Dude Where's My Landcruiser?

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 Elephant in the Sitting Room

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

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

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

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

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

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

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

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

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

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

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