Of Hamlet and Per Diem

‘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

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

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

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

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

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?

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.