Surviving the COVID 19 pandemic: the view from a Ugandan surgeon and epidemiologist

May 12, 2020

     By Duncan Green     

Guest post by Dr. Olive Kobusingye

In managing the pandemic, Uganda seems to have checked many of the right boxes so far. Schools were closed, large gatherings banned, and some form of physical distancing adopted before Uganda registered its first case of COVID 19. The sole international airport was closed on March 23, 2020, a day after the first case was confirmed. Then followed a creeping lockdown – first stopping public transport, then private cars, and finally discouraging all non-essential movement, even on foot.

Tracing and quarantining contacts of those who test positive is ongoing, and seems to have yielded good results. At 79 positive tests and no deaths, Uganda has the lowest number of confirmed COVID 19 cases in the East African region. The majority of these cases have been discharged from hospital, having tested negative at least twice following treatment.

Some would say that Uganda has an unfair advantage – if repeated encounters with Ebola can be called advantageous. Between 2000 and 2014, Uganda experienced four Ebola epidemics, and learnt some useful lessons, so that physical distancing, movement restriction, and contact tracing are not new, at least among the public health community.

But behind this veneer of success is a less rosy story that needs to be told.  

Uganda has one of the largest government administrations per population in the world. For its 41 million people, the country has 80 ministers, 426 Members of Parliament, more than 400 salaried presidential advisors, and layer upon layer of bureaucracy from there down, including a special representative of the president in every one of the 134 districts, called the Resident District Commissioner (RDC). The minimum academic qualification for this representative is a Senior Four certificate (Ordinary Level certificate, two years shy of a high school diploma).

It was to this rather unwieldy structure that the pandemic containment task fell, once it was confirmed that the virus had entered the country.  A national taskforce was hastily put together, headed by a military general. The Ministry of Health which had seemingly wasted 2 months of lead-time jumped into action – barely funded, understaffed, poorly equipped, and heading into a hurricane with no roof over their heads. The President saw fit to entrust the district level management and substantial budget for the pandemic into the hands of RDCs – beginning with the authority to determine who could move, and what patients could benefit from the scarce ambulances.

Within a couple of days of the near-total lockdown it became apparent that most Ugandans were unprepared for the extreme limits on movement. Only vehicles carrying essential personnel and goods were allowed on the roads. Bodaboda (motor cycle taxi) riders were barred from carrying passengers. Movement permits in the form of stickers were issued by the Ministry of Works & Transport. Before the genuine ones were done being distributed, counterfeit ones hit the roads.

Initially, anyone needing to go to hospital was required to call the RDC for permission to use a private car, or for an ambulance to pick them up. The RDCs were totally unprepared for the avalanche of calls, and most either went unheeded, or the promised service was never sent. (Later this was relaxed to enable different modes of transportation to take patients to hospitals.) 

There was instant outcry about the lack of transport from essential workers – health workers, market vendors, and utility services personnel. Doctors were arrested and held at Police Stations because they did not possess the right stickers. Informal workers, such as roadside vendors, cleaners, and porters in markets, were constantly harassed for leaving their homes to come to trading centers, and they in turn complained that if they stayed at home they and their families would starve.

Security agents ruthlessly enforced the lockdown, and in two separate, widely reported incidents, two bodaboda riders were shot, one fatally, for disobeying the lockdown regulations. Many essential workers stayed home for fear of violence at the hands of the security agents. A Member of Parliament found distributing food to poor families was violently arrested and imprisoned. Patients could not get to hospitals, and some died in the community. During the first two weeks of the lockdown at least seven women were reported to have died in childbirth, and another two had still births, having failed to access care.

While all the drama ensued on the roads and in the villages, the really big story was unfolding behind the closed doors of Parliament and would soon spill out into the media, houses and slums. MPs sat – one would hope safely distanced – and passed an emergency supplementary budget. A tidy sum of €600 million was to be borrowed from the European Union by the Executive, and the Legislature quickly obliged. Then the splitting of the money began.

First off, €100 million went to the President’s household as classified expenditure, meaning that it was not open to scrutiny. The President did not have to explain to anyone, ever, what he did with the money. The remainder was shared between the Ministry of Health, the Office of the Prime Minister, Ministry of Defence, the President’s Office, districts, and the RDCs. The story would probably have been hushed up completely, had Parliament not thrown in €5000 for each MP, ostensibly to help with ‘community sensitization’.

Once the media caught wind of the story, things started to unravel. Here was starvation, and the people’s representatives were, it appeared, climbing in bed with the Executive to pocket the bulk of the money borrowed on their behalf. The equally important story of doctors and nurses working without Personal Protective Equipment (PPE) was drowned out in the noise around the money.

The relief food procurement ran into problems over corruption. Some senior officers were arrested and charged with fraud. When the distribution did get under way, some of the food was found to be expired, or otherwise of such poor quality as to be unfit for human consumption. Weeks into the exercise, only a minority of those targeted by the relief have so much as seen the food trucks.

If corruption and an inefficient government were the only problems, Uganda would probably scrape through just fine. But the majority of Ugandans are also too poor to comply with the measures being advocated to fight COVID 19. 78% of the population is under 30, and youth unemployment is above 50%. With an average per capita income of US$800, a large proportion of urban Ugandans have to find food daily, and they could not practice social distancing even if they wanted to. It is hard to ‘stay home’ when home is a one-room dwelling that houses at least five people, with the doorway to the adjacent home only a couple of meters away.

One in every three Ugandan under 5s is malnourished to the point of stunting, and one third of women in child bearing age are anemic. The lockdown’s extreme conditions have the potential to tip many vulnerable people into acute malnutrition. For now, most are simply trying to survive the day, and the lockdown. They are not even thinking about the general election, just ten months away. But if they make it there, at least there might be something coming to them during the campaigns.

Dr Olive Kobusingye is a Distinguished Fellow at the George Institute for Global Health and an A&E surgeon and Injury Epidemiologist at Makerere University College of Health Sciences, Kampala, Uganda. She is the author of The Patient.

May 12, 2020
Duncan Green