraints of austere terrain and climate. Given the immense logistical challenges of getting patients from primary care to secondary care or even specialists out to primary care the most viable option is to connect the system electronically and in turn connect the regional ‘health intranet’ to the world, enabling economies of scale and access to bodies of medical knowledge hitherto inaccessible. It would bring healthcare to the patient rather than the other way round. The critics argue that the idea of ‘technology jumping’ whilst fine as a ‘vision thing’ ignores the realities of life ‘at the sharp end’. They further contend that the fundamentals need to be in place first: regular electrical power sources, communications, potable water, trained healthcare staff and properly equipped health facilities within reach of communities. They say, in a world of limited resources, the priority should go to immediate needs and not dissipated on ’bridging the digital divide’, an idea whose time has yet to come

Teach a Man to Fish
During my musings I came across a paper in the Canadian Medical Association Journal of September 2001 on the issue of telemedicine in Africa, written by a Dr Ellen Einterz who at the time of writing was working in a rural hospital in Cameroon. The redoubtable Dr Einterz argues powerfully from a position of practical knowledge, she has worked at the sharp end healthcare in Africa for over 27 years. I have critiqued her paper as it crystallizes the doubts and reservations I have heard these past weeks. I hope she will forgive my criticism but she is the only person I have found brave enough to publish her opinions.

She begins delightfully by revising the much-overused aphorism…’teach a man to fish and he eats for a lifetime’, to ‘teach a man to fish and he’ll need to buy a fishing rod, reel, selection of hooks, lines, lures, tackle box and boat’, as a metaphor for the demands and limitations of telemedicine. She acknowledges that [telemedicine] has great potential for continuing medical education, specialist consultation over distance and the exchange of knowledge and ideas but counsels that the ‘seduction of satellites’ should not divert resources from the earthbound problems of healthcare in the continent.

Limitations of Technology
Her catalogue of social and healthcare ‘realities’ in her community is an echo of Sudan and for that matter most countries in Africa. The list includes lack of potable water, unreliable electrical and power sources, no paved roads or telephone system, inadequate healthcare and education, high levels of illiteracy and customs and practices steeped in superstition and myth. I have no quarrel with her argument regarding the challenges faced by her and most healthcare providers in rural Africa. I even agree with her description, borrowed from a Sunday Times of London article, that “the instruments of our computer age are stupid, unreliable pieces of plastic that can, when the wind is in the right direction be so incredibly useful that you can forgive them almost all their faults on the spot”. We diverge in our thinking when she describes the demands and limitations of telemedicine.

She argues, “for telemedicine to work not only must the wind be in the right direction but the rain must not be falling too hard and the electricity must be on; people who until now have never see a computer or used a telephone must be capable of operating, maintaining and repairing equipment; spare parts, updates and upgrades must be budgeted for and available. The increased need for thousands of miles of high-speed telephone lines and large bandwidth must be addressed… Massive droves of teachers, nurses, physicians and surgeons should be trained and induced to serve where they are needed…Telemedicine will not be able to save the millions who die every year of preventable, treatable acute respiratory tract infections or diarrheal diseases… …It will do nothing to halt the spread of TB or HIV/AIDS. Not one millimeter of fibreoptic cable is needed to improve basic obstetric care…”

Western Model
My counter to her indictment of technology is that her model for telemedicine seems to be that developed for medicine in the Western world and it fails to take into account man’s ability to adapt technology, particularly in Africa. Why must there be an archetypal electricity supply? Almost every electrical gizmo on sale in Africa for use in austere environments is designed to use minimum power and has a solar power source developed for it, from mobile telephones, to lighting systems, radio transmitters, computers and satellite dishes. When the sun doesn’t shine industrial strength batteries or lightweight cheap generators take over. Copper wire telephones are history; more mobile telephones are sold every day in Africa than in Europe. As computer manufacturers realize the developed world has reached near saturation point in hardware, they have turned to the developing world for markets; computers are quickly becoming more robust, user friendly, reliable, cheaper and easier to maintain. Satellite communication too is rapidly becoming easier and cheaper. Lightweight, robust and inexpensive hardware such as Vsat™, Rbegan™ and the Thuraya™ satellite phone are driving demand and decreasing costs of both equipment and transmission. Digital cameras are dropping in price and increasing in capability at almost the same speed. Digital microscopes, portable ultrasound machines and a host of telemedicine tools for consultations over distance, are becoming commonly available as manufacturers recognize a potentially huge market for rural healthcare the developing world. Above all, the mobile telephone is shaping and driving the communications revolution and economic future of Africa.

Technology and Health Education
The concept of training and deploying large numbers of nurses, doctors and surgeons to rural areas [where the majority population of Africa still lives] is commendable but history has shown, very hard to achieve. A significant reason for the reluctance of healthcare workers to serve in remote areas is the loss of contact with their mentors, peers and the infrastructure in which they trained. Telemedicine is an ideal means of maintaining that contact and a first-rate tool for continuing medical education.

Finally, the contention that telemedicine will not be able to save the millions who die every year from preventable disease, may be true but I contend that neither will the ‘masses of nurses, physicians and surgeons’ she advocates. History shows that the most vital tool in public health is an educated and active public. The same communications technology that provides for medical diagnostics and specialist opinions can also serve to educate the people; we might call it ehealth. Satellite TV is rapidly becoming one of the most powerful and ubiquitous means of mass communication in Africa; the government of South Africa, which has a national health education program using TV, has long recognized its potential as a health education tool. There is currently a plan in train to trial the program in Kenya, using funds from NEPADS

Communications Revolution in Kenya
A glance at the telephone and Internet systems of Kenya shows how quickly technological change is sweeping Africa. Five years ago there were 300,000 copper wire telephone links in a country of 32 million souls. Today there are only a few more but 1.5 million cell phones. They are simple cheap and use ‘scratch cards’ to pay for airtime. Text messaging is cheaper and more popular than voice. People can talk to each other across three countries of East Africa, Kenya, Uganda and Tanzania, and ‘text’ Africa and Europe for a few cents. Already some ‘wealthy’ young city dwellers are using camera phones. Two years ago Internet access from here was expensive, erratic, confined to big cities and slow as a glacier. Thanks to ICT revolutions such as GSM and GPRS, I can now access and send email in the remotest areas, simply by using my mobile phone. I am convinced that within a year, GPRS and 3G phones will be commonplace in Kenya and across east Africa. The Internet has come to Africa, through the mobile phone rather than the PC. Two years ago a friend who is now the Foreign Minister, told me he had a vision that one day every Kenyan would have a personal address [currently there are only Post Office Box numbers for those who can afford them]. When I expressed my doubts he told me it wouldn’t be a physical address [home or office] but an Internet address unique to every Kenyan. I have little doubt that it will happen. Such is the potential for technological innovation here.

Taking Healthcare to the People
Healthcare and technology are converging fast in this part of the world. There is every incentive for it to happen. The people remain overwhelmingly rural and their healthcare is sparse. Like most countries in the world the epicenter of healthcare expertise and resources in Africa remains in the cities. Given the huge logistic costs and social changes needed to physically expand healthcare out to the people it has failed to happen, despite the efforts of governments and international organizations. The result is the people come to healthcare in huge numbers and enormous cost. By innovative and appropriate use of technology it is possible to take healthcare to the people and significantly improve the current quality and access to care. I don’t know what the technological infrastructure that will shape future healthcare in Kenya or Sudan will look like, only that the systems and technology must be simple, reliable, robust and affordable. I am pretty much sure therefore, that it will be based upon mobile phones rather than PCs. I also am convinced that investing in telemedicine and enhancing healthcare resources in the Horn of Africa need be neither a linear progression nor mutually exclusive.

Returning to the metaphor of ‘teaching a man to fish, in the occupation of fishing Dr Einterz compares telemedicine to teaching a man to fish for trout on a river filled with carp. As a veteran fly fisher who has hunted trout in Africa I can assure her the tools and techniques are equally effective on carp. The technology is not important it’s how you use it that matters.

Frightened for Fifteen Minutes

2007-05-01T08:44:00.000-07:00

My counselor’s name is Mercy. She is in her early twenties and pretty with intensely sad brown eyes. She speaks so quietly I have to lean forward to hear her. I have the strangest flashback, I am eleven years old again and about to be examined for nits by the school nurse. I am suddenly and irrationally anxious. The morning sun is beating on the tin roof; I can feel the radiated heat and begin to sweat. She is cool and dignified in her clinical coat. In matter-of fact tones she explains the intimate biology of HIV/AIDS pausing now and then to ask me, “Do you have a question?” Each time I answer, a little too firmly, “No.”

We are sitting facing each other; she looks into my face and tells me this is a voluntary test and asks me if I wish to carry on. She follows this by asking me if I am prepared for the result to be positive and what I intend to do. I reply with an overly firm “Yes” and “ I will tell my sexual partner(s). ” She has one more question. Do I understand there is a “window period” between infection and antibodies being produced and if I have had “risky sex” within the last six weeks or so I could test negative but still be at risk? I assure her I am not at risk but have another bout of white-coat hypertension.

Mercy explains the procedure we are about to embark upon. She unwraps the RapidTest. It is a small flat white plastic strip with a long “V” running its length. The test takes ten minutes. She will place one drop of my blood at the cleft. It will disperse and move down the “V”. After about two minutes it will leave a fine red line about three quarters up. This is the control line. If within the next eight to nine minutes a second line appears between the cleft and the control line it will indicate that I am almost certainly HIV Positive (but another test will be made to be certain) if no line appears I am negative.

She produces one of those awful little stabbing instruments; I suppress a shiver and offer the middle finger of my right hand. She cleans it with a soapy disinfectant and squeezes the last knuckle until the pulp is dark red. She picks up the “stabber”…my cell phone rings! I frantically search for the phone to switch it off but she insists I answer it. It’s the garage, my car is finished its service. Sotto voce I answer, “Can I call you back, I am in the middle of…something.” I wonder what his reaction would be if I had said “ an HIV test.”

I apologize. She stabs; I wince and watch the drop of blood ooze to the surface, she deftly places it the cleft of the “V”. We both stare at the plastic strip in silence. I search for something to say. I ask how long she has worked as a counselor, she tells me three years. She is a volunteer counselor, which means she gets paid a stipend whilst she trains and looks for paid work. All the time, I have one eye on the test strip. A line appears three quarters along! Mercy whispers it’s the control line. Inanely I answer “Oh good!” We carry on with the small talk. I ask her if later I can interview her and the other staff for an article I want to write on VCT. I don’t hear the answer; my eyes are glued on the strip. I was last tested in 1997 and although a lot of water has gone under my personal bridge since then I am neither promiscuous nor stupid. But I live in East Africa where hundreds of people die of HIV/AIDS every day; it’s easy to be irrational even if you are sure you are not at risk.

Mercy looks at her watch. Ten minutes are up, no second line. I am negative. I cannot suppress a grin of relief. I thank her (a little too profusely?) and tell her I will be back in a short while to do the interview. Outside, the day looks even more beautiful as I join the throng from our office We have come for a group VCT, an idea dreamed up to promote a national VCT and “know-your-status” campaign. The argument being we cannot exhort people to do it unless we do it too. We all admit to being anxious waiting for the second line. They clamber into vehicles chattering happily and roar off in a cloud of dust. I cannot help thinking how lucky we are; relatively well off, educated and having the support of our friends. What must it be like to come to this place poor, alone and worried?

I return to the small, neat blue-painted building. It is one of a number dotted around the periphery of a huge slum at the edge of the city. The staff is made up of one paid and three volunteer counsellors.
Between them they counsel about 15 clients a day. Few are local, they prefer not to be recognized going into the centre. The majority too (about two-thirds) are women. Most seek help because they are worried or unwell or both. Mainly they come alone but married Muslims almost always together. The test costs the equivalent of $0.50. The key is continuity of caring. Whether the result is positive or negative, clients are encouraged to join the “Post Test Club” which meets frequently in the largest of the center’s rooms. The aim is promote self-help and for the negative to mix with and care for the positive. They also take part in ‘Income Generating Activities’. The NGO that runs the VCT will bank whatever money they can muster until they reach the equivalent of $8.00 which qualifies for a loan to begin a small business such as selling charcoal, or cooked maize snacks. In the face of abject poverty and huge levels of disease in the slum, it may all seem too little too late. But my time in Africa has taught me that only community solutions work and that small is best.

I am buoyed by the moment and the sheer dedication of the staff. Then I witness the classic VCT client case; a metaphor for HIV/AIDS in SSA. She is 32 years of age, a single mother of one small daughter. Her only living relative is a brother who does not want to know her. She is a ‘commercial sex worker’. She uses Depo-Provera as contraception and tries to insist that her clients use condoms but they most times simply refuse and find another sex worker. She needs the money so she takes the risk. She has come to us because she is worried. Her test is negative. She is more determined than ever to give up sex work but desperately needs money to feed herself and her child. She agrees to join the ‘Post Test Club’ and to start saving what little she can of her earnings, to make the key $8.00, so she can get a loan; she thinks she can make a living selling children’s clothes. I look at her face, full of desperate hope, know that the only way she will save that money is from continuing to sell her body, and pray she stays negative for another three months.

My interview finished I head for a cold beer. I think about Mercy taking a two-hour ride to her brothers and sisters totally dependent on her and the mother whose only hope is to get out of commercial sex work. I think back to this morning and my own experience with VCT. I remember the feeling of being ‘frightened for fifteen minutes’. And I feel a fraud.

Of Hamlet and Per Diem

2007-04-25T04:40:00.000-07:00

‘Something is rotten in the State of Denmark’ – Shakespeare’s Hamlet

ABC
Anyone who has even a superficial knowledge of HIV/AIDS in Africa will know that Uganda has an almost mythic reputation as a success story in the long war against AIDS. Long before HIV/AIDS became a global issue, years before the international community began trucking in Wells Fargo-loads of cash, encyclopedias of advice and armies of technical advisors, Uganda had embarked upon its own unique national plan.

In 1986 the new Ugandan president, Yoweri Museveni responded to the emerging HIV crisis with the speed and determination that characterized his rise to power and early years as a national ruler. He embarked on a nationwide tour to tell people that avoiding AIDS was a patriotic duty, they should abstain from sex before marriage and then go on to remain faithful to their partners and to use condoms. This message became the underpinning national strategy, known as ABC, Abstinence, Be faithful and use a Condom. The same year, Uganda's Health Minister announced to the World Health Assembly that there was HIV in Uganda, and the first AIDS control program in Uganda was established. It focused on providing safe blood products, and educating people about HIV/AIDS.

Over the next five years the national programme fought an uphill battle against the disease, which had already reached catastrophic levels. Best estimates show that by the early 1990s the national adult prevalence rate peaked at around 15% and exceeded a staggering 30% among pregnant women in the cities. There is no accurate data on mortality rates during this period but they are believed to have been very high. In 1992 the government ramped up its efforts, adopting a multi-sector approach and coordinating the response to it. The strategy appeared to pay off with surprising speed. HIV prevalence in young pregnant women in Uganda began rapidly to decrease. In 1995 Uganda announced what appeared to be declining national trends in HIV prevalence. Over the next five years, the prevalence rates continued to drop. A national program to prevent mother to child transmission, using ARVs was introduced. By 2001 UNAIDS estimated the national prevalence rate to be around 5%.

The government and international agencies attributed this remarkable success to a combination of strong leadership, open national debate and information programs, community-level prevention and treatment programs and a national strategy based on a simple message, ABC. The model and the message has now become the basis of national strategies across sub-Saharan Africa and world-wide.

AB Small c
So where are we today? Put bluntly, the national strategy is in disarray, victim of politics, religious dogma, corruption and public apathy. The crisis began some years ago with a subtle shift in government policy away from ABC towards greater emphasis on ‘A’ – abstinence. Led by President Museveni and his First Lady, government policy and social marketing strategies now stress abstinence as the cornerstone of current HIV/AIDS prevention strategy.

The result is uproar amongst the national and international AIDS activist communities. The rhetoric and action have been neither balanced nor objective. Museveni caused international consternation at the 2004 International AIDS Conference in Bangkok when he argued, policies that promote abstinence and sex within marriage are more effective in preventing AIDS than those which stress condom use. In April 2006 the Ministry of Education issued a directive banning the promotion and distribution of condoms in public schools. Also in 2006 a Human Rights Watch report claimed that information about HIV transmission, safe sex and condom use had been removed from the school curriculum in Uganda and replaced by information emphasizing abstinence.

PEPFAR
The USA is smack in the eye of ‘Hurricane Condom’, specifically the Administration’s pet project the President’s Emergency Plan for Aids Relief (PEPFAR) which aims to provide life-saving drugs to at least two million people with HIV, prevent seven million new infections, and care for the sick and orphaned in 15 countries world-wide. Critics have, from its inception, argued that the initiative is fatally flawed in that it has overtly moral strings attached and is heavily influenced by the views and mores of America’s Christian conservatives. Beneficiaries must emphasize abstinence over condoms and in some cases, condemn prostitution. As one of the first beneficiaries of PEPFAR, Uganda was given $137m for HIV prevention and treatment programmes for 2005 and an additional $170m in 2006. Critics of PEPFAR, both national and international have spent a great deal of energy and resources ensuring the Ugandan media inform the people of this moral agenda.

Matters came to a head in the Fall of 2006 when the Ugandan media launched a string of reports detailing a national shortage of condoms, which they argued had been deliberately precipitated by the government’s nationwide recall of condoms - distributed free in health clinics- on the spurious grounds that they were defective. The debate was further enflamed when the UN Secretary General’s Special Envoy for HIV/AIDS in Africa, Stephen Lewis, told a world-wide teleconference on AIDS, that Uganda’s policy shift has been influenced by the US government “which is now mainly promoting pro-abstinence programmes and less of condom use”.

The truth is far more complex. The US global AIDS coordinator, Dr. Mark Dybul, has repeatedly stated there is no change in US policy and the current emphasis on abstinence is only to ensure a more balanced ABC strategy, which in the past has mostly focused on condom use. I have no reason to doubt his veracity, but it does not really matter. Perception is reality and there is now widespread belief, in Uganda and elsewhere that the USA is attempting to inject its own moral agenda into the global HIV/AIDS debate. It is using the power of money to do so and its actions threaten to undermine what little progress has been made so far, in mitigating the impact of AIDS in Africa.

Scamming the Global Fund
In October 2006 a team from the Geneva-based Global Fund to Fight Aids, Malaria and Tuberculosis arrived to announce the immediate suspension of all grants to Uganda, after a probe revealed “gross mismanagement of its funds”. A subsequent inquiry, led by a respected Judge, revealed mismanagement and fraud on an epic scale.

The total sum granted by the Fund was $201m over two years. The initial report stated that ‘to date only (my emphasis) $45m had been disbursed’. An initial investigation by outside auditors revealed “financial, procurement, governance and management structure irregularities,” a euphemism for fraud and theft. A few examples illustrate the extent of the mess: about $300,000 was lost by poor management of exchange rates between the dollar and Ugandan shilling and $1m was misdirected from monies meant for the private sector into government departments. “Monies amounting to millions of dollars” were paid to national NGOs and private businesses with little or no record of where the money went or how spent.

Government staff were paid hugely inflated allowances for tasks ranging from out-of-hours photocopying to attending workshops and what are known in local vernacular as ‘trainings’. (I am constantly surprised at how much employees of even small local CBOs know about allowances, the term Per Diem is an essential phrase of Ugandan bureaucratic language.)
My two favorite stories from the inquiry were: One official sent his daughter off to an international program for health education using GF monies. Another official presented a series of suspect receipts for fuel spent on official travel. Such was the level of his incompetence, once receipt was made out to a vehicle whose number plate belonged to a caterpillar tractor.

Whilst I was stunned by the blatant nature of the scamming, I was not surprised by the event. The first time I visited the Ministry of Health Kampala I re-named it the Ministry of Land Cruisers – I counted 56 in the parking lot. At the end of 2006 the MOH failed to organize the purchase of 15m doses of Co-Artem – the new WHO-approved malaria treatment – for which the Global Fund had provided $28m. One national newspaper suggested it was because there was little opportunity for fraud. The Minister of Health and his two deputies were forced to resign but despite public indignation and international irritation, none of the culprits have been brought to book. I have no idea how much if any of the money was ever recovered

Root of All Evil
If there is a moral to these two stories it is the corrosive and corrupting effect of money on people and governments, particularly when it is accompanied by explicit donor agendas and is poured into countries, institutions and communities on a scale which overwhelms existing systems for accounting and distribution. I have heard senior government officials publicly state they believed Uganda would be better off without PEPFAR and Global Fund money, that they did fine before it arrived; they invented ABC without outside help and were controlling the epidemic without huge donor funding. The advent of these two funds alone as spawned over 2,500 local NGOs and CBOs, a new national industry, almost impossible to regulate, which serves more to line the pockets of 'snake- oil' salesmen than tend to the sick and needy.

Shocked, Truly Shocked
Although Ugandans are dismayed at the corruption and mismanagement of HIV/AIDS funds they are equally angry at the donor community. They feel they should be given the money, without strings attached; where there is fraud and waste, they should deal with it. They see more than a little hypocrisy in the international community’s reaction and cite international NGOs dissembling over how they spend donor monies. They have a valid point. I am no expert, but I would guess that if you 'followed the money' from K Street to a Ugandan village, of every dollar that begins its journey, only a few cents arrives. It may not be fraud or waste but it certainly smacks of dysfunctional systems.

But Ugandans reserve their greatest disdain for those ‘aid industry’ experts who express their shock and outrage at local mismanagement and corruption, from the comfort of their luxury offices in Geneva or Washington. On command, they descend in hordes by first class flight to Entebbe, issue injured-sounding rebuttals or scathing criticism from the Sheraton Kampala and jet back to their comfortable homes. Rarely is there an admission that they might be part of the problem. Surely someone in PEPFAR could have predicted the birth of a conspiracy theory over the condom shortage and taken early action? Surely someone in the Global Fund knew at least the rumors surrounding the some of the Ministry of Health staff, particularly the Minister? If not, they only had to read the local newspapers (available online) to get the picture.

Now For Something Completely Different
If, as I have argued, things are so SNAFUd, what is to be done? We cannot keep doing what we have always done and when it shows not to be working simply try harder and throw more money at it. The time has come for original thinking and novel approaches. The key is to reduce the opportunities for misappropriation, get more, of every dollar donated, onto the final target and develop long-term independence by making individual Ugandans responsible for their own health and future.

There are many original thinkers in this part of the world. My favourite is a member of the Ugandan Parliament, the Honourable Mr Madada. He launched a project which offered free university education for virgins. In short, any young women can apply for college education providing she is from Kayunaga District and a virgin, she must prove this by subjecting to a virginity test, the details of which were never made clear. Needless to say the concept failed but at least it was original thinking!

Health Savings Accounts
I offer another ‘out of the box’ idea. Somebody out there give me $1m, no strings attached. I will put it in a Ugandan bank (best exchange rates I can get). I will then advertise for 1,000 volunteers from the class of 2010 at Makrere University. All will be required to undergo an HIV test. The first 1,000 that show negative will have a bank account opened in their name, for the sake of propriety we will call it a ‘health savings account’, containing $900 in Ugandan shillings. The contract will be they remain negative until they graduate. At that time they will be tested again and those still negative will have unrestricted access to their savings account and do whatever they please with both the original sum and the interest accrued. How individuals stay healthy - ABC or any variation thereof - is a personal and private concern. If the project is a success, it will be repeated and widened, dependent on donor interest and funding ( if I had access to the $200m given to Uganda by the Global Fund I could impact on 200,000 people).

I can almost hear the howls of indignation from the politically correct. ‘This concept smacks of bribery, it has no place in respectable social science’. I offer the following for consideration:
Almost certainly more than 1,000 will volunteer; those who are positive will be able to seek treatment and long-term care, the negatives will know their status and adjust their lives accordingly
1,000 ‘at risk’ individuals will be trying to stay out of the ‘risk pool’ for three years (over time, this must have some, albeit mathematically small, impact on infection and prevalence rates)
Money spent on administration will be minimal (much less than the majority of current prevention programs).
Opportunities for mismanagement and misappropriation of funds will be very limited
The capital sum will be available for national investment in the intervening years
On successful completion of the three year term, all monies, the capital sum plus interest accrued, will go directly to the individual, without caveat.
The money saved will most probably be spent or re-invested in-country on an individual basis.
Each individual will be incentivized to make personal decisions regarding their current and future health status. Successful completion of the first period may convince them to maintain healthy behaviour.
Individuals will recognize that they are capable of determining their own future.

I doubt that, at first blush, I have convinced many that this idea is anything more than the crude use of financial reward to manipulate social behaviour. Well, that might be true, but is it any more odious than many current schemes? At least it has no moral strings attached, requires minimum administration and does not lend itself easily to misappropriation. Has anyone out there got a better idea?

The Elephant in the Sitting Room

2007-04-09T14:07:00.000-07:00

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.

The Road to Hell

2007-03-29T01:41:00.000-07:00

The Road to Hell

The road to hell is paved with good intentions – Samuel Johnson.

Poisonous Aid
In early 2006, when President Museveni of Uganda, was threatened by donor countries who did not like his ‘undemocratic methods’, essentially ‘fixing’ his re-election, he announced that Uganda did not need any foreign aid, particularly aid which came with conditions often harmful to his country. It was a storm in a teacup. Within a few months Museveni was forgiven and most of the bilateral aid was switched on again.

I think he is, for the most part, right. Aid, particularly so-called development aid, is poisoning Uganda, creating a culture of dependence and resentful beggary, undermining rather than aiding economic growth. Today, of every dollar spent by the Ugandan government, 40cents is aid money. Such levels of economic dependence, totally distorts every aspect of the nation’s economy. It is the manure, which enables a corrupt government to thrive. Nor is Uganda unique in this respect. There is a growing and uneasy realization that the huge amounts of aid money poured into Africa has had little effect on the average poor African. I am convinced there is an urgent need, not to increase aid to Africa but to fundamentally overhaul the existing system, even to cut it radically in certain areas.

When war and natural disasters strike immediate humanitarian relief aid is often needed and can have a good effect, it can save lives. But if aid could make Africa prosperous it would have done so by now. Despite nearly a trillion dollars of aid since independence in the 1960s, much of Africa is worse off now than it was then. We like to think that the reasons lie in flawed strategy, much was spent by outsiders with little knowledge of Africa’s needs or consultation with Africans, the continent is littered with abandoned projects roads leading nowhere and factories without fuel or raw materials. We also are told, by luminaries such as Bono and Geldorf, we simply haven’t given enough. To ‘make poverty history’ we must do things better and double our spending. Digging deep in our wallets we don’t stop to ponder the unintended consequences of our overwhelming helpfulness on fragile African societies and economies.

Dependent and Resentful
Aid makes up half the domestic budgets of half of Africa’s countries. Making some as dependent as when they were colonies. In many, aid serves to undermine the economy, stifles entrepreneurship and enables poor governments to abdicate responsibility for providing services to its citizens. Uganda for example, is currently struggling to manage the sheer volume of foreign money coming into the country to fund aid programs, which it estimates as about $1bn this year. One effect is to push up the value of the Ugandan currency, which in turn makes the country’s fragile export market (coffee, tea and flowers) less competitive, threatening jobs and economic growth and increasing dependence on aid.

Aid creates and sustains unequal relationships, talk of partnerships between donors and governments are a distortion, Richard Dowden of the Royal African Society writes “We like it when they take ownership of the program but we mean our program. We don’t like it if they start having their own ideas”. This high-handed attitude creates resentment at every level of government. It is exacerbated when the people exerting control have little cultural understanding, are paid salaries many times greater than local staff and drive around in huge gas-guzzling SUVs. When programs are ineffective or fail even the poor African who rarely feels the direct impact of aid, notices and resents the ‘dude in the Land Cruiser’

Aiding and Abetting
Aid sometimes enable governments to pursue and sustain policies, which harm its citizens. The Ugandan Government’s terribly defective strategy to defeat the LRA in Northern Uganda by corralling the people into IDP camps is aided and abetted by the World Food Program . Without this food the government would be forced to find an alternative solution to the conflict. Ethiopia’s seemingly endless and biblical famines are not just the result of drought and over-population, but of a fatally flawed Marxist government policy, which denies land ownership to individual peasant farmers. Tenant farmers have no incentive to care for the land. Every famine, the government cries out for and receives international food aid and avoids dealing with the deeper political issues.

Quality of Mercy
My greatest criticism of contemporary development aid is its quality. It seems to me that the basic ethos of aid remains a voluntary transfer of charity from rich countries to poor. We give money, tell them how to use it, minutely scrutinize their activities and hold them accountable for failure. There is little or no donor accountability, particularly downwards to the people meant to benefit from the aid. The result is that aid is hugely distorted and badly managed by donors.

Real Aid
Last year, the NGO Action Aid produced a very revealing study of modern development aid, entitled Real Aid. It shows that every donor country exaggerates the true quantity and quality of its aid, though some are more self-interested and economical with the truth than others. The first revelation is that globally only 40% of development aid goes to low income countries and only 30% to countries in Sub-Saharan Africa. The majority of aid goes to middle income countries, which strikes me as an odd strategy for poverty reduction. Second, debt-relief is counted as Official Development Assistance, jargon for aid. This despite the fact that most debt relief is no more than a paper transaction to narrow the gap between what a country is due to pay and what it is able to pay. Third, services for immigrants/refugees are also counted as ODA. Both seem to be double accounting and there is no doubting its distortion. France spends $0.5bn a year on its national refugee issues and over 40% of its ODA is debt relief.

Experts and Exports
When it gets into the details of how the actual money is spent the revelations are eye-popping. A quarter of all aid is spent on Technical Assistance (TA) a catch-all phrase encompassing companies and consultants from donor countries to provide the recipient with expert advice and assistance often at huge cost. In Africa alone, donors employ an estimated 100,000 technical experts. Some donors are very exclusive in their choice of expertise, for example, 25 of the 34 largest recipients of the UK technical assistance contracts listed on the Department For International Development (DFID) website are British. None of the remaining nine is from a developing country. Lest Americans feel self-righteous, the UK spends 16% of aid on TA, the US is top of the class, spending 47%.

Transactional and administrative costs gobble up another 14% of the money. Not to mention time and effort, the average African country is estimated to produce 10,000 quarterly reports to donors a year and to host 1,000 donor visits. But the prize for pork goes to something called ‘tied’ aid. A whopping 40% of all aid outside of TA and food aid is tied to the purchase of goods and services from the donor country. As an example, the President’s Emergency Plan for AIDS Relief (PEPFAR) which has committed $15billion over 5 years, requires funding is only provided for branded drugs. US pharmaceutical companies get lucrative contracts but less people will get life-saving treatment than if cheaper generic drugs were used. The US is not alone in tying aid in this fashion but it certainly heads the pack at 70% of its aid, with only Italy beating it at 92%. Some countries, including Britain, have recently untied their aid but there is a long way to go to end this form of ‘aid as trade’.

Moral Guidance
Faced with these facts, it is small wonder that African governments appear less grateful and enthusiastic about aid than many donors believe they should. It is also easier to understand why funds get misappropriated with impunity within recipient countries and corruption is endemic to aid programs. Quite frankly, the examples set by most donor countries - exaggerating amounts, round-tripping monies through TA , tying aid to donor commercial interests and the profligate waste of funds through poor management – provide very poor moral guidance.

Aid and Dignity
In questioning whether Africa needs aid in order to develop, whether aid should be increased, even doubled according to findings of last year’s G8 Summit on Africa, I realize I run contrary to such great ‘social scientists’ as Bono and Geldorf (but I still like the former’s music and could never stand the talent-less Boom Town Rats). I have though, no qualms in criticizing the current quality of development aid, the dissembling, waste and distortion, clear for all to see. There is an urgent need to clean it up before increasing it.

I also believe that giving aid feels good and indeed our intentions are mainly good (though they may pave the way to hell). But there must be better ways to help Africa. We must pursue policies that enable Africa to develop its own way under its own steam, with dignity, able to compete and earn its living in the world.

The Selly Oak Saga

2007-03-21T03:20:00.000-07:00

The neglect of care for even one wounded soldier is unconscionable, the Defence Medical Sevices (DMS) and the NHS in Selly Oak should be ashamed. However, this sorry incident should not lead to the re-writing of history. There are those who hold that this alleged failure of care for wounded soldiers, is a symptom of a much deeper and serious problem, the demise of military hospitals. The reality is that for many years, up to the Defence Review of the early 1990’s, the DMS were ‘hollow’ at every level, including military hospitals, and the reason was not simply a lack of money.

The modern military comprises a relatively small number of fit young men and women who do rather well at not getting hurt or sick and is a veritable desert for medical practice. Consequently, for forty years at least, it had been very difficult to recruit, train and retain clinical specialists, or indeed any medical professional, because they could not obtain the breadth and depth of clinical practice and training necessary to qualify and compete in the civilian professional arena. The system reached critical proportions in the late 80s when the DMS was so short of expertise, individual consultant surgeons were taxied round the military hospitals of the British Army Of the Rhine (BAOR).

Deployed medical units had to be cobbled together in a system called ‘Robbing Peter To Pay Paul’, starting from the Regimental Aid Post and working back. The Navy closed its hospitals to man one hospital ship in the Falklands War and the still had to be reinforced by the Army and RAF. In the first Gulf War, one Army Field Hospital in the UK Order of Battle (ORBAT) comprised thirty different cap-badges. When the 1992 Defence Review offered the military medical services an opportunity to reorganize, many within sighed with relief.

The first role of the DMS in peace is to train and organize for war. Future military operational concepts required that we [the DMS] support a smaller military, based at home, deployed in relatively small numbers for specific operations. Moreover, combat power no longer measured by ‘bayonet strength’ – numbers of men on the ground. The DMS did not need to be organized, equipped and manned to managed the predicted casualty estimates for industrial war.

Once a soldier was injured and out of the fight fight he/she needed to be out of harms way. Moreover, we didn’t have just one casualty, his/her mum/dad/wife/husband/kids etc were also casualties, at least until they sat by his'her bed. Everything pointed then, and does now, to getting ‘Tommy’ home, quickly, to his/her family and to the best definitive care available. That care, is best provided by medical teams experienced in trauma care and its long-term management. The Defence Services had, since the early 60’s only had such expertise in the Reserves, drawn from the NHS.

The logical conclusion was to bring the wounded to those experts in the NHS. In this scenario, the increasingly anachronistic military hospitals were redundant. A military medical organization was designed from the frontline combat soldier through hybrid military/NHS UK hospitals to The Joint Services Rehabilitation Unit at Headley Court. Manpower deemed essential in peace and war was designated Regular or Active DMS, the balance to come from the Reserves, TA and individual reservist.

The result, today’s DMS, is a more balanced organization better able to manage the complex missions of modern war. I have no doubt that the current organization is a work in progress, as it should be. Neither do I doubt that there are real faults to be fixed. However, we should not contemplate going back to the days of the Cold War. As to the siren voices of the military hospital lobby, I offer a comment from [I think] Basil Liddle-Hart “There is only one thing more difficult than getting a new idea into an Officer’s head, and that is getting an old one out’.

Cutting Down the Mango Tree

2007-03-21T02:59:00.000-07:00

Cutting Down the Mango Tree
“I recently visited the village where I was born. It was overgrown and crumbling, but the most heart-breaking sight was the Mango tree, the centre of community life for generations, it had been cut down, to deny the LRA food”. - Rose, an Acholi lady

The ‘Forgotten War’
For twenty years, largely unnoticed by the rest of the world, a violent insurgency has wracked an area of the Great Lakes Region. Though commonly described as ‘the war in northern Uganda’, it encompasses northern Uganda, southwestern Sudan and northeastern Democratic Republic of the Congo (DRC). It is a regional conflict. Despite it’s cost, in resources and human misery – 1.6m people driven from their homes, thousands killed and many thousands more dying of disease. The war has for the most part remained un-noticed or been forgotten by the rest of the world.

Presidential Blues
For the past two years, this conflict has played out against the background of political turmoil within Uganda. President Museveni has, through questionable means, changed the Constitution to allow him to serve a third term as national leader and conducted a political campaign against his rivals that has bordered upon the despotic. There was genuine concern that the 2006 elections would dissolve in to violent internecine conflict.

Events unfolded more peacefully than many observers expected, Museveni won the Presidential elections but significantly, he and his governing party, the National Resistance Movement (NRM), received few votes in the North. A day after the results were announced, a national newspaper showed a map with each region colored according to which party had won. The south was mainly yellow, the color of the President’s NRM, but the entire region north of the Karuma bridge over the Nile, which essentially divides the country north/south, was blue, the color of the main opposition party. This is the starkest indicator that, whereas the Ugandan Army may claim it has won the [20-year] military campaign against the Lords Resistance Army (LRA) – military intelligence reports the LRA is reduced to “a few hundred” LRA in two groups, one in southern Sudan and the other in Democratic Republic of the Congo (DRC) – the Government is comprehensively losing the political war in the North. How did this come to pass?

War or Insurgency?
It seems the Government failed to grasp the nature of the conflict it is fighting. The issue turns on the question whether it’s a conventional war or an insurgency. It may illuminate the debate to offer [simple] definitions of both.
In conventional warfare, the enemy’s centre of gravity is usually its military forces. Other times it’s territory, economic infrastructure or resources. Physical entities, though the final goal will be the destruction of the enemy’s will to fight.

Insurgency can be described as an organized movement aimed at the overthrow of a constituted government through use of subversion and armed conflict. In insurgency warfare the population is the center of gravity. To eventually control the country, the insurgent must control the people or at least prove conclusively that the government cannot. Support is a measure of the insurgents’ ability to control the population, whether through [their] willing cooperation or the result of insurgent threats, acts of terror, or physical occupation of their community. In short, the insurgents need only win the “minds” of the population, not its “hearts.”

Insurgency strategy and tactics are designed to avoid committing usually inferior military strength of the insurgents to open battle with the superior military force of government. Insurgent strategy will include actions designed to cause an over-reaction (usually military) from the government, which in turn makes life more fraught for the people and further undermines their trust in the government.

Countering Insurgency
The centre of gravity in counter-insurgency must therefore also be the population, not the insurgent forces. Though their [insurgent forces] destruction is an important element of success, it must be pursued only as part of a broader, over-arching political strategy, which will include socio/economic and public information strategies. The central tenet of counter-insurgency is winning ‘the hearts and minds’ of the population. The people must be convinced their lives will be better if the government wins (hearts) and that the government will win (minds). This is what the French soldier/writer Trinquier, in his groundbreaking book of 1961, called ‘[M]odern warfare’ and General Sir Rupert Smith, in his new and excellent book , calls ‘[W]ar amongst the people’

Political Primacy
The first and vital element of a counterinsurgency (COIN) campaign is recognition of the essentially political nature of the conflict. This must be underpinned by a clear unambiguous political endgame, a goal that is much more than the destruction of the enemy’s armed forces. Such a strategy might include a more inclusive political process, economic reconstruction, greater regional autonomy etc.

The second is an organization that enables a unity of effort to meet the identified and agreed political goals. A civilian ‘political supremo’ must direct this structure. Military, public information, economic and social strategies will be executed by respective experts but they will always be subordinate to the political director who will answer directly to the government for the successful conduct of the COIN campaign.

Role of the Military
The military’s foremost task is security, protecting the people from attacks and retribution by the insurgents. Attempts at economic reconstruction and political reform in the absence of security will almost certainly fail. A single successful insurgent attack can have disastrous effect on the population’s morale. The second [task] is attrition of insurgents by incisive and precise military action. It is vital that such actions avoid as far as possible, hazarding the lives and property of the civilian population. Failure to do so plays into the insurgents’ strategy of militarization. Moreover, if the military is to operate amongst the people in the name of the law, it must do so within the law. To do otherwise would be to undermine a key strategic objective, to establish and uphold the law.

Conversely, concentrating on military action in the absence of political, social, economic and public information strategies will be futile, wasteful violence. The people caught up in the middle will lose trust in the military. Destruction of [relatively small numbers] of insurgents will be countered by insurgent retribution on the people (proving that the government cannot protect the people). Deaths and injuries to the civilian population, destruction of their property and perceived mistreatment of the ‘innocent’ caught up in armed conflict, in what is euphemistically called ‘collateral damage’ acts as a recruiting sergeant, drawing new fighters from the population.

Conflict in Northern Uganda
"To the man who only has a hammer in his toolbox, every problem looks like a nail." Maslow
The conflict in northern Uganda is an insurgency and not a war in the conventional sense. Yet, to date, the Ugandan government’s strategy has been to give primacy to the military, which has conducted predominantly conventional warfare, aiming at attrition and destruction of the LRA; they have acted as Maslow’s ‘hammer’. Military strategy has been underpinned by a public information campaign – aided and abetted by an international media, hungry for ‘If it Bleeds it Leads’ stories - that paints the LRA as a bunch of ill-trained thugs lead by a murderous psychopath, Joseph Kony, who wants only to rule Uganda according to a warped version of the Ten Commandments.

True, the LRA have committed awful crimes against the people, child abduction and mutilation being only some of the horrors, but if that’s all the LRA is about, why has the war lasted so long? To understand the root causes of the conflict, it is essential to look further than the past twenty years of the insurgency, back to the birth of Uganda as a nation state.

Origins
“..[a]s in most civil wars – northern Uganda is a place where history is in the plural.” Hugo Slim
A detailed study of Ugandan history is outwith the scope of this essay, but an explanation of key events and issues is essential to understanding the conflict’s origins and identifying a strategy to end the war. Much has been written about the people of the region and the history of the war, arguably the best by academics such as Atkinson , Finnstrom and Allen . This essay has borrowed heavily from the writings of latter, who offers an illuminating contemporary account of the conflict, particularly the recent involvement of the International Criminal Court, which has issued arrest warrants for Kony and his key lieutenants.

After the Ugandan Protectorate was set up in 1900, it took the British a further ten years to impose stability. Under [British] rule there was fifty years of relative peace on both sides of the border with the Anglo-Egyptian Condominium of Sudan. It was during this period that the British administration moved populations in the region and concentrated them for administrative reasons. In doing so, they created the population groups or ‘tribes’ from the Lwo-speaking people, today known as Acholi, Langi and Alur. The final demarcation of the Sudan/Ugandan border, either by neglect or design, divided closely related Lwo-speaking clans. There remains a substantial Acholi population in southern Sudan, which, in some part, explains how the LRA has always been able to move freely on either side of the border.

Independence, in 1962, began with Edward Mutesa II, the kabaka (king) of Buganda as the ceremonial president, and Milton Obote, a Lwo-speaking Langi from the north, as executive Prime Minister. By 1966, Obote had overthrown the constitution and declared himself president. To maintain himself in power, he drew heavily on the support of the Army, which, due to British pre-independence influence, was dominated by northerners. It proved his undoing, in 1971, one of his officers, Idi Amin, ousted him in a coup.

Amin, from the northwest, took two immediate measures to consolidate power: he courted the south and took action to ensure no counter-coup from soldiers close to Obote, the Lwo-speaking northerners. Officers and soldiers from the Acholi and Langi tribes were summoned to their barracks and massacred. Thousands more fled the country and formed insurgent groups; principal amongst these was the Ugandan National Liberation Army (UNLA). In 1979, following Amin’s abortive invasion of Tanzania, the UNLA, together with another insurgent group from the south, FRONASA, led by Yeoweri Museveni and supported by the Tanzanian military, invaded Uganda and overthrew Amin. He went into exile where he died in 2003.

In 1980, Obote was returned to power in rigged elections. From the outset he faced insurrection, particularly from a region north of the capital Kampala, known as the Luwero Triangle. Many southerners too, refused to accept Obote’s rule. In 1981, Museveni went to the bush again and founded the National Resistance Army (NRA). Obote became completely dependent on the UNLA, nominally the national army but dominated by Acholi and Langi, to keep him in power. UNLA actions in the northwest forced thousands to flee into Sudan. In Luwero this was not option, the population were caught up in a vicious guerrilla war between the UNLA and Museveni’s NRA. In classic insurgency fashion, the NRA gained support from the local population and the UNLA reacted by treating them as collaborators. Thousands were herded into camps and an unknown number were killed. The slaughter in Luwero continued until Museveni seized power in 1986.

There was a short but historically significant interregnum between Obote’s fall and Museveni’s assumption of power, which became a defining moment in the current conflict between the Acholi people and Museveni’s government. In 1985, the Acholi military leadership, disillusioned with Obote, overthrew him and forced him into exile. An Acholi general, Tito Okello assumed the Presidency and signed a peace agreement with the Museveni’s NRA, the NRA to ignored it, marched on the capital and seized power. Okello fled north together with large numbers of Acholi soldiers.

The NRA moved on the north to avenge the UNLA excesses, meteing out harsh treatment to the population. Many former UNLA soldiers fled to Sudan, some formed insurgent groups to fight the Dinka-led Sudan People’s Liberation Army (SPLA) as proxies of the Khartoum government, others formed an anti-government group, the Uganda Peoples Democratic Army (UPDA) to fight Museveni’s NRA, later to become the national army, the Ugandan Peoples Defence Forces (UPDF). Obote fled the country and died in exile in 2005. “[T]hen something unpredictable happened, the emergence of insurgent groups motivated by spirit cults and led by charismatic spirit mediums” .

Spirit Cults and Conflict
Contrary to contemporary belief, insurgent groups underpinned by an ethos of occultism are not a new aberrations or peculiar to Uganda. Spirit mediums and cults have featured in many past and recent conflicts, Sierra Leone and Liberia are examples. Nor is the phenomenon inexplicably strange when examined in the context of African culture. Many African peoples have traditional beliefs, which explain misfortune, disease and even good fortune as intervention from the spirit world. This does not mean ignorance of the facts, rather a more definite attribution. Even the advent and adoption of Christianity, Islam and scientific medicine, did little to undermine these beliefs. Moreover, as the scale of modern misfortune has increased - AIDS, poverty and intractable conflict - and the technological might of the developed world has been unable to mitigate the misery, the people have turned increasingly to spiritual guidance, be it the Bible, Quran, witchdoctors or spirit mediums.

In 1985 Alice Auma established a healing cult in Gulu. Alice was possessed by various spirits including ‘the Wrong Element’ (from the US) a Moslem called Kassim and Lakwena (Lwo term for messenger). Alice led her Holy Spirit Mobile Forces (HSMF) in a highly effective armed insurrection against Museveni’s government from 1986 to 1988 before being defeated. She fled into exile and died in a refugee camp in Kenya in early 2007. Many of Lakwena’s followers too escaped and joined groups, which had been influenced by her ‘spirit cult’, the most significant were movements connected with Severino Lukoya, Lakwena’s father, and with Joseph Kony.

Joseph Kony and the Lord’s Resistance Army
Joseph Kony has claimed a family connection with Alice Lakwena but its veracity is doubtful. Born in the 1960’s Kony dropped out of primary school after 6 years and trained as an ajwaka (‘witch doctor’). At the time the HSMF was active Kony began to be possessed by spirits. Alice was operating in the Kitgum area so Kony recruited ‘fighters’ in Gulu District. He tried to form an alliance with Alice but she rejected him. Humiliated, he responded by killing a number of her followers.

Kony’s early campaign was an insignificant affair, but in 1988 Museveni’s government signed a peace deal with a major insurgent group, the UPDA. Many disaffected insurgents turned to Kony, including one of UPDA’s key commanders, Odong Latek. He [Latek] built and trained the Movement as an effective insurgent force and taught Kony guerilla tactics; Latek was killed in battle in 1990. After his mentor’s death, Kony named his movement the Lord’s Resistance Army. Working with a small group of fighters, Kony developed an insurgency campaign against the government and increasingly against anyone perceived to be collaborating with the government. Why the LRA moved to barbaric acts – mutilation, appallingly brutal murder and kidnapping of children - aimed at his own people, may me be in part have been a means of ensuring his reluctant recruits, forced to commit the atrocities, were bound by their deeds to the LRA and ostracized from their communities

The size of the LRA was always a matter of speculation. One estimate in 1997 suggested as many as 4,000 combatants . This critical intelligence gap resulted from: fluctuations caused by battlefield attrition, intentional LRA leadership strategy to conceal its size, poor government intelligence and the fact that the main insurgent bases were secreted away in southern Sudan and eastern DRC. The number of insurgents operating in northern Uganda at any one time, was rarely more than a few hundred. This appears to be the result of deliberate strategy rather than NRA/UPDF actions. From the outset, the LRA conducted a textbook insurgency, eschewing the concentration of force, with its accompanying vulnerability – a large logistic footprint - and avoided major force-on–force engagements with numerically superior and more heavily armed government forces.

LRA military tactics were deliberately limited to ambushes of small UPDF formations and attacks on isolated military positions. Engagements invariably were at a time and place of the insurgents choosing against weaker forces that could not be rapidly reinforced. In combat, the insurgents showed a surprisingly high level of tactical skills, particularly fire discipline and coordination. Much of what is known about LRA training and tactics is shrouded in myth and disinformation; in part because these type of engagements, bloody, chaotic combat, often at night and in isolated areas, leave very few survivors capable of coherent after-action reports, and because government forces, in order to hide their own military shortcomings, have been economical with the truth.

In late 2006 peace talks began in Juba, southern Sudan, under the aegis of the Government of Southern Sudan (GOSS). The talks were preceded by a series of meetings between the LRA leadership and the international media. This media blitz had the effect of demystifying the LRA, its leadership, tactics and structure. As the fog of war cleared, it was evident that the LRA, again in classic insurgency style, had concentrated its efforts in developing a complex intelligence system which insinuated IDP camps and towns in the north and further afield. There were probably many times more LRA ‘fighters’ involved in covert intelligence gathering, than combatants in the bush. It is probable that Kony’s prescience in predicting UPDF attacks owed more to the mobile phone than divine intervention.

Political Agenda
Contrary to the Government’s many public pronouncements, the LRA always believed that it represented the Acholi people in its decades long conflict against a
‘repressive and unrepresentative Government which has conducted a twenty year war against the people of the north, designed to destroy the Acholi people and their culture’. This may explain why, despite the horrors inflicted by the LRA on its own people, a substantial part of the population remains ambivalent about the LRA, and why the conflict has dragged on so long. Moreover, it had long been believed the LRA has a nascent political wing in Uganda and further afield in Africa, Europe and the USA. The Juba peace talks witnessed an emergence of this infrastructure, which has its base in a number of individuals worldwide, known as the Acholi Diaspora. The majority of the ‘LRA representatives’ at the Juba talks are from this group.

Ugandan Military Operations
The actions of the military did much to reinforce the LRA’s political mutterings and the ambivalence of the Acholi people. Large scale military operations such as Operation North in 1991 and ‘Iron Fist’ in 2002, were notorious for the brutality meted out to the civilian population, first by the UPDF, searching for collaborators and then by the LRA, in retribution for suspected collaboration with the Government.

UPDF strategy was based on search and destroy operations, using large formations of marginally trained and often poorly equipped soldiers operating in what wer essentially ‘free-fire’ zones The number of civilians killed in these areas is unknown. Crucially, the UPDF lacked and probably still does, the essential tools to conduct counterinsurgency operations, small units of highly trained and well equipped Special Forces (SF) operating covertly and backed up by a highly mobile ‘quick-reaction’force and, most vital, ‘actionable intelligence’. This form of intelligence, gathered by human agents (HUMINT) and electronically by such systems as Remotely Piloted Vehicles (RPVs) – small pilotless aircraft with on-board cameras communicating to SF formations, can provide accurate location and identification of the enemy. It also enables rapid concentration of lethal force in precision operations. The time from locating to engaging the enemy is reduced to hours or even minutes. In the absence of such military capabilities, capturing or killing Kony and the LRA leadership was always a ‘game of chance.’

Isolating the Insurgents from the People
The only significant effort to win ‘hearts and minds’ of people was to move the population, about 1.6 million, into IDP camps. At first they came voluntarily, to escape the depredations of the LRA and government forces, but around 1995, the people were forcibly moved into the camps. The Government is currently moving many occupants to smaller satellite camps in a programme known as ‘de-congestion’. Many people are using the lengthy cease-fire and the peace negotiations as an opportunity to return to their villages and begin normal lives.

The idea, to isolate the people from the insurgents was a reasonable concept ( probably imitating successful British counterinsurgency strategy in Malaya in 1948 – 1960) but badly executed. The camps were always too big to be administered effectively, at the height of the campaign some camps had more than 50,000 occupants and security so poor, the LRA often moved in and out at will. The UPDF and government militias, tasked to defend the camps have repeatedly been accused of serious abuse of the people. Unable to sustain themselves in water, food, and protect themselves from disease, the people relied on humanitarian agencies for their very existence.

The issue of humanitarian assistance to the camps is fraught with ethical difficulties that limited the effectiveness of aid. The UN and NGOs shied away from activities that could be construed as accepting the permanence of the camps. This in turn led them to view the conflict as a 20-year humanitarian crisis, devoid of a coherent and coordinated long-term strategy. The result was and is huge resources and effort spent on humanitarian relief with little improvement in the quality of life of the people. Some actions, such as the unconditional provision of food support by the UN World Food Program and major international NGOs, without demanding corresponding political action to end the war, was and remains unconscionable. At the height of the IDP camp crisis, an anonymous aid worker offered, “[T]he camps are prisons. The UPDF are the prison guards. We feed the prisoners.”

As mortality rates from disease, inter-personal violence, suicide and child abuse rose, morale in the camps hit rock-bottom. The people talked freely of feeling hopeless and of lost dignity. Many believed that the camps were part of a government conspiracy to rob them of their traditional lands, to be sold to ‘foreign agro-businesses’ and talk of ‘cultural genocide’. This viewpoint prevails amongst large numbers of Acholi.

No one who visited a camp could fail to be moved by the plight of the people. The sight of large numbers of men and women passively lining up to collect food from the back of trucks, was both chilling and depressing. During day-time the camps resembled ant-hills, with thousands of adults and children moving in and out carrying bundles of wood, thatch and whatever food they could cultivate and harvest within the limited areas they were allowed to move.. The production of illegal and often toxic alcohol was and remains a major occupation and huge amounts are consumed, contributing to the high levels of crime, violence and disease.

The people, rural, small farmers, have traditionally valued large families, as a labour force and as insurance against the ravages of disease. Captivity in the camps did not changed this tradition and the fertility rate (Uganda has a fertility rate of 7 - one of the highest in the world) increased. Given the appalling over-crowded and unsanitary conditions in which the people live and the rudimentary healthcare available, it is not surprising that the maternal and infant mortality rates were and remain staggeringly high. The children, dirty and scarcely clothed, with bellies swollen by malnutrition and disease, swarm everywhere, neglected by parents too busy or too worn down to care. The average age of the camp population is estimated in the early-teens. These children have little prospect of education above primary school level and even less of finding employment in the future. The Region has become a demographic ‘time-bomb’ set to detonate within a decade.

The Government and the military took great exception to what they believed was a campaign of malign misinformation, such as the appalling state of the camps, abuse of IDPs by the military, and appropriation of land by individual government and military leaders. They blamed the mainly foreign NGO community for fomenting distrust and discontent to further their own personal agendas, particularly fund-raising activities.

The NGOs in turn, voiced outraged indignation at the often ‘brutal’ behaviour of the Army. Neither the military nor NGO community appeared to understand two verities of modern war: the first casualty of war is the Truth, and the key battleground in modern warfare is the Fourth Estate – the media. The Government, for the past two years at least, constantly talked of the impending end of the LRA and yet endlessly procrastinated over moving the people back to their villages. Many of those interned, now view the camps as ‘worse than LRA’. It is through an appallingly badly executed IDP strategy that government lost ‘the battle for hearts and minds’. Recovering it will take many years.

Political Strategy
Up until the peace talks in Juba, there had been no coherent, coordinated government political strategy for ending the conflict in the North. The military jealously guarded its primary position, conducting battles of attrition complete with regular ‘body counts’ of the enemy. Suggestions that the LRA were winning the political war, were treated as hostile criticism. Neither Museveni nor his main challenger in the recent elections, have ever articulated a clear strategic political plan for the north.

Attempts to negotiate a peaceful conclusion, by various civil society leaders were stymied over the years, by a combination of LRA distrust and Government dissembling. The involvement in mid-2005, by the International Criminal Court (ICC), issuing arrest warrants for Kony and his top lieutenants only muddied the waters, undermining the existing national amnesty laws and threatening the current peace talks. In late 2006, Museveni announced to the ICC that Ugandan national interests and Constitutional law trumped international law and the ICC should leave justice for the LRA to the Ugandans. The ICC in turn insisted that Uganda’s responsibility under to international law is to deliver Kony et al to The Hague. It remains to be seen who will back down first and how.

At the time of writing, talks in Juba, led by the GOSS Vice President, Riek Machar, have dragged on for almost 9 months and have reached a critical juncture. Thanks in the main to the political grandstanding of the LRA ‘delegation’, mainly from the Acholi Diaspora, none of whom had fought in the conflict, the LRA have doggedly refused to negotiate detailed terms. Millions of dollars have been focused on a series of circus-like events, to little avail. The LRA leadership, as often in these circumstances, has become so self-absorbed, it cannot recognise the endgame. Museveni, wants no more than a quiet time with no nasty surprises between now and the Commonwealth Heads of Government Meeting in Kampala in late November 2007

A New Plan
President Museveni must move decisively if he is to avoid the current conflict mutating into yet another insugency, led by another charismatic leader and deepening into intractability. He must suppress the bellicosity of his Generals who openly state that the ‘war is won’, fear that an end to the conflict would diminish their political power and continue to amass fortunes through the misappropriation of resources and dubious land deals. He must find an end to the insurgency that deals with the LRA in a way that is acceptable to the Acholi people as much as the international community. There are encouraging signs that Museveni is committed to ending the conflict definitively. His response to the stalling Juba talks at the end of 2006 was both rapid and incisive. His message to the ICC, that he wishes to be released from the constraints of the arrest warrants for the five key LRA leaders, has impressed the people of the north.

He must develop, promulgate and implement a new post-conflict plan and begin by appointing a civilian ‘Minister for the North’ with Cabinet status, to design and lead it. Responsibility for post-conflict reconstruction should be moved from where it currently resides, the Office of the Prime Minister (OPM) an office already weighed down with the day-to-day administration of the country, including solving such crises as the electrical power crisis that threatens the economy and preparations for hosting the 2007 Commonwealth Heads of Government Meeting (CHOGM) in Kampala.

The CHOGM meeting may actually be a catalyst to ending the war quickly. The GOU and particularly Museveni, will not want the huge and prestigious event ( one third of the world’s national leaders will be present) they are planning and working towards, marred by the continuing presence of about one million people in IDP camps and the LRA thumbing its nose at the Government. One could speculate that holding the Meeting in Uganda was a deliberate act, designed to apply ‘soft power’ politics to ending the conflict,

The appointment of a Minister - a civilian ‘political supremo’ - to head up conflict resolution and long term reconstruction and rehabilitation of northern Uganda will be key to long-term peace. The individual will need to be a respected and powerful figure to cope with the inevitable pressures from the many vested interests, particularly the military. The Minister’s immediate short-term goal must be guaranteed security of the camps and the people, as they return to their land. This should now be the primary mission of the Army. Second and most vitally, he/she must restore the rule of law in the north. This requires the rebuilding of the civilian police force and the courts, and the establishment of primacy of Constitutional law over Military law.

The third and equally vital task must be to develop and implement coherent and coordinated plans for Disarmament, Demobilization and Rehabilitation (DDR) and humanitarian relief and development for the north. To date these do not exist. As a consequence the myriad of NGOs/CBOs that operate in the region, do so according to their individual agendas. The result is duplication of effort and huge waste. Those areas where expert assistance is critically required, such as healthcare and a public health organization capable of disease surveillance and prevention, are woefully inadequate. There is an urgent need for coordination of effort, even if this requires directing the work of NGOs/CBOs.

The next immediate need is a detailed, unambiguous plan to return the people peacefully and quickly to their land and provide for their security. This is no small task. A formal end of hostilities and disbandment of the LRA will not guarantee the end of violence. Small villages and communties will require robust protection from criminal gangs, whose activities are increasing. Moreover, years of social upheaval, erosion of cultural memory and misappropriation of lands, have set the conditions for potentially bloody internecine conflict over land rights.

The war in northern Uganda has reached a critical point where it will end quickly or mutate into intractable conflict. The coming months will require cool heads, new ideas and compromise. It would be unwise to predict the path to a peaceful outcome, but it is reasonable to contend that the solution to the war lies in its true origins, which go much further back than the LRA, and that is what the new government strategy must identify. To borrow from the historian, John Lewis Gaddis, “[S[tudying the past has a way of introducing humility – a first stage towards detachment – because it suggests the continuity of the problems we confront and the unoriginality of most of our solutions for them”.

The Utility of Force - Future War and Military Medical Readiness

2007-03-14T05:09:00.000-07:00

The Utility of Force - Future War and Military Medical Readiness

The Utility of Force
I have recently finished an excellent book on the future of military conflict, ‘The Utility of Force’, the author, General Sir Rupert Smith, an old friend and mentor. For anyone interested in the art of war in the modern world, I highly recommend this book. in In his inimicable straightforward and pragmatic manner, the author lays out in clear terms his basic tenet that war as we know it, industrial war, conducted by nations or groups of nations, no longer exists. There are no predetermined fields of battle. All conflicts are adversarial activities and opponents each seek to choose and shape a field, which allows the greatest exploitation of their strengths and guards against their weaknesses. He believes, however, it is a good idea to look for trends in the changing battlefields and, as we see opponents seeking tactical and technical advantage, to study the direction of developments. He sees specific trends evident in the characteristics of recent conflicts which point towards the way wars may be fought in future. I offer my précis of his ideas.

Complexity
The first trend concerns the objectives or ends to which we commit forces. Increasingly, wars are being fought for aims unrelated to national survival or enhancement. The aims of the nation state characteristically produce unambiguous objectives for military force, to take, hold or destroy. They also generate clear protocols for use, organization, equipment and legal standing. Force is used with the explicit intention to bring about a favorable decision. Now we are deploying multinational forces with each nation contributing according to its interest and judgment of risk. We deploy forces to intra-state rather than inter-state conflicts with objectives to do with vague and ill-defined concepts such as humanitarian law, open to interpretation and motivated by popular concern. The simple objectives of inter-state war are being replaced the complex objectives of recent conflicts. Forces are deployed not to decide the matter but to establish the conditions where decisions might be found.

This trend toward political complexity has a number of effects on the military command process and the command system. Political factors are being included at ever-lower levels in the military command hierarchy and across the full spectrum of military functions. Constraints on the use of force are more intricate. Nations have differing perceptions of risk and reward. The business of not just generals but colonels, captains and sometimes corporals can have profound political effect. It is they who deal with coalition forces, local leaders, government agencies and non-government organizations like Human Rights Watch and UNHCR or the media. Small tactical actions often have unforeseen results at the strategic level. Traditional military decision processes are often found wanting and, most vitally, commanders at the tactical level often lack the experience, training and delegated authority to deal rapidly and decisively with complex crises.

War Amongst The People
The second trend is for operations increasingly to be conducted amongst the people. This occurs when our adversary uses the people to conceal or protect himself, whether the people cooperate or not; the freedom fighter, terrorist or criminal each in their own way operate amongst the people and depend upon them for concealment and sustainment. Given the first trend toward political complexity, if we are to operate amongst the people in the name of the law, we must do so within the law. To do otherwise would be to undermine our own strategic objective, to establish and uphold the law.
Furthermore, we operate amongst the people in a wider sense. TV and the Internet have brought war into the homes of leaders and electorates around the world. Leaders are influenced by what they see and their understanding of the mood of the wider audience, the electorate. This external influence in turn effects the political input to the decision process in theater. General Smith’s puts it best:
“Whoever coined the term Theatre of Operations was very prescient. We are conducting operations now as though we are on the stage, in a amphitheatre or Roman arena; there are at least two producers and directors working in opposition to each other, the players, each with his own version of the script are more often than not mixed up with the stage hands, ticket collectors and ice-cream vendors, while a factional audience, its attention focused on the noisiest part of the auditorium, views and gains an understanding of events by peering down the drinking straws of their soft drink packs.”

Preserving Force
The third trend is that we fight so as not to lose force. There are various reasons for this, the most obvious being known as the “body bag” effect. Democratic governments conducting operations for indirect objectives in coalitions often have to fight for popular support at home. Casualties can rapidly undermine this support and can cause nations to place constraints on the use of their forces.
Another reason to seek to preserve force is that it is difficult, time-consuming and costly to replace men and materiel. Conscription, the human production line, is being phased out in many countries and maintaining subsidized production lines of war material is expensive and distorts economies.
The consequence is a concentration on physical measures of force protection, body armor, heavily armored vehicles and well protected bases. All these measures, whilst providing protection, distance the force from the people, amongst whom they operate, who may conceal the adversary, who are the primary audience and the source of information.
To meet the needs of this trend and to be more effective, forces will need to fundamentally reorganize. Currently most forces deploy with very large administrative structures designed for wars of maneuvering mass. They require guarding and fortifying. The more they are secured the more isolated they become and the more a target. The principle should be to introduce into the area of threat only those necessary for the particular task and to protect the man before the equipment or the system.

Timelessness
The fourth trend is that operations are increasingly timeless. This has come about for two reasons both connected to the other trends. The first is to do with the need not to give battle unless there is a perceived advantage in doing so, so as to achieve precision, to localize the use of force or to preserve the force; the method of the terrorist and guerilla. And the other is to do with the chosen objective: the complex objective to establish conditions to be maintained until a strategic decision can be reached by other political, economic or social means.
The trend of timelessness has particular implications for sustainment of operations. Previously we needed reserves, stockpiles and large numbers of manpower to create a greater mass on mobilization and to fight wars of high intensity but often, short duration. We procured and obtained equipment, trained and organized manpower to serve this concept. Now we need our reserves to sustain our operations of lower intensity over time and we find the assumptions on manpower needs, attrition rates, usage and maintenance are false. The soldier and his equipment, trained and organized for one concept must be adaptable to the theater’s changing demands. Equipments and systems in small numbers should be adapted and procured for local circumstances and prototypes deployed and employed in a continuous development, which brings the technician and scientist into the frontline.

Using Systems Differently
The fifth and last trend is that we are using weapons systems in ways that they were not intended when procured. Smith argues that this trend in itself should tell us we are in a new situation. The cruise missile is used in a way never intended and the GPS launched on the open market was a free gift to terrorists Moreover, many weapons we now field are unsuitable on the modern field of battle. Heavy and more warlike weapons like the main battle tank and artillery piece are difficult to employ to advantage in urban settings. Their use is often seen to be an over reaction and disproportionate. They damage infrastructure. They are often vulnerable in close proximity to people with simple weapons. New weapons systems are needed, designed to operate effectively and safely in
a civil society.

Organized for the Future
General Smith concludes these trends are interconnected and that if they point the way to the future we need to shape our thinking and doctrine correspondingly. We must also develop our tactics, equipment, procedures and systems accordingly. We should demand the greatest degree of adaptability and modularity so as to allow systems, equipment, commanders and men to task organize to meet particular circumstances.

Implications for Medical Readiness
How might these trends point the way for military medical readiness in the future? I offer the following:
• The complexity of modern operations requires that we rethink the basic concepts of leadership training in the medical services. It ought to be less about training and more about education. Leaders at every level from colonel to corporal need a clearer understanding of the political issues underpinning military operations and actions, a knowledge of what has been described as the “operational art at the tactical level”. Wars in the future will rely increasingly upon the actions the “strategic corporal”. He or she must be developed. The current risk-averse attitudes that pervade the military medical services must be abandoned and greater emphasis placed upon devolving responsibility and decision making downwards to the lowest level required for rapid and decisive action.
• Modern operations will be conducted as Joint and Coalition affairs. This simple sentence has deep implications for the military medical services. The time is ripe for the development of joint medical doctrine and training. This does not necessitate a Joint medical service, rather the working of the three services to a common plan. Until “jointery” had been mastered, it is unlikely that coalition medical planning will advance from more than a cliché.
• The increasing number of “actors” each with their own piece of the political agenda is a key characteristic of modern conflict. Nowhere is this phenomenon more obvious than in the health arena. Military medical staffs and units deployed into theater must understand the interplay of these organizations and learn to play with them. Only by increasing understanding and cooperation between military healthcare and the other health agencies, government and non-government, can all available resources be used well. Education in the dynamics of complex healthcare environments should be a key part of military healthcare training.
• The mission of military medical support in a complex theater of operations has long been a vexed issue. As military operations increasingly occur amongst the people, the questions reemerge. What medical and health responsibilities does military medicine have for the health of the population at large? Recently the US military has kept this responsibility to the minimum. In future operations I believe it will be neither wise nor possible to constrain it. Often in the past military medicine has played a key tactical and strategic role in winning “hearts and minds”. If my understanding of future war is correct then military medicine will be a key tool in future conflicts.
• One of the most interesting questions yet to be raised about this new form of war concerns the laws of war. Will the ones we have lived with, that have underpinned military medicine for a hundred years, be redundant? Will the laws on prisoners of war apply? What if any will be the impact on the Geneva Conventions for the Care of the Sick and Wounded? I cannot imagine we could abandon them completely if we are to work within Smith’s premise that modern conflicts are underpinned by the rule of law but they need revisiting and may require significant rewriting.
• The interconnection of these trends create the conditions that will markedly effect the future shape, size and capability of deployable military healthcare. Our primary role will be the conservation of force through the prevention and treatment of disease and injury. As manpower becomes more operationally vital our importance will increase. Expectations will grow. We will also have to sustain medical support over longer times, putting greater demands on limited numbers of providers. The diminishing size of the administrative footprint will require new medical systems. The key will be to deploy expert care far forward for rapid accurate triage, resuscitation and structure a longer medical “reach” to evacuate rapidly out of harms way. All this will have to be achieved by small, task-organized units, working jointly and with coalition forces, able to reorganize and redeploy rapidly. The key to this ballet will be the music score. Detailed and accurate medical information delivered rapidly.

Final Thoughts
Reading this essay, some might conclude that there is little new in it, if that is so I have either missed the point and that is not unusual, or we are on the right track in thinking about change. I hope so. The time for fundamental and far-reaching transformation is upon the US military healthcare system.

The First Water War?

2007-03-08T06:57:00.000-08:00

The First Water War?
“…and We made from water everything that is alive.” Surat ‘The Prophets’, Verse 30, The Koran

Just over a year ago today Uganda awoke to the stunning news, from the CEO of the Ugandan Electrical Regulating Authority, that “[E]ffective Monday 6 [February] in order to save the Lake [Victoria], generation is going to fall from the current 170 MW to 140 MW.” From that day to this Uganda has endured constant power outages - euphemistically called load-shedding - of between 12 and 24 hours in duration. This time of year is the height of the dry season and stunningly hot. The town’s [Lira] piped water supply, which we are lucky to be tapped into, is powered by electricity and the little water left in the reservoir is not being pumped out. In sum, I spend a great deal of the time sitting in the dark with warm beer and smelling ripe. If it wasn’t for our overworked generator I would be writing this on parchment by the light of a candle.

How it came to pass that Lake Victoria is drying up, is a tale of incompetence, corruption, environmental destruction and nemesis in the form of Mother Nature. First though, I am beginning to suspect my recent interest in hydrology may be the cause of friends going home early, so in the interests of brevity and comprehension, I will keep the story short. A few facts: Uganda, owns half the surface area and two thirds the shoreline of Lake Victoria, the biggest lake in Africa, about the size of Ireland. It has the only natural outlet from the Lake, Owen Falls at Jinja, the source of the [White] Nile. The Nile runs for hundreds of miles north through two large lakes before leaving the country into Sudan. For almost its entire length within Uganda, it has what a US Department of Agriculture report calls “..[e]normous hydro-power potential.”

The country’s first hydro-electric powerstation and large scale source of electrical power was built between 1954 and 1969 at Owen Falls - renamed the Nalubaale dam - producing 180 Megawatts of power. During the 90’s, as the Ugandan economy blossomed, demand for electricity surged and a second dam, the Kiira, was opened in 2002, producing 200 Megawatts. It seems today’s crisis began at that point, resulting from political hubris, craven technical advice and a liberal dose of corruption. Engineers thought the Kiira dam was to replace the aging Nalubaale and advised accordingly. The advice was either whispered to or ignored by government and the now-privately-owned electical power company and both dams, close together, continued to run, supposedly producing 380megawatts of power. Someone failed to notice or else hid the fact that the dams were competing with each other, could not generate the expected total power and were drawing extra water from the lake.

Desperate for yet more power to grow the economy and achieve Museveni’s grand plan of rural electrification, the Government, together with the World Bank and a US-based constuction company drew up plans to build a third hydro-electric dam, the Bujagali, just down-stream from the other two. The project was contentious, hugely costly and riven with corruption. It also threatened an area of outstanding natural beauty. This attracted a Berkley-based ‘eco-NGO’, the International Rivers Network (IRN) which combined with local environmental groups and forced a public investigation. The environmentalists won, the US company pulled out and the World Bank tore up the check. But, the current crisis has put the Bujagali project back on the agenda, this time funded by an international consortium and [President] Museveni has stated he will not to allow ‘foreign interests’ to intervene. I can see his point. It is a bit rich for an NGO based in a country where the average individual flushes 100 liters of water down the toilet every day and uses more energy in a day than an African does in a year, to lecture Africans on environmental degradation and government hubris.

Early in 2006, in a desperate attempt to reverse an impending economic and social crisis, Museveni and what one wag called the ‘Minister of Darkness’, announced a two-part strategic energy plan. The short term plan is to establish two thermal power generators, capable of producing 150megawatts, to supplement hydro power. The long-term plan is to build three more dams on the Nile. The flaw in Plan A is thermal power uses heavy fuel oil. The stuff is expensive and costs are at the mercy of the global energy market. It also has to be imported, all the way from the Kenyan port of Mombasa and almost all by road. A thermal power generating plant already exists in Kampala, designed to supplement the hydropower supply. It uses huge amounts of diesel every day ( imported via Kenya) and costs a colossal $110m a year to run.

The Mombasa/Kampala road, Uganda’s aortic artery, is truly “the Road to Hell”, in places so neglected and over-used it looks as if it has been carpet bombed. The cost of moving a truck-load of fuel along its length has been estimated, by Jeffery Sachs and his ‘Jedi Knights of the Aid world’ at $2,500 and movement along the 1,000kms is an average of 5kph. Plans to enhance fuel delivery by pipeline from Kenya have stumbled along for years and even immediate implementation would mean years before completion. The same is true of plans to regenerate the old Mombasa/Kampala railway. Fuel shortages are already endemic in Uganda and costs have shot up 100% in twelve months. Huge gas-guzzzling generators will push up the cost of electricity and add to the burden of getting fuel into the country. The problem with Plan B is it will be four years before the first hydro-dam comes on line and it assumes Lake Victoria will fill up again, or at least not drop further.

The immediate effect of the power crisis is to stop the Ugandan economy in its tracks. Kampala’s commercial and industrial businesses, critically dependent upon electricity are limping along. Supermarkets have limited frozen food and fresh food. Bank ATMs work every other day etc. Significant improvement in power supplies without huge additional costs seem at least four years awa

A concatenation of events has brought Lake Victoria to its lowest levels in 80 years; it’s down by almost 2 meters and the shoreline has retreated by 40m in some places. First, the Great Lakes Basin is one of the most highly populated regions in the world, there are over 30m people living close to the lake, the numbers are growing and the area is intensely cultivated; pollution and water abstraction have risen accordingly. Second, there seems little doubt that the Ugandan power stations were emptying the lake at an unnatural rate. Before they were built it was agreed that the amount of water flowing through the turbines should mimic the amount that used to drain over the falls. The formula known as the "agreed curve", established under the 1959 Nile Waters Treaty between colonial Britain and Egypt - the ultimate user of most of the Nile's water - sets a maximum flow at between 300 and 1,700 cubic metres a second, depending on the water level in the lake. A recent independent study shows that the dams have been exceeding the ‘agreed curve’ by over 50% for the past two years at least. ( Now you know why our friends go home early!)

Third and most worrying is that the lake is not filling up at anywhere near the normal rate. This may be due in part to the regional drought which lasted over three years until late 2006, affecting the whole of East Africa, causing starvation in Kenya, Tanzania, Somalia and Ethiopia. If so, history shows such droughts are common and pass as this one has. But there seems a more insidious problem and its man-made. Almost half of the water flowing into the Lake and the [White] Nile comes from the highlands of Kenya. Over the past thirty years, population pressure and unchecked industrial deforestation have reduced the forest cover in the highlands by about 98%, with consequent considerable reduction in rainfall, silting of feeder rivers and reduction in flow of water to the Lake. Without urgent action by Kenya, water levels will continue to drop, with drastic effects on those living around the Lake and along the Nile from Uganda, through Sudan to Egypt.

It is Egypt which, will be most worried by current events, for the Nile is its very existence. Though it only receives about 15% of its annual water from the White Nile and 68 % from the Blue Nile, originating in Ethiopia; the latter is seasonal and from January to June - this time of year - the White Nile provides more than 80% of Egypt’s water. Before Egypt’s Aswan High Dam was completed in 1971, the White Nile watered the Egyptian stretch of the river throughout the year. The Blue Nile, carrying seasonal rain from Ethiopia, caused the Nile to flood, which in turn dictated the size and shape of Egypt’s agriculture and food supply. The Aswan allows Egypt to cultivate its land throughout the year and cope with a demographic explosion, which has seen its population rise from 20 million people 50 years ago to 70 million today.

. …[T]here will come a time when the people of East Africa and Ethiopia will become too desperate to care about these diplomatic niceties. Then, they are going to act." Meles Zenawi, Prime Minister, Ethiopia
The current crisis of Lake Victoria and in turn my [lack of] electricity, is only part of a much bigger regional crisis, which has simmered for fifty years and now threatens to boil over. Whereas Uganda, Kenya and Tanzania are bit players, the key actors are Ethiopia, Sudan and Egypt. Ethiopia is the source of the Blue Nile at Lake Tana, yet it is prevented from exploiting the river to develop its medieveal agricultural system - long since overwhelmed by population pressure and poor governance. All attempts to use even a small precentage of the Nile’s water are thwarted by a combination of the out-dated 1959 Nile Waters Treaty, inexplicable lack of enthusiasm from aid donors and veiled threats from Egypt. Consequently, every few years Bob Geldorf and the World Food Program have to come to the rescue and Ethiopian dignity is ground in the dust. The current regional drought and famine, which prompted the above comment from Ethiopia’s Meles Zenawi, may be the events that force the people to act.

Sudan too, has long had issues with Egypt about how much water it is allowed to take from the Nile under the Treaty. The capital, Khartoum, is on the confluence of the Blue and White Nile and a new Sudanese dam, the Merowe, is under construction north of the city. What the Egyptians think about this is unclear. Kenya, Tanzania, Rwanda and Uganda too have complained for years about the unfairness of a ‘colonial era treaty’ which prevents them taking water from Lake Victoria or the Nile and they are clamouring for change.

Viewed from Cairo, Lake Victoria’s disappearing water, combined with Ethiopia’s desperate need to use its own water to drag itself out of the Middle Ages and Sudan’s clear intention to expand an oil-based economy which in turn will require more use of the Nile’s waters, must seem a clear and present danger.

Almost twenty years ago, when I was teaching at the British Army Staff College, I remember the Egyptian Ambassador lecturing on Middle Eastern issues. He spoke mainly about Arab/Israeli affairs but culminated in a discussion of the Nile as the life-blood of his country. He warned that any attempt to interfere with the Nile would be seen as an act of war, “[T]he culprits would be bombed.” At the time, I thought his comments overheated to the point of being funny.
Today, I do not.

In Flew Enza

2007-03-04T00:59:00.000-08:00

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."

Occam's Razor and the Silver Bullet Gambit

2007-02-23T01:15:00.001-08:00

Entia non sunt multiplicanda praeter necessitatem (Entities should not be multiplied beyond necessity.) - William of Ockham, 14th C philosopher

It began in the early New Year when I traveled to England on family business. Within 48 hours of landing in cold, crowded Heathrow I had a nasty Upper Respiratory Tract Infection (URTI). Notwithstanding my brother and I discovering our recently deceased father’s stash of old and distinguished whiskies, and consuming a plentiful amount in his memory, I felt increasingly miserable and the cough got worse.

After ten days in wintry England I began my two day journey back to northern Uganda, feeling very sorry for myself, convinced my URTI was morphing into pneumonia and regretting not seeing a doctor before leaving. The first night back in Lira I spiked a temperature of 101F and alternately sweated and shivered the night away, resolving to find a doctor, have a chest x-ray, whatever other diagnostic procedure was available and start industrial strength antibiotics post haste. The following day I felt better and convinced myself my ‘chest-cold’ had been exacerbated by the long journey and the abrupt change in climate. That night I spiked another fever and all the alarm bells rang…well, at least with my wife who insisted I get a test for malaria in the morning.

At 8am we were in a small mission clinic in town, sat amongst a group of fifty or so patients, mainly women with babies or pregnant or both; the nurse told me, most probably had malaria. Eventually I took my turn to be stabbed in the finger by a young laboratory technician called Fred, who explained what he was doing and how he would reach a diagnosis. Half an hour later he emerged from the lab to announce “ Mzee (respectful title for elder male) you are a strong man, you have over 50 parasites to 100 WBC!”

My immediate reaction was in character, I was overwhelmed with self-pity. Malaria? Why me? How? I am so careful and have never had it before in my life. Etc etc. The next 36 hours is a bit of a fog. I know well enough the standard treatment protocol and always have a stock of Co-ArtemÒ (a combination of artemether and lumefantrine) in the fridge. I have used it on patients in the middle of no-where and it works like magic. Given that I had a weapons-grade dose of the disease, I embarked on a ‘take-no-prisoners’ counter-attack: a full course of 20/120 Co-ArtemÒ plus 100mgs of Doxycycline twice daily as insurance, analgesics and gallons of water. My wife nursed me diligently. My temperature see-sawed around 101F to 105F, I crawled to the shower, ached in places I did not know I could and was visited by very strange creatures which walked the bedroom walls . After 72 hours, I emerged from my bed an old man. It took a further week to nurture my appetite and get out and about.

“If you hear hoof beats behind you, look for horses not zebras” - Dr Jay Sanders, an old friend and mentor.

My purpose in recounting this story is not self-indulgence. It raises some very clear issues for me. The first is how easily I reached a [wrong] conclusion as to what ailed me. In my defense, I had strong circumstantial and symptomatic evidence to support my ‘diagnosis’. Though I don’t take prophylactic antimalarial medicine – it’s neither feasible nor affordable over years – I do take every other precaution, covering up in the evening, use insect repellents and always sleep under an Insecticide Treated Net (ITN). I am rarely bitten and have never before had malaria.

My initial symptoms where of an URTI and I contracted that in the UK. The cough and chest pain became the focus of my illness. It was 13 days from the time I left Uganda and 2 days after I returned before I suffered my first classic malaria rigor and by that time I had a very high level of parasites in my blood. The malaria is long gone but I still have a hacking cough. I had followed the age-old saw of medicine drawn from Occam’s premise, to suspect the obvious and commonplace – horses not zebras. I made two errors, I was living in a part of Africa where there are no horses only zebras and I had ignored another famous medical saw, Hickam’s Dictum, “a patient can have as many diseases as he damn well pleases.” I had both an URTI and malaria, a disease from each continent and one masking the other. It’s not a mistake I will make readily again.

No-one who lives in Africa can ignore malaria, and I have written about it on a number of occasions; now I have first-hand knowledge of the illness. It is not something I wish to repeat. But I was lucky, I had the education and resources to protect me and to be diagnosed and treated when prevention failed. For most of my neighbors in Lira and Uganda in general, there is scant help and many die. About 400 Ugandans die every day from malaria, mostly children under five and pregnant mothers. The data for other countries in sub-Saharan Africa are similar. Despite the efforts of international organizations, governments and non-government organizations (NGOs) nothing seems to be making a dent in the death toll, to the contrary, it is inexorably rising.

In 1998 the UN, WHO, a host of governments and NGOs launched a program, Roll Back Malaria (RBM), aimed at halving deaths from malaria by 2010 – almost 90% of these deaths are in sub-Saharan Africa. With less than three years to go the annual number of deaths worldwide from malaria is higher now than in 1998, rising from 5.5m in 1998 to a staggering 16m in 2004. If ever there was a failure of an international initiative, one that has been trumpeted around the world in every manner of global forum, and funded to the tune of hundreds of millions of dollars, the Roll Back Malaria is the classic example. It is a damp squib. Why? If Uganda is any example, the impending demise of RBM is a result of broken promises, ineptitude, misplaced reliance on ‘silver-bullet’ solutions and the defeat of science by soap opera. In theory Uganda has the three tools needed to curb malaria deaths—effective combination treatment based on artemisinin, ITNs and insecticides. A glance at each might throw some light on why Uganda is losing the fight.

The reality is that most Ugandans consider malaria like Americans view a common cold, hardly something you visit a physician for unless it gets really bad. The parallels between the US and Uganda in this regard are striking. Americans, with colds, rather than navigate the complexities and costs of a physician consult, will self-medicate or at most, seek the advice of a pharmacist. Ugandans do the latter. But they rarely have access to trained pharmacists and they have to pay out of pocket. They opt for the cheapest plan. This can be anything from traditional herbal medicine through dangerously ineffective but cheap combination therapies like chloroquine and fansidar, to effective but hugely painful intra-muscular quinine. Combination treatments based on artemisinin, that rescued me from who-knows-what, are being made available through the WHO and Global Fund but given the ineptitude of the Ugandan healthcare system, are only slowly permeating down to the ‘village’. As in all matters Ugandan though, there is always a way for those who can pay.

Talk to any member of the malaria prevention cognoscenti and they will wax lyrical about the ITN and its life saving properties. It is the ‘killer app’, the ‘silver bullet’ of modern malaria intervention, single-handedly able to reduce malaria deaths by over 60%. Despite what Sharon Stone and other glitterati would have us believe, ITNs have been around a long time and yet have not made a significant impact on malaria. Why? The ITN lobby insists it is a problem of supply, not enough are available. But there are more complex issues that the ‘silver bullet’ theorists downplay. ITNs cost more to distribute than to make and distribution is complex business, fraught with issues of local politics and economics. Then there are some banal practical facts: you cannot live 24/7 under an ITN, mosquitoes bite most in early evening and morning, when ordinary folks are up and about. They are hot to sleep under, particularly when there are eight people living in a small hut, and they are a fire hazard in huts where the only means of illumination is a candle or paraffin lamp. This is not a dismissal of ITNs, I swear by mine; rather a recognition that ITNs alone cannot beat malaria.

The third leg of the triad, vector control with insecticides, is the most contentious, mainly because it involves a dirty word, Dicophane or DDT. This is not the time or place for a history lesson on DDT, most readers are well aware of Silent Spring and the American experience with agricultural use of DDT. I have also expressed my bias in previous articles. For anyone who wants a serious scientific opinion on the issue, I recommend, “Balancing Risks on the Backs of the Poor” by Amir Attaran et al Nature.

The plain fact is that in terms of cost and effectiveness, DDT has no rival as an insecticide in vector control of insect-borne disease. Despite libraries of research, much conducted during and immediately after the time when DDT was used on a huge scale in the USA and elsewhere, there is no science to support the claim that DDT harms human health. Moreover, the strategy for DDT use in vector control, is to spray, small amounts of oil-based liquid inside selected homes and buildings once or twice a year in a tactic called Indoor Residual Spraying (IRS). To put this in perspective, back in the old days, US farmers would spray 1,100kgs of DDT on 100 hectares of cotton in four weeks. IRS would use this much to spray every building in northern Uganda in a year. It is not surprising therefore that the Stockholm Convention on Persistent Organic Pollutants (POPs) in 2004, exempted DDT for use in control of insect borne disease. Nor that in September 2006 the WHO announced their support for IRS using DDT in malaria control.

When, shortly after the WHO announcement, Uganda announced it would embark on IRS using DDT as the third leg of its RBM initiative, the reaction and rhetoric from activists, local and international, resembled a soap opera. Every well-worn cliché and threat was rolled out, ranging from the disastrous impact on agricultural exports to ‘recent studies that showed massive IQ loss in children whose mothers were exposed to DDT’. Even if tiny amounts of DDT from IRS, leached into agriculture it’s a stretch to see how this would destroy the nations principal exports, cut-flowers, tea and coffee. My favorite warning of agricultural Armageddon resulting from DDT use in Uganda came from the British American Tobacco company, delivered without a hint of irony!

As to IQ loss in children, I have not researched the study quoted, but I doubt that the damage, if any, could match the destruction of children’s brains inflicted by malaria every year here. As a small measure, my wife plans to fund a project for care of epilepsy patients ( there seems to be a correlation between infantile malaria and epilepsy) in Lira; there are an estimated 1,000 plus – in a population of less than100,000. No rational argument seems to sway the activists in Physicians for Social Responsibility (PSR) or the Pesticide Action Network (PAN), maybe because it threatens their funding and their salaries. But every day they succeed in delaying the implementation of IRS, they need to explain why hundreds of Ugandans must continue to die.

What Uganda needs is a coherent, well resourced and managed plan to ‘Roll Back Malaria’; by every measure, the current plan is not working and I am a recent victim. The Plan must include all three legs of the triad, effective treatment, nation-wide distribution and use of ITNs and IRS, using the best insecticide currently available, DDT. Over-reliance on ITNs will fail. As to the siren calls of PSR and PAN so concerned about our future but with no solutions for today, I have only one comment. Close down your expensive offices in malaria-free San Francisco, Washington DC and Nairobi and open them in Lira. Bring your families, leave behind your expensive malaria prophylaxis and designer insect repellants. Come and sleep under an ITN and work here for a couple of years. Then you will have a credible voice at the table.

Combat Stress and the Modern Warfighter

2007-02-21T00:50:00.000-08:00

This is an article I wrote for a US Special Operations Forces (SOF) training program in 2001, shortly after the beginning of US military action in Afghanistan. Though much has happened in terms of military conflict since those heady days, I believe the the fundamental tenets of men in battle have not changed and that the themes I have drawn out in the article remain just as true today. I have therefore posted it as a blog, in almost its original form.

COMBAT STRESS AND THE MODERN WARFIGHTER

“What battles have in common is human: the behaviour of men struggling to reconcile their instinct for self-preservation, their sense of honour and the achievement of some aim over which other men are ready to kill them. The study of battle is therefore always the study of fear and usually of courage; always of leadership, usually of obedience; always of compulsion, sometimes of insubordination; always of anxiety, sometimes of elation or catharsis; always of uncertainty and doubt, misinformation and misapprehension, usually also of faith and sometimes of vision; always of violence, sometimes of cruelty, self-sacrifice, compassion; above all, it is always a study of solidarity and usually also of disintegration – for it is towards the disintegration of human groups that battle is intended.”- John Keegan, Face of Battle

“ Ninety-five percent of American casualties in wars throughout this century came from "close-combat" units -- aircrews, infantry and armor. So to protect these troops, America needs to take a closer look at how to prepare them for battle”.
This was how the eminently sensible and recently retired Commandant of the US Army War College, MG Robert Scales, began his address to a DOD conference on combat stress a couple of years ago. At the same meeting, Mark Bowden, the author of Blackhawk Down, told the group "stress seems too polite a term for what those men went through. I think 'terror' is a more correct terminology," he said. "I doubt that anything could fully prepare someone for being in that kind of a situation. … the word 'stress' seems too polite a term for it." Bowden explained. "(In combat,) you face a level of terror that no training exercise can really prepare you for.”

I confess to being disturbed by Bowden’s address. He seemed to suggest that all battle is so terrible no man can be adequately prepared; all will be in some way psychologically damaged by it and all will need expert help to fully recover. This is a message supported by a well-meaning industry of contemporary mental health experts. Implicit in this theory is that the modern warfighter, though generally physically stronger and healthier than his forefather, is not as psychologically robust or suited to the rigors of conflict. I do not accept this premise. My experience has been that many men who endured terrible battles never have felt the need to seek out mental healthcare. (Others, whose exposure to the stress of war has been minimal, have spent years on a couch.) I will accept that in many ways the tempo and intensity created by modern weapons systems and the scope for unfamiliar threats, particularly urban and counter-insurgency operations, are increasing the “friction’ of war and putting new and greater demands on our warfighters. But I am not convinced that urban conflict produces markedly greater incidence of combat stress than combat in other environments. It is the intensity of combat and the weapons used that most affects rates of stress casualties. I also know that many of the young men and women I have met in recent years, have shown just as much “fighting spirit” as their forefathers.

"I am content that the opinion that ‘the problem of the psychiatric casualty is much too serious to be left to doctors’ be attributed to me. Soldiers, unable to get bogged down in the morass of diagnosis and treatment, might be persuaded to concentrate on prevention in which doctors have achieved little success " - Maj Gen FW Richardson L/RAMC 1978

I have argued often that man is more important in war than technology and debated the costs and difficulties of recruiting, training and replacing military people as against machines. It is clear to me there is a deliberate shift in modern military healthcare towards the prevention of illness and injury and away from fixing broken bodies. This ethos should also extend to mental health, in peace and conflict. In the context of readiness we must examine more closely what can be done to prevent, or at least limit the worst psychological effects of armed conflict rather than plan for the inevitability of attempting to fix damaged minds and broken spirits.

I have reservations about the current doctrine, which leans heavily on the medical services and particularly on mental healthcare professionals. It argues from a basis that all will succumb. To suggest that the modern warfighter has no defenses against the psychological impact of conflict seems to set him or her up for failure. Moreover, there appears to be little understanding as to what point education and awareness cross into the realm of over-awareness and expectation of, or justification for failure. “Preventive” measures emphasize the psychological and emotional limitations of the individual warfighter and need for early recognition of breakdown. Its center of gravity and resources lie with the Critical Incident Response Team, a necessary and valuable tool but orientated to mitigation rather than prevention. I am not sure I would go as far as one WWII military physician who thought “ psychiatrists were incompetent to judge normal men because their experience is mainly with abnormal ones. I do, however, agree with Major General Richardson, this subject is first and foremost the province of the warfighter. It is an issue of leadership, selection and training and far too important to be left to health professionals of any hue. Having hopefully stirred up an entire medical MOS, I intend to risk their further derision by reverting to some old-fashioned concepts and language to reinforce my argument.

Courage is the essential quality of the warfighter. As it was at Midway and Mogadishu, so it is in Afghanistan and Iraq and other conflicts in the future. It enabled SOF sergeants to storm bunkers in Afghanistan and will permit the young E3 to face up to an angry crowd in Kabul tomorrow. Courage manifests itself in two forms, physical and moral. We tend to emphasize the physical but the moral is often more important, particularly for leaders, yet it is rare a commodity. Many of the criticisms voiced by junior officers and enlisted about their senior leadership tin recent years, concern the need for moral courage. “Moral courage is the most valuable and usually the most absent characteristic in men” – General George Patton.

Physical courage is present in most men and women and it can be enhanced and eroded by a host of external factors. In the final analysis, courage comes down to the power of individual mind over body. Churchill’s personal physician, Lord Moran, in his famous thesis on the First World War defines it as “ a moral quality, it is not a chance gift of nature like an aptitude for games. It is a cold choice between two alternatives; it is a fixed resolve not to quit, an act of renunciation, which must be made not once, but many times by the power of will. Courage is will power” .

In attempting to depict and understand what causes men to succumb to the stress of conflict, there few who have described it more succinctly than Moran “men only have a certain amount of courage in the bank and that the call on the bank may only be a daily drain or it might a sudden draught which threatens to close the account” The key questions are what factors cause this daily or sudden drain and how can the effects be prevented or mitigated.

“Fear is the common bond between fighting men”. – Richard Holmes. The Firing Line
The major drain on a man’s bank of courage is fear; it manifests itself in many forms and is a perfectly natural and defensive reaction to threat or danger. I would argue that Bowden’s use of the word terror is hyperbole. Terror connotes a state beyond control. I don’t think that those he wrote about were ever at point where they lost self-control. In conflict, fear varies in proportion to real or imagined danger. Most warfighters overcome fear by effort of will and the support of others. Recognizing, understanding and controlling individual fear is an essential part of combat stress reduction. Education and training to achieve this is a subtle and difficult challenge. It is however, not the province of mental healthcare professionals, often with no combat experience, to lecture to warfighters about fear in the abstract. This task is a key leadership responsibility and cannot be abrogated to or assumed by the medics. Certain circumstances magnify fear and increase the drain on the bank. I would put the following factors on my list:

Failure. In nearly all men and women, the fear of failing is a deep instinctive force. In some, this fear that they will fail in combat and let their friends down is a real and disabling stress that must be managed by the leader. For many, the fear of failing will drive them to actions that they would not otherwise consider and has driven men to great acts of heroism. The interplay between courage and fear of failure is complex but they appear essential elements of the “fighting spirit”.

The Unknown. The downside of the human imagination is that it is difficult to control. For the warfighter it is at times an essential tool, enabling him to out-think the enemy. At others, it can plague him with doubts and fears to the point of breakdown. This is particularly so when he or she is faced with something new. Fear of the unknown is most marked when a warfighter is alone and especially at night – modern conflict relies increasingly on warfighters operating alone and at night. This requires psychologically robust individuals who are, above all else, well trained.
“What a man has not seen, he always expects will be greater than it really is” - Onasander 1st Century AD

The Unexpected
It is of first importance that the soldier high or low should not have to encounter in war things which seen for the first time set him in terror or perplexity. – Clausewitz
Surprise is a principal of war. Although good training will lessen the chance of a warfighter being presented with something he has not expected, it is highly unlikely that he will never be surprised. History is replete with examples of what happens when warfighters meet the unexpected: their will crumbles. The key lies deeper than learning the enemy’s weapons and tactics. It requires inculcating upon individual warfighters the need to act on their initiative when faced with something unforeseen. This is a principle that SOF have long adhered to and probably what sets them apart from the average warfighter.
Anyone who has been in combat will tell you it is a very noisy affair. War is about destroying the enemy’s will. Noise is very effective in that it limits the ability to think or act. Even at the battle of Agincourt fought between the English and French in the early 15th Century, before the days of gunpowder, the sound of 5000 arrows every ten seconds and the shrieks of dying horses and men were terrible. Being on the receiving end of a dozen modern 155mm artillery rounds is stunning.
Widespread death and destruction in many cases does not affect the individual warfighter as much as the loss of one member of his immediate group. There is little that can be done to prepare the warfighter except meeting and talking with people who have endured and survived. The physical effects of combat serve to increase the drain on the bank of courage. Fatigue, thirst, hunger, disease and above all the climate can reduce the physical state of a warfighter so quickly his “fighting spirit” is broken. Providing logistic support for the warfighter to insulate him or her from the worst is a vital task, but in the final analysis some degree of “combat acclimatization” is essential.

In the face of these challenges, preventing or at least mitigating the worst effects of combat - the draining of the bank of courage - seems more than a little daunting. I offer only three issues for discussion though I know there are many more.

Trust
"His majesty made you a major because he believed that you would know when not to obey his orders."- Prince Frederick Charles
Trust is the basic building block of leadership and vital tool in overcoming the stress of combat. It is a two-way contract, the leader trusts his subordinates and they in turn trust him; it will not succeed in the long-term as a one-way function. It is most powerful when a leader shows complete trust in his or her subordinates. The strength of the German Wehrmacht in WWII lay in the concept of Auftragstaktik. It epitomizes the precept of trusting subordinates. In simple terms it provided leaders at every level with a “commander’s intent”(what had to be achieved and broadly, how) and relied on individual initiative to deal with the unexpected as it arose.
This very successful way of fighting requires an ethos of risk-taking and devolution of responsibility. It is an essential skill in the very complex environment of Counter-Insuregency Operations where often decisions of tactical and even strategic impact have to be taken at the squad level – what the British call “the Corporal’s War”. The contemporary US military is in general a politicized, risk-averse organization, shaped by doctrinaire field manuals on every conceivable subject and, through the medium of modern IT, over-controlled from the top down. It is highly unlikely that the freethinking, risk-taking, confident young E3 or lieutenant will blossom in this environment. SOF, who pride themselves in the practice of freethinking must strive to maintain independence of thought and action at every level.

Training
“Training had come to an end. There had been twenty-two months of it, more or less continuous. The men were as hardened physically as it was possible for humans to be”. 'Band of Brothers', Stephen Ambrose

There are two generally accepted verities in combat stress management. First, although personnel selection methods can weed out those manifestly unsuited for combat, selection is notoriously unreliable. Second, even the best prepared, equipped and motivated warfighters will eventually ‘empty their bank of courage” if they are subjected to enough stress. (Studies carried out in WWII showed that after 90 days of continuous combat even the best fighters began to deteriorate rapidly). Training therefore has two vital functions in combat stress reduction. It acts as a continuous selection system to further weed out the unsuitable; and it prepares the remainder, mentally and physically, for the demands of combat. But training is only of any value if it is realistic. Within the limits of reasonable safety, it must be both physically and psychologically demanding. It must train and test the individual but also, perhaps more importantly it must test the group or team. Good training will always impact the team and make it stronger. Lack of training and poor preparedness will bring disaster. In his book Band of Brothers Stephen Ambrose describes how the men of Easy Company the 506th, who jumped behind Omaha Beach on DDay were at their peak and almost invincible. In their twenty-two months of training their battalion had gone through 5000 enlisted soldiers to produce 1500 fit for battle. Compare them to the US Army only eight years later in Korea. T. R. Fehrenbach writes, “ the Army of 1950 was physically untrained for combat tasks, emotionally unprepared for its stresses. They had to learn in the hardest school there was, that it was a soldier’s lot to suffer and that his destiny may be to die. They were learning something that they had not been told: that in the world are tigers”. Whatever else the current operations in Afghanistan produces in terms of attrition of the enemy, it is the finest training available.

Teams
“They knew and trusted each other…they made the best friends they had ever had or would ever have. They were prepared to die for each other, more importantly, they were prepared to kill for each other”. - Band of Brothers

History shows that the strongest motivation for enduring combat is the bond formed among the members of a squad or the crew of a weapon system or aircraft. Simply put, warfighters fight because of the other members of their small unit. Most warfighters value honor and reputation more than their lives, because life among comrades whom a
warfighter has failed seems lonely and worthless. The cohesion found in small teams provides shelter from the horrors of battle and enables warfighters to persevere in combat. The team provides the individual with security, the belief that that danger can be overcome, a coping mechanism to deal with the trauma of death and killing and a sense that what the team is doing has meaning. J. Glenn Gray, in his book 'The Warriors', described the real value of the team as both the essence of combat and the key to mitigating stress. “Soldiers have died more or less willingly, not for country or honor, or religious faith or other abstract good but because by fleeing their post and rescuing themselves they would expose their companions to great danger. Such loyalty to the group is the essence of fighting morale”.

Conclusion
I believe there is an urgent need to re-examine the way we deal with the stress of modern combat. The issue is not that contemporary operations will necessarily increase the incidence of stress, it is the way we are planning to deal with the issue. It is dangerous predicate our thinking on the expectation that the modern battlefield will be so overwhelming all will succumb and that the medics will be required to mend huge numbers of broken minds and shattered spirits. There is a clear role for the medic in managing combat stress but it should not be the first line of attack. I believe today’s warfighters are just as robust as their forefathers. With the right training and leadership they will equip themselves every bit as well. The key will be how much we trust them, how well we train them and above all, bonding them together in teams and taking every possible measure to keep them together.

A Modern Leper

2007-02-20T11:55:00.000-08:00

As a middle-aged white man traveling in the eastern border region of Kenya, I am used to being stared at. Adult African men are usually polite and often friendly. Women tend to avert their eyes if you return their gaze; in groups they often giggle when you have passed them. Children in gaggles will regularly call out, muzungu! or kawajia! Swahili and Arabic respectively for white man. Somali kids frequently use the less friendly epithet, galadin! Meaning ‘white pagan’, sometimes it is accompanied by a few lumps of dried goat droppings.

I was therefore not surprised by the patient’s inability to take her eyes off my face when she walked into the examination room. I was, though, disturbed by a sudden look of fear. I was even more troubled when the nurse led her to a chair in the far corner of the room; the girl carefully spread out a plastic bag on the seat and sat on it. Her shoulders drooped; head bowed she stared at the floor. Michael, the surgeon whose clinic I was sitting in on, began to speak to the nurse in his usual quiet tone.

The nurse explained the girl was from a village over the border in Ethiopia. Most unusually she had arrived alone at the clinic the day before (young women in this part of the world seldom travel alone). The nurse had conducted a brief examination and extracted a full story from the young woman; although she was not on the surgical outpatient list Michael had agreed to see her. I sat mute as her story unfolded and Michael interpreted.

Her name was Athar and she was nineteen years old. Her tiny body, curled up on the seat seemed more like a twelve-year olds. In accordance with local tradition, shortly after the arrival of her first period her family had arranged her marriage. She was thirteen years old; her husband was in his twenties. Within a year she was pregnant and went into labor before her fourteenth birthday. Like the majority of pregnant women in Africa, she was to deliver the baby at home. Her mother-in law and other female family members would assist. If there were problems a traditional birth-attendant, with no formal obstetric training or medical equipment, could be called upon to help. The nearest medical facility was days away. Antenatal care was unheard of.

After two days of labor during which her relatives had told her to just keep pushing and her only sustenance was water, the traditional birth attendant was summoned and paid. For three more days Athar endured the excruciating agony of obstructed labor, growing weaker by the hour. On the sixth day the birth attendant laid her on the hut floor and sat on her belly and pressed and pressed. She remembers little more of her ordeal.

Over the ensuing days the terrible pain in Athar’s abdomen began slowly to subside but she was unable to get out of bed. He mother-in law finally told her baby had died. One morning she woke to find to her horror that her mattress wet, she was dribbling urine and she could not control it. The women of her family examined her, held a brief discussion, carried her from the house and laid her on her wet mattress in a hut next to the chicken coop. She was told never to enter the house again.

The months and years that followed were almost too awful and sad to relate. Her incontinence made her clothes and bed permanently wet and despite all her efforts, she began to smell, constantly and terribly. Her husband sent her back to her family he didn’t want her anymore. They too rejected her and banished her to an outhouse. Her childhood friends deserted her and she was soon completely alone, even the village children threw stones at her and held their noses. This was to be Athar’s existence for the next five years; she was an outcast, a modern day leper.

A weaker person might have succumbed to the loneliness and the shame. But Athar was made of stronger stuff. She took odd jobs, mostly carrying heavy loads of wood, and built a hut on the edge of the village. She kept as clean as she could and raised a garden to feed and keep herself strong. She was reconciled to a life alone. One day an erstwhile friend spoke to her. She told of a hospital across the border in Kenya where doctors visited and helped women with her affliction. Now here she was, desperate to be ‘made clean again’.

Michael spoke to her softly for a little while; she raised her head, put back her shoulders and nodded in reply. Her face lit in a smile and I saw in her eyes the strength that had got her this far. Michael had told her he would help her; the first step was to examine her thoroughly in the operating theatre that afternoon. As she stood up to leave I realized the significance of the plastic bag on the chair, this was how she coped with life sitting in her own little puddle. Very carefully she folded in the edges and trapped the fluid to carry it away.

Athar suffers from Vesico-Vaginal Fistula, commonly known by the acronym VVF. She is one of an estimated 2 million young women in the developing world, mainly in Africa, who suffer from this painful and devastating consequence of complications in childbirth. The most usual cause and effect is that the young woman’s pelvis is too small to allow the passage of her baby’s head or the baby is badly positioned and she goes into prolonged obstructed labor. In the absence of trained medical assistance and resources (usually to perform a Caesarian Section) the labor ends disastrously, the baby dies and the mother’s birth canal is badly damaged. Prolonged pressure of the fetal head compresses the bladder against the bony sidewall of the pelvis. Crushed in this way over a period of days, the tissue dies creating an abnormal communication or fistula between bladder and vagina. Sometimes the fistula will be between vagina and rectum, or both, creating a constant leakage of urine or feces.

VVF seems to have been common throughout history, evidence of the affliction has been found in an Egyptian mummy. Once widespread in Europe and America, fistulas were eradicated by modern medical care early in the 20th century. They are still pervasive in the developing world, where malnutrition and stunted growth make obstructed labour more likely, where cultural practices lead to early marriages and early pregnancies and where health care is largely unavailable or extremely limited. It is estimated in Africa alone there are over three million deliveries annually where the mother survives and the complication occurs in about two to five cases per 1,000 surviving mothers; this means about 6,000 to 15,000 new VVF cases a year.

While VVF is devastating, it can be repaired. The surgery is relatively straightforward but each procedure costs about $300 and requires that surgeons be trained in the techniques. This raises two problems. The price is out of reach of most young women and must be performed at no cost, offering little incentive for surgeons to train and work in the specialty. Second, the scale of the problem, up to 15,000 new cases each year, and its distribution, in the under-served rural areas, necessitates a huge training bill, which cannot be met by most health ministries in Africa. As a result, much of the work in VVF in Africa is undertaken by outside organizations, particularly missionary hospitals and NGOs.

AMREF’s surgical outreach service (on which I was accompanying Michael when I met Athar) has provided VVF repair at no cost to the patient for over 20 years. Its service differs from other organizations in that it emphasizes taking specialist care to the remote rural hospitals – some 30 hospitals in Kenya, Somalia, Sudan, Tanzania and Uganda – rather than bringing the patients to specialist centres. AMREF’s current specialist surgeon, Dr Tom Raassen, performs hundreds of cases annually in rural hospitals and has a teaching programme in a number a of major hospitals throughout the region. His aim is to both alleviate the suffering of young women and to create national pools of surgical expertise.

As with most healthcare problems in Africa, the size of the task is beyond existing resources. Dr Ruth Kennedy of the Hamlin Fistula Hospital in Addis Ababa crystallized the debate “…There are more than 100 new fistula cases every day. At the rate we are going and if we have no more fistulas from today on, it would take 400 years to repair the ones that exist today." There must be more effort in prevention. We cannot solve the problem by concentrating all our efforts on fixing the broken.

In 2002 the UN Population Fund (UNFP) launched a two-year campaign to address VVF, through the provision of financial and technical support to train doctors and nurses and provide essential medial equipment. The programme is due to end this year; its impact has yet to be felt in this part of the world. I am convinced that a viable prevention programme must focus on:
• Eleveating poverty
• Educating women
• Educating communities to modify early marriage and end juvenile pregnancy
• Reproductive health education and providing family planning resources
• Building sustainable antenatal and obstetric care resources in rural areas
• Enhancing existing repair capability, particularly in rural areas

Later that same afternoon, Athar was wheeled into the operating theatre. A heft dose of Pethidine had given her a sloppy grin. She was uncomplaining as Michael undertook a detailed examination of the terrible damage to her body. He concluded that whereas the injury was repairable, she should be referred to an experienced specialist in VVF, Dr Tom Raassen, who would be visiting the following month. A few hours later, I watched as Michael explained to her what he had found and what should be done. She chewed on her bottom lip and shed a solitary tear as he told her she would have to wait another month for the surgical repair. A short while later I watched as she carried her little bundle of belongings out of the ward and into the dusty, hot street. What would she do alone in this border town, waiting another month for surgery? I will never get used to the bravery of African women.