Uganda: an uncivil war
BMJ 2005; 330 doi: https://doi.org/10.1136/sbmj.0504166 (Published 01 April 2005) Cite this as: BMJ 2005;330:0504166
- Michael J Westerhaus, masters student in medical anthropology1
Northern Uganda is an unsettling locale. Eighteen years of war has devastated the minds, hearts, and vitality of the Acholi people, an ethnic group who endure life amid the harshest of circumstances. The Acholi people have witnessed 20 000 of their children abducted to fight as child soldiers,1 100 000 civilian deaths, and the migration of 1.8 million people into internally displaced people's camps, with limited health and education facilities.2 Current international aid meets 43% of the amount needed to provide minimal humanitarian assistance. 3 Memories of the peace that existed nearly two decades ago create a pining for the chance to reclaim the culture, fertile lands, and comfort of security.
Institutionalised war
The war in northern Uganda results from a historical tension that has divided northern and southern Uganda since precolonial times. Colonialism institutionalised these differences by dictating distinct occupational roles. Northerners were assigned to military positions, and southerners were given privileged public service jobs. After Ugandan independence in 1962, a series of totalitarian regimes alternately representing northern and southern interests encouraged further animosity between the north and south. This antagonism led to war between the Lord's Resistance Army (LRA), primarily Acholi from the north, and the Ugandan military (UPDF), largely southerners, which continues today.
In early July 2004, as I neared Gulu, a town four hours' drive north of Uganda's capital, Kampala, we passed some camps for displaced people. The tarmac gradually became hemmed in by streams of children moving towards the town for safety at night.
Malaria, tuberculosis, and AIDS
The war has profoundly disrupted the provision of healthcare in Gulu. Malaria, tuberculosis, and AIDS punish without remorse in a setting where drugs and access to clinics evade most people. St Mary's Hospital, Lacor, contains 481 beds that are regularly partitioned among 1500 patients. Fifty to 60 patients inhabit the poorly ventilated tuberculosis ward. A few patients normally occupy the tuberculosis isolation rooms with cases that fail to respond to treatment, a harbinger of multidrug resistant tuberculosis.4
Uganda's world renowned HIV/AIDS success remains foreign to northern Uganda. Militarisation of Gulu has led to the destruction of healthcare infrastructure, rape and prostitution in the camps, the ravaging of traditional Acholi culture, and the absence of parental and societal guidance for children growing up as night commuters. Since 1998, the official prevalence of HIV measured in an antenatal clinic at St Mary's has hovered near 12%, but national prevalence has dropped to 4.1%.
St Mary's holds an HIV outpatient clinic each Tuesday and Thursday afternoon. Six thousand positive patients attend in the course of a year, vying for one of the limited consultation slots and drugs. In the medical ward, AIDS and tuberculosis are the leading causes of admission and death. The patients and staff have waited a long time for the arrival of antiretroviral medications, drugs that US doctors began prescribing in 1996. In September last year, antiretrovirals were finally made available at St Mary's. Combining the efforts of clinicians at St Mary's Hospital and community health workers at a local non-governmental organisation, the treatment project in Gulu aims to provide antiretrovirals for 1000 patients.
Unsettling standards
Spending two months in the HIV clinic at St Mary's Hospital last summer unsettled me. Most unsettling for me was recognition of the ways in which our world settles with grotesque inequality and needless suffering. By settle, I mean to stop short of pushing for structural change, to apply different standards, and in many ways to value human life differently depending on economic status, race, ethnic background, sex, sexual orientation, and age. Settling means permitting ourselves to help up to a certain level and then halting. Upon reaching personal discomfort, it becomes too burdensome or perhaps threatening to push for further change. Settling, in fact, seems to be a way to placate ourselves with having done enough or “our part” in the face of overwhelming suffering and inequality.
At St Mary's, I witnessed how we, the international medical community, health policymakers, non-governmental organisations, and government officials, repeatedly settle in ways that profoundly affect everyday decisions in healthcare facilities around the world. For example, chloramphenicol is provided as an antibiotic to cover chest infections in poor HIV infected patients. Although true that chloramphenicol kills microbes in most cases, it also carries a vicious side effect profile— for example, chloramphenicol induced aplastic anaemia. Nevirapine only combinations of antiretrovirals are available when, again, the side effects can be devastating, as fully understood by patients. I witnessed some sat on their beds, their skin peeled away as a result of Stevens- Johnson syndrome, a severe drug induced reaction that causes necrosis of the skin and mucosal surfaces. Worst of all, their antiretroviral options were exhausted unless they could raise a couple of hundred dollars for second line treatment, unlikely for most in Gulu. In the medicine ward, patients with cryptococcal meningoencephalitis, a treatable opportunistic disease associated with advanced AIDS, slipped into unconscious states, excluded from those considered worthy in the world of access to amphotericin B or fluconazole.
On top of this, well trained Ugandan doctors battled with untenable moral dilemmas of working without the drugs, laboratory tests, and imaging studies that they needed to properly treat patients. Sending patients home to die knowing that drugs exist weighed heavily on the conscience of St Mary's doctors.
SVEN TORFINN/PANOS
Escape from the Lord's Resistance Army took days of fleeing through the bush
Further examples of settling pervade policy decisions about the treatment of disease of resource poor settings. Doctors working in places such as Gulu place great value on treating drug susceptible tuberculosis in HIV positive patients, but believe that treating drug resistant tuberculosis is unrealistic because it is too expensive. These sentiments originate in the formulation of global public health strategies that deem treatment of tuberculosis drug resistance beyond the limits of cost effectiveness. Even though antretroviral therapy became available eight years ago, only now has a consensus of policymakers agreed upon the importance of implementing HIV treatment programs in resource poor settings, such as northern Uganda, where AIDS accounts for 69% of all deaths.5 Also, many HIV treatment programmes purchase antiretrovirals from big pharmaceutical companies, when generic companies could provide cheaper high quality medicines providing treatment for many more people.
As a Harvard medical student, I am unquestionably entitled to keep a free course of post exposure antiretroviral prophylaxis in my suitcase while similar drugs are kept from thousands of people in northern Uganda who actually have HIV. For a myriad of reasons ranging from cost to expedience, gross differences in HIV treatment between wealthy and resource poor settings are tolerated.
In medicine, settling occurs all the time, often at the expense of the poor and at the convenience of those in power. There are many ways that I settle, one of which is through silence. In conversation, I avoid challenging others about HIV/AIDS and global injustice and excuse myself by settling with the notion that “this person has a different world view and won't understand me,” or “this person is just going to get really upset with what I have to say and what good will that do?” Yet speaking out and sharing the stories are essential to creating new policy, raising awareness, and inciting action in others. In my silence, I settle by failing to fully express what I witness as injustice in the world, thereby dismissing a chance to perhaps make life better for at least some. And this is inexcusable.
My time in northern Uganda convinced me that working on HIV/AIDS demands constant mindfulness to avoid complicity with an international order that normalises inequality and suffering. The normalisation of suffering confines far too many people who are infected with HIV to spaces of exclusion and neglect. The collapse of these spaces requires a serious engagement with the ways in which the world settles. How can we move away from settling? We must call for socially responsible business practices in the pharmaceutical world; challenge wealthy nations, such as the United States, to contribute more to the Global Fund to fight AIDS, Tuberculosis, and Malaria; take time to reflect and empathise with what it actually means to live with HIV in a place like northern Uganda; imagine new ways to redistribute wealth and resources; and, most of all, strive to provide the best health care possible in every part of the world. In the field of medicine, we must refrain from settling until a radically different paradigm exists in which everyone has access to quality health care.
Responses published this month
LIFE
Uganda: an uncivil war
Michael Westerhaus (April 2005)
Michael Westerhaus
(April 08, 2005)
4th Year Medical Student/Medical Anthropology Student, Harvard Medical School michael_westerhaus{at}student.hms.harvard.edu
As author of this article, I would like to express discontent with the decision to choose the article title, “Uganda: an uncivil war.” This title was chosen without my consultation. The choice of the word 'uncivil' creates false stereotypes of those living in Northern Uganda as inherently disorderly and 'uncivil' people, a misconception that I was in fact attempting to dispel. Misleading stereotypes of this sort result in ascribing blame for the prolonged violence in Northern Uganda to the Ugandan character, thereby distracting from the international community's responsibility in contributing to conflict and healthcare inequality. In the article, I hoped to express that what is happening in Northern Uganda is in fact very connected to structural factors throughout the world. Finding solutions to the war and the healthcare setting in Northern Uganda requires us to discard views of Ugandans as 'uncivil' and instead appreciate the interconnections of the world that create inequality and conflict.
LIFE
Uganda: an uncivil war
Michael Westerhaus (April 2005)
Ozge Tuncalp
(April 10, 2005)
Postdoctoral Fellow, Yale University School of Medicine ozge.tuncalp{at}yale.edu
As a volunteer who is planning to go to Uganda this summer under the auspices of Uganda Village Project, IFMSA-USA, I found the article really informative, though the district that I'm going to be working is in the southern Uganda.
I would also like to emphasize how important it is for magazines like sBMJ to include such topic. Because, unfortunate enough, people tend to “get used” to events, how horrible they may be, that are taking place over a longer period of time, like the war in northern Uganda or Sudan.
For those who would like to read more on the subject, I'd recommend “The disease profile of poverty: morbidity and mortality in northern Uganda in the context of war, population displacement and HIV/AIDS” by Accorsi et. al, which was published in Transactions of the Royal Society of Tropical Medicine and Hygiene (2005) 99,226—233.
I have no one golden solution to offer, but I really do hope that the war in Uganda will not be a Hollywood movie 10 years later from now and shake us deep within like it is the case with Rwanda (Hotel Rwanda). I am still a firm believer that we, as human race, learn from our mistakes, against all odds.
Notes
Originally published as: Student BMJ 2005;13:166