Are we dragons? Can we shed our scales?

It’s 4:00am

“Doctor, please come now”

I sleep not very well on a bamboo mat in our most remote health center Pwunu Dyang. The rain starts pounding on the roof, and soon also on my conscience.

Midwife Scovia has fear in her eyes and since I know how tough she is, her fear soon becomes mine too. To cut a long story short, Lucy* is in labour. She had 4 previous cesarian section operations to remove babies from her womb, so there’s no way Scovia can safely deliver her baby in the health center. If Lucy doesn’t get an operation in the next few hours, her womb might rip open and kill her and the baby.

Except that the hospital which performs the operation is 4 hours away

And the road is close to impassable, even on a motorcycle

And the rain pours

And its 4:00am

But we can overcome these challenges. Scovia’s husband had hired a motorbike for a couple of days, and is willing to brave the rain and the road to take Lucy to a halfway point, where she can catch a NGO ambulance the final two hours to the hospital. You might scream “how can a woman in labour with scars on her uterus travel two hours on the back of a motorbike on terrible road?” To which I can offer only an insufficient answer.

Because she must

But one challenge remains – Lucy has no money. And the motorbike transport needs money, as does the ambulance driver. She needs about 20 US dollars in total, not a huge amount even here but still money Lucy doesn’t have. But this time everything might just be OK, because the rich white man is here. The rich white man who can pull 20 bucks out of his pocket and not even notice it has gone. The rich white man who 10 years ago used to earn that 20 dollars in a mere half an hour. The rich white man who used to earn the same amount in a week as our incredible midwife Scovia who’s skills might save Lucy’s life earns in a full year of hard work.

This dragon who hoarded his wealth, is about to flick one of his thousand gold coins towards a suffering mother who might then survive the day. Should this dragon feel good about that? Am I somehow a good person because I “helped” someone with 20 dollars?

Midwife Scovia and Nurse Alfred staff the amazing Pwunu Dyang health Center

$#!%loads of money in this world

There’s Ugandan book that you can buy on the bus and in the market entitled “Why have you chosen to be poor when there is so much money in this world?” That could be a good question, if it wasn’t for the “chosen” part and the poverty shaming (we’ll get to that). There is in fact $#!%loads of money in this world, more than enough to go around. The per capita GDP on this humble earth is US$11,000 a year for every woman, man and child. With some change in our global systems we could all happily live on that much money. There’s more than enough money in this world to transport this woman to hospital. More than enough even to transform the healthcare infrastructure so that her transport and healthcare could be free.

But unfortunately that won’t happen tonight. The $#!%loads of money does not reach midwife Scovia, let alone labouring woman Lucy. And why is that?


Because we are dragons

A lot of us are dragons of various sizes, hoarding our wealth as we build our personal or family empire. Us dragons pour our money into bigger and bigger dragons dens (houses), bank accounts with many zeros and the kind of lifestyle the other half of the world can only dream of.

And the dragon problem is getting worse. Inequality during the pandemic has skyrocketed across the globe. In America during the pandemic, the top 1% of Americans looted an incomprehensible 50 Trillion dollars from the bottom 90% of the population. Those dragons must need a massive cave just to store that much gold. An estimated 300 new HUGE dragons (billionaires) were also spawned during the pandemic, on average one a day.

Many of us smaller dragons in Western countries like to take aim at much bigger dragons like Bezos and Musk, who to be fair are twisted enough to fly into space for fun while a global pandemic rages. Instead of cavorting into space, those two could have paid to vaccinate the whole of Africa for coronavirus by now*.

But I digress, because we are indeed dragons too, not just Jeff and Elon. Most of you reading this are rich, perhaps richer than you realise. If you own assets worth more than just $90,000, you hoard more gold than 90% of humans. If you have just $4000 of assets to your name, you are richer than half the people on the earth. I’m not saying this to evoke guilt, only to bring us to the realisation that yes, you and I might just both be dragons.

How did I become a dragon?

Well most of it was probably chance. There may have been sound decisions and hard work along the way, but your path to a healthy hoard was largely decided even before you were born. You won the lottery, congratulations! Or perhaps more accurately a series of lotteries. Two lotteries define the lions share of how rich we will become. Your birth country, and your parents’ wealth

Lottery 1: Your birth country. For me I spun New Zealand, and straight up won the lottery. Your birth country usually has the biggest effect on how much money you will be able to earn and save. A minimum wage earner in New Zealand might not feel lucky because they will understandably compare themselves to their richer neighbours. But by age 40 or 50, many minimum wage earners in New Zealand will find themselves in the top 10% of the world’s richest people. Even an unemployed New Zealander has a higher living standard than our amazing midwife Scovia, who is tertiary educated and gainfully employed but earns just $120 a month. While unemployed in New Zealand though, you will probably live in a house with more than one room (Scovia has a hut), have running water, electricity, free high quality education for your kids, free healthcare and perhaps even a car! I’m yet to meet a Ugandan nurse who owns a car.

Lottery 2: Your parent’s wealth. Even here in Uganda, if you are born to the tiny percentage who are rich, you will have a decent chance to amass a healthy hoard. While Uganda isn’t rich enough to provide your children with the ingredients for financial success, the good education and healthcare your children need can be bought. Even in richer countries, it has been demonstrated that you are better off being born rich than having ability or talent. In the lead author’s words

People with talent often don’t succeed. What we found in this study is that people with talent that come from disadvantaged households don’t do as well as people with very little talent from advantaged households.”

Lottery 3, 4, 5 etc.. Your race, gender, orientation, neural make up and countless other dice were also rolled before you were born that might affect your potential to stash cash in this harsh world.

The lotteries of life are real. So perhaps we should not feel too guilty about our dragon status, because it mostly happened due to factors outside of our control. For the same reason we shouldn’t be proud of whatever hoard we have amassed. Much of the reason we are rich was probably because of our favourable background, more than our back breaking hard work. For the most part we don’t “choose” to be rich or poor, the lottery decides.

But can we shed our scales?

So what can we do about it? Can we shed our scales? I’m not going to espouse my personal opinions on potential systematic changes like tax or universal basic income, but instead focus on three steps all of us dragons can take to change ourselves and shed our scales.

1. Realise you are a dragon. This may be the hardest step of all. It’s tempting and easy to tell ourselves and others that we are in fact one of the financial strugglers, usually by comparing ourselves to an even richer dragon. I’m afraid there’s always someone richer, unless you are Jeff. Once we realise though that we actually do have a $#!%load of money at least by global standards, we are set free to do something about it and take steps 2 and 3.

2. Disperse your hoard. Whether through personal connections or high impact charities, it might be time to start dispersing your hoard. If you’re interested in the best ways to give money to make the biggest difference, check out this thing I prepared earlier. You won’t be alone, giving away large amounts of money is no longer longer a fringe or religious activity. Through the movement “Give What You Can”, over 7000 people (many very young) have pledged to give at least 10% of their income to effective charities for the rest of their lives – a beautiful commitment.

I also want to personally thank a growing group of insanely generous partners and friends who have given away huge portions of their stash, often thousands of dollars at a time towards launching health centers in remote places like Pwunu Dyang through OneDay Health


3. Shift our future focus
from stashing gold, to making a better world. We are so blinded by all our dragon friends with their huge hoards, we feel the need to keep up with the Jones’s by making our hoard bigger and bigger and BIGGER. When we realise we have more than enough to thrive, we can choose to change our life’s trajectory. Whether it’s through choosing a job which makes the world better, volunteering for charity or our struggling neighours, or even earning lot’s of money for the express purpose of giving it away, there are plenty of ways we can shed our scales or at least become better dragons. Be inspired by Gandalf, who knows a thing or two about dragons.

“I wish it need not have happened in my time,” said Frodo. “So do I,” said Gandalf, “and so do all who live to see such times. But that is not for them to decide. All we have to decide is what to do with the time that is given us.”

And while the committed, talented, skilled and grossly underpaid Scovia rushed around to orchestrate the saving of Lucy’s life, I put my head in my useless hands and cried. I cried at my own iniquity, I raged at the unequal, unfair and unnecessary state of this precious earth we call home, but in the end I allowed myself more than a sliver of hope.

“Well, he peeled the beastly stuff right off … And there was I as smooth and soft as a peeled switch and smaller than I had been… and there it was lying on the grass: only ever so much thicker, and darker, and more knobbly-looking than the others had been. Then he caught hold of me – I didn’t like that much for I was very tender underneath now that I’d no skin on – and threw me into the water. It smarted like anything but only for a moment. After that it became perfectly delicious and as soon as I started swimming and splashing I found that all the pain had gone from my arm. And then I saw why. I’d turned into a boy again…”

Dragon Eustice has his scales shed – C. S. Lewis, The Voyage of the Dawn Treader 


* Lucy is not her real name
* Conservative estimates of over 7 billion dollars spent by Bezos and Musk on their space race would have been enough to buy enough to vaccinate the 1.4 billion Africans twice.

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Nick on a podcast! Global Health, OneDay Health and Coronavirus in Uganda

A few years ago, Sofia offered to help OneDay Health with the non-glorious, time consuming task of counting huts to help estimate population of healthcare black holes. She’s now running a blog and podcast on the Harvard Public health review, and we had a great wide ranging conversation about local health, global health, OneDay Health and a bunch of other stuff

Here’s an overview on different parts of the conversation – feel free to dip in to a few minutes that you’re interested in!

1-7 mins: What Tessa and I are are up to in Uganda
8-9 mins: Early response to coronavirus in Gulu, Uganda
10-18 mins: Community health and Global health
18-35 mins: The OneDay Health story and reflections
35-40 mins: Coronavirus lockdown and uganda
40-46 mins: Inequality in corona vaccine rollout
47-48 mins: Nationalism and money wastage challenges global health efforts
49-50 mins: What can anyone do to help in global health?
50-54 mins: “Preferential option for the poor” – what drives our work

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Four Angels: Lessons about Lockdown

I woke up on Saturday morning not expecting a lesson. I had hoped for a quiet, restful morning and was annoyed that my time and space kept getting interrupted. I had no clue that I was about to get schooled on the reality of coronavirus lockdown, even less by four angels who by midday reduced me to tears.

Angel of the children
Anena’s* smile was so big, I struggled to get grumpy when she knocked on the door. She came to read a book with us, the only semblance of formal education in her life right now. She struggled to read the five word sentences, but was delighted to finish the book and take a new one home.

But reading the odd book with a couple of try-hard non-teachers isn’t going to help Anena learn what she needs to get ahead. Under lockdown, young children haven’t been at school for 16 months, which will hold back the futures of some, and decimate the futures of many. We pray Anena will only be held back.

3 Cool Cats, none of whom have been at school for 16 months and counting…

Angel of the young women
16-year-old Priska has piles of responsibility. She cooks, looks after her younger siblings while earning some money on the side. That’s why we met on this fateful Saturday morning – she washed clothes for us for some extra money. But when school is off, and every teenage girl and boy in the community is at home, you can imagine what too often happens. Although data is scarce, one report from Comboni Samaritans estimated that almost 18,000 girls between 12 and 17 became pregnant during lockdown.

And like many kids here, even before coronavirus Priska had already missed a lot of school. She’ll be around 20 when she’s finished primary school and chances of secondary school are slimmer than ever. Coronavirus lockdown could well be the last nail in the coffin, ending her chances of further education.

Angel of the sick
Id never met Angela before, as she walked up to the door with one leg, and one old crutch. Her 9-year-old daughter was next to her, not looking too well. It turns out they were both sick. Malaria had been multiplying in her daughter’s blood for 3 days, while Angela wondered how she would scrape together the two dollars required to get tested and treated. Fortunately, I had some malaria tests and medication and was able to help her out this time.

Sick people with little money struggle even more under lockdown. Many street sellers, transporters and market vendors have lost their source of income, and therefore have lost the ability to pay for healthcare. In the village it’s even harder, as transport has been restricted and motorcycle taxis risk beatings by the police as they carry the sick.

And if you have a serious illness like heart disease or cancer, I have no idea how you’ll manage to get to Kampala, the capital, for treatment. Your chances of survival are slim.

Angel of the working poor
At 25, Omiya’s life already could be the opening scene of a movie. Through grit and determination, he supported his brother through school and built homes for his family – despite being an orphan who didn’t complete primary school himself. Despite being unable to read or write, he overcame the odds to complete a carpentry qualification and has just now built a simple workshop out of wood offcuts and used iron sheets. Within weeks he had filled a few orders and things were looking good.

And then lockdown hit

“Cene dong pe ba.” – “There’s no more money”. Today was only the second time in seven years that Omiya had run out of money. Carpentry orders had dried up, there are no odd jobs around and he’s out of luck providing for his wife and young child. Make no mistake: if Omiya was born in New Zealand, he would have achieved more than we ever could. He just happened to lose the geographic and socio-economic lottery and so here we are, on an extraordinary Saturday morning with a hard-working and enterprising person asking us, his lucky, rich, Western friends, for help.

The lockdown will devastate the working poor

After Omiya left, my self-indulgent grumpiness finally melted. The reality of the four angels sunk in and tears started flowing. My expectations of a quiet and relaxing morning had led me to miss the gravity and reality of lockdown all around me, and I had failed respond with the kind of love required.

Perhaps too late, the voice of God finally broke through a stubborn heart.

“Forget not to show love unto strangers: for thereby some have entertained angels unawares.”



*Names used are not people’ actual names to preserve privacy.

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What is Kindness? Is Jacinda Ardern really kind?

When our much vaunted, Nobel peace nominee leader Jacinda Ardern campaigned in 2017, she preached a beautiful, counter-cultural message. When asked the qualities that underpinned her path to leadership, she responded with

“Kindness, and not being afraid to be kind”
“I want the government…. to bring kindness back”

But is Jacinda really kind? And what about you and I?

Kindness is complex. I wish it was as simple as smiling at your neighbour and baking cookies for your friend (which is a great start), but the rabbit hole runs deep. I use Jacinda Ardern as an example, first because she has claimed the high ground of kindness, and second because her actions as prime minister are plain to see. At the end of this musing I hope you’ll ask yourself the same questions I’m asking myself right now

“How kind really am I?”, and more importantly “How can I do better?”


Three levels of kindness

To help us think about kindness, I propose three levels of kindness. We start at level one with interpersonal kindness – kindness to the people we meet along our road. Our families, our workmates, the homeless person we pass by every morning. Level two is kindness to our wider community. People we may never meet but who share our supermarkets, schools and tax code. And third, kindness to people far away in space and time. People we rarely consider – those on the other side of the world, and those born in the future. This three level framework is a flawed model with ambiguity and overlap, but perhaps it can help us to understand the complexity and depth of human kindness.

Three Levels of Kindness


Level One – love your neighbour

On March 15th 2019, A gunman walked into a Christchurch mosque and murdered 51 people. In the midst of the anguish, Jacinda’s response was incredible. She listened to the victims, cried with them and embraced them with her arms, words and actions. An iconic picture of her embrace with a victim’s wife captured her kindness, empathy and compassion while sending ripples around the globe. Jacinda displayed incredible level one kindness, the kindness we show directly to our neighbours, our families and the suffering people we meet on the way.

Jacinda Ardern is an expert practitioner of level one kindness. You can feel it in the tone of her voice, her warm smile and well chosen words she speaks through every crisis.

Level one kindness is the where the rubber in our heart hits the road. It’s not easy to be kind to our neighbors and those we meet on the road of life. It takes effort, empathy and time. But there is rarely a large price to pay for level one kindness. Jacinda can be kind to those suffering from a crisis without hurting anyone, unlike the next two levels of kindness where something has to give. To achieve level two and three kindness there are personal, financial and political prices to pay. I would argue that for politicians, level one kindness is important, but is the least important of the three levels, because the job of a country leader is to be kind to millions, not just a select few.

Level Two – Kindness with a cost

Level two is kindness to our wider community – people we don’t know and may never even meet. People who share our tax code, our hospitals and our schools. We display level two kindness when we pick up rubbish, pay our taxes and vote with our whole community in mind, not just our selfish ambitions. But level two kindness often has a tradeoff. We sacrifice our money when we pay tax and vote for higher taxes. Picking up rubbish can be pretty gross and time consuming. Also, level two kindness often goes unrecognized. People will never  know if we’ve put all our rubbish in the bin.

For politicians, level two kindness even harder. In order For a politician to be kind to the wider population, they usually have to harm some people. Truly “win win” policies are rare. Leaders ask (or force) one group of people to sacrifice something for the benefit of another. You harm one group, to help another. When we practice level two kindness, we hope that the total good will exceed the smaller harm to some people. I’ve visually represented this below, with the greater good eclipsing the necessary smaller harm.

In some areas Jacinda has demonstrated admirable level two kindness. The most obvious is the Covid-19 lockdown. She made the hard decision to harm some people, to bring about a greater national good. The lockdown decimated tourism, with many businesses forced to close, in order to keep the virus out. Families have been separated in order to keep the virus our. We went into recession, in order to keep the virus out. But the benefit of keeping the virus out was far greater than these harms.

On other occasions however she has refused to display level two kindness. New Zealand is in the midst of a housing crisis, with house prices among the most expensive in the world and rents skyrocketing. Fixing the crisis requires bold Level two kindness, as Jacinda would have to harm richer home owners, sacrificing political support in order to lower house prices for hundreds of thousands of poorer New Zealanders who are struggling with the skyrocketing price of property.

In 2019 a Tax working group recommended that the government implement a capital gains tax which might have helped stabilise house prices. Jacinta refused to implement the experts’ recommendation, with full understanding that she was rejecting level two kindness for political gain. To her credit, she even conceded that she was not doing the right thing for political reasons.

“Under my leadership, we will no longer campaign for, or implement a capital gains tax – not because I don’t believe in it, but because I don’t believe New Zealand does.”

Jacinda understood the right thing to do – implement the tax. But to use her own words against her, she was “afraid to be kind” because of the political and personal cost. I respect her intellect and honesty, but don’t respect her making the unkind decision.

Level Three Kindness – Fight injustice from afar

Scott Morrison, the prime minister of Australia has been criticised for not being kind, some seeing him as an antithesis of “kind” Jacinda. But in the last year, he has been world leading with astonishing level three kindness that harmed his own people, to the tune of over 3 billion dollars of lost business, in order to do the right thing for people suffering on the other side of the world. The perhaps genocidal treatment of Uyghur Muslims by the Chinese government is arguably the largest scale human rights abuse of our time. With over a million Urghurs locked up in “re-education” camps, tens of thousands undergoing forced labour and evidence of forced abortion and sterilization, the treatment Urghurs by the Chinese government has been described as the largest incarceration of an ethnic group since the holocaust. World leaders haven’t done enough, but at least leaders like Boris Johnson, Donald Trump and Angela Merkel openly condemned the Chinese AND put some sanctions in place.

The real heroes though are the Australian government, who were among the first to speak out strongly against the Chinese government, and have suffered severe backlash from the Chinese including 100% to 200% tax on Australian wine imports. The Australian government is causing their own citizens to suffer a little, in order to fight injustice abroad.

On the other hand, Jacinda Ardern has been one of the least kind world leaders to the suffering Uyghurs. Her pathetic statement that the situation is “an issue of grave concern” and her lie “I don’t know what could be stronger than raising it face-to-face with the leadership in Beijing” (how about sanctions or far stronger public words) illustrate the famous concept All it takes for bad people to prosper is for good people to do nothing”. She has chosen political and national financial gain over kindness to millions of people she will never meet. How can someone who professes to be kind, ignore what is perhaps the greatest human rights abuse of our time? As a New Zealander I’m ashamed to be part of this unkindness.

Fighting climate change is perhaps the ultimate test of level three kindness. Action to prevent climate change primarily affects people who haven’t been born yet, and that’s not easy for politicians. It’s not easy to harm people who are living now, in order to do good to humans who don’t exist yet. People who haven’t been born can’t vote for you! Unfortunately there is no alternative – almost every policy we use to fight climate change does economic harm now, in order to safeguard our future.

On climate change Jacinda has failed the level three kindness test. New Zealand isn’t a world leader on any climate change front. Our carbon tax is pathetic, we barely regulate farming (our biggest emitter) and we are 10 years behind the rest of the world on electric cars. Much maligned ‘Murica just pledged a far more ambitious carbon reduction target than New Zealand’s. Indeed it is hard to find a developed country doing less to combat climate change than New Zealand. The problem again is that Jacinda would have to hurt some people now in order to safeguard future generations – a kind of kindness Jacinda doesn’t appear to possess.


Level 1000 kindness – Love your enemies

As a final note, there is a level of kindness which extends beyond these three. A level that we rarely (me included) reach. Far harder than being kind to our friends, building a generous welfare system or even fighting injustice around the world is loving our enemies. if even a significant minority of humanity were to reach this level of kindness, our world would look very different.

Can we learn to love our enemies – our annoying workmate, our extortionate landlord, or those far right/far left “idiots” we despise? It’s easy to say “well that’s just not how the world works” (which is true) but it’s harder to be part of changing how the world does work. While those across the political spectrum use free speech and cancel culture to punish their enemies, there are ways to love those we hate, and bridge divides. We have role models like Deeyah Khan, the Muslim film-maker who engages face to face with the very Neo-nazis who persecute her, and has even compelled some to abandon their hateful ideology. The only time Jesus tells us to be perfect is when he commands us to love our enemies – that level of kindness has no parallel. 

So here’s the challenge not just for Jacinda, but for all of us. How are we doing at all levels of kindness? How kind are we to people we meet along the way? Do we consider our wider community with our actions, and what about those around the globe or future generations who haven’t been born yet? Is there even a way we can be kind to the person we hate the most?

“I tell you, love your enemies. Help and give without expecting a return.

You’ll never, I promise, regret it”

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NGOs should only do one thing

As a rule (with VERY few exceptions), NGOs should do one thing, one activity and do it well. Most household NGO names do the opposite, but many great NGOs out there both large and small do one thing very well and have enormous impact.

The Against Malaria Foundation distribute mosquito nets. GiveDirectly give cash transfers to the poorest people. Doctors without borders provide quality medical care in unstable areas. They do one thing, do it again and again, and do it well. On the other hand, most big NGOs do a large range of unrelated activities and usually don’t do many of them well. Here’s a couple of screenshots NGO web pages, where they outline their large range of unrelated activities.

So why should an NGO avoid doing so many activities? Why shouldn’t an NGO mix in some education projects, drilling boreholes and agricultural trainings? To be Effective, NGOs should display the 3 Es Expertise, Experience and Efficiency – and unfortunately these 3 Es are impossible to achieve over a wide range of activities. And to add the icing on the cake the Evidence backs up the theory that the best NGOs only do……. one thing.

  • Expertise: Any organization that does a wide range of activities will at best be a jack of all trades and master of none. NGO workers here in Northern Uganda constantly work in areas where they have no formal training – they try hard but are not experts. In the morning an NGO worker with a general degree in development studies might train people how to run a savings and loans group, while in the afternoon they run a focus group on domestic abuse. The next day they try and teach poor farmers the best way to plant maize. These NGO workers are experts at no part of their daily job. They are neither accountants nor counsellors nor agriculturalists, but they are forced do an average job in all those areas. NGOs do hire experts (often temporarily) to assist and run their programs, but this is far from universal.

I’m a doctor, and once attended a “training” on malaria partially run by a guy with a degree in public administration. It was terrible, the poor guy tried hard, but how could someone with no expertise expect to teach medical professionals? We wouldn’t tolerate this in developed countries, why do we tolerate it in Uganda? An NGO can’t maintain expertise in a range of unrelated fields

  • Experience: You trust Macdonalds (maybe) to make you a burger because they’ve made billions of them and have built a reputation. Whatever we think about Macdonalds, they are experts at making cheap burgers. Lionel Messi is the best football player (maybe) in the world not just because he has talent, but because he has played football for over 20,000 hours. He has a wealth of experience at doing one thing well. Macdonalds isn’t about to start up a hairdressing chain, and neither is Messi going to start playing professional tennis.

The same goes with NGOs. I trust Doctors without Borders to provide top quality medical care in conflict situations because their operation is run by experts who have experience doing it many times before. Doing the same thing over and over again is the only way to gain real mastery. To learn what works and what doesn’t, to become more efficient, to become the best. This doesn’t mean that an NGO shouldn’t change and adapt gradually all the time and even branch out to related activities, but it does mean that the same NGO shouldn’t do a spattering of wildly different things, like mediate land conflicts today and teach sewing tomorrow.

  • Efficiency: When you aren’t an expert at what you are doing and you don’t have a lot of experience, you waste your donors’ time and money – your work is inefficient. You set up projects and perform activities slowly and inefficiently. A recent 5 year multi million dollar project here supported health centers to deliver high quality maternal health – a noble goal. Unfortunately the project took over a year to set up and only actually supported health centers for 2.5 years – half the total project time. The project was doomed to be inefficient from the start, because the organization running the multi-miilion dollar project wasn’t an expert healthcare provider. They had to start from scratch, build a team, hire experts, consult consultants before even getting started.

Healthcare initiatives should only be run by healthcare focused organisation which already provide quality healthcare. Education initiatives should be run by education focused NGOs which which already provide quality education support.  When the Against Malaria Foundation” distribute mosquito nets, they don’t waste months and millions of dollars planning and developing the project. What they do isn’t a project at all, it’s their regular work They have distributed nets times before countless times. They know what to do, know the challenges they will face and how to overcome them. They have expertise and experience, which makes them efficient and they don’t waste stacks of generously donated cash.

  • Evidence: The highest rated NGOs do only one thing. If you aren’t convinced by these arguments, then look at the evidence. I love the adage “An ounce of evidence is worth more than a pound of theory”. Givewell are the biggest organization that looks at which charities are the most cost effective* – charities that do the most good for each dollar they spend. ALL NINE of their top charities , and ALL NINE of their standout charities , do only one thing, and do it well. That’s right, all 18 charities which made their cut, do one thing, do it again and again, and do it well. Keep in mind though that Givewell only rate large NGOs, so many small organisations may also be highly cost effective, but don’t meet their size threshold for assessment.

So when the pitfalls of doing many things badly are so clear, why do most of the most of the biggest NGOs do exactly the opposite? Why do they continue to do many different activities poorly and inefficiently, wasting lots of money?

  1. NGOs follow the money. One major reason NGOs do many different activities, is to chase funding. Every year, the mood of major funders like USAID and DFID changes. One year a funder might give 10 million dollars to agriculture projects, but the next year 5 million to  healthcare projects and 5 million to climate change. To access all of these pots of money, your NGO has to have activities in all of these areas. You need an agriculture project AND a healthcare project AND a climate change project. Right now in Northern Uganda, money had been flooding in for agriculture and climate change mitigation, so NGOs (large and small) scramble to design projects to access that cash even if they have no expertise or experience in the are. On the other hand If your NGO specializes in only one activity, you limit the money you can access. Unfortunately, doing a whole lot of activities badly can be a better way to raise money than doing one very well.  
  •  “Holistic help” is a better fundraising story than doing one “boring” activity. Stories can be dangerous. Saying “We bought Filder a school uniform, gave her food ever day and paid all her school fees, now she hopes to become a doctor” makes a better story than “we handed out deworming pills to 10,000 school children”. Even though handing out the deworming pills might actually be a better way to spending money helping more Filders become doctors.

    Stories that show you’re helping the whole person, or even the whole community bringing about “holistic change” sound wonderful and attract funding, but as charity evaluator Givewell showed with their assessment, holistic approaches don’t work as well as focused ones. You’ll help childrens’ education more by deworming 1000 schoolkids, rather then buying 10 kids a uniform, books and pens. You’ll improve childrens’ health more by giving out 200 malaria nets, then by providing 10 kids with a “holistic” combination of health talks, nutritious food and vegetable seeds. The story isn’t as good, and it goes against our instincts, but we should beware the dangerous “holistic” narrative.

So where should I give my money?
My message is simple. Give to NGOs who do one thing, and do it well. This means staying away from many household NGO names. Most big charities have fallen deep into the pattern of doing a wide range of activities, and are horribly ineffective and inefficient. This doesn’t necessarily mean that you should only give to the large “Givewell” charities however. There are many other smaller organisations, for example here in Gulu Uganda our own OneDay Health (blatent plug) which provides remote healthcare in remote areas, and a fantastic literacy NGO Read4life that have proven they know how to help kids read, and could use your support


What if my NGO already does many activities?
If you’re still doing a wide range different activities, the time to start changing is now. Figure out what you are really good at and focus on that. Work on shifting from an organization that does an average job at 10 things, to an organization that does great job at one (or at least a few) activities.

As always, am super keen to hear your feedback and have a conversation in the comments, on facebook, or through e-mail (which you can findin the “contact” section of the blog”

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Grateful for my 2020 life – believe it or not

Many of you had little to be grateful for last year – my heart goes out to you. To those who lost loved ones, your jobs, or even your motivation to keep going, I pray that this 2021 brings renewal and joy. We mourn and laugh together.

I was fortunate enough to have much to be grateful for despite the challenges. I express this gratefulness with some trepidation. Not out pride or competition, but perhaps to spark at a little joy and hope for the year ahead. I am grateful for so many things in 2020. Here are 7.

Grateful for our home, – simple by New Zealand standards, while opulent in the eyes of many Ugandans. Just being at home can fill our cup. “For the homeless and the cosseted, may your home be simple, warm and welcoming”

Grateful that coronavirus largely spared the poorest region on earth. Here in sub-saharan Africa (besides South Africa), coronavirus hasn’t wreaked havoc. It’s rare to have a global tragedy where the poorest suffer less than the rich, but the respite is welcome.

Grateful that we launched 11 OneDay Health Centers this year, and extend healthcare to tens of thousands of people in remote places. I’m Especially grateful for Emma in Gulu, Josephine in Kitgum and Innocent in Lira who overcame dead months and transport challenges to achieve remarkable things.

Innocent and Fiona launch Chwagere OneDay Health center, which in just 3 months has treated 500 patients

Grateful for my inspirational wife, who will again tomorrow bike 100km on dirt roads to help remote communities both keep their only home, and aspire towards an unlikely but beautiful peace. Blessed are the peacemakers, for they will be called children of God”

Grateful for the overflowing generosity of people who thought beyond themselves during a crisis to give even more than we needed to live here this year, and to support launching health centers, building health centers, peacemaking and co-vid relief. You know who you are.

Grateful for our nurses Elec And Acire, who overcame enormous odds to work with the community and build a beautiful new 4 room health center in Pwunu Dyang. The community now boasts the most remote health center in the Gulu sub-region, more than 4 hours travel from town.

Grateful for one of the best holidays I’ve had in years, with a bunch of fine people who both think and care deeply about the people around them.

Grateful for discovering John Mark Comer, a spiritual teacher who has sparked new insights into our world, our culture and the sorry state of my own heart. I’ve realized more than ever the need to work first on myself, before I leap too fast to judge others.

love your enemiesbless those who curse you, do good to those who hate you, and pray for those who spitefully use you and persecute you

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The WHO is promoting meaningless human rights abuse in Uganda – in the name of corona.

All around Uganda, people with asymptomatic and mild coronavirus are being locked up in “isolation facilities”, which achieves nothing and endangers the health of both those with coronavirus and the medical staff looking after them. This must stop now.

This is more than just a blog, it’s a plea to the WHO and Ugandan government to stop abusing the human rights of innocent people with coronavirus in isolation facilities around Uganda. People with no symptoms or mild symptoms should be immediately released from the forced isolation centers around the country. In particular the hazardous Namboole stadium which could hold over 1000 people inside should be immediately closed, and the poor people allowed to isolate safely at home

I’m calling out the WHO specifically, because they support the “institutional isolation” initiative both passively through their institutional isolation policy, and actively through membership on the Uganda National Task Force, the body which has instigated this policy in Uganda. The WHO should know better than this, and should not be supporting the policy but rather actively campaigning to stop it. There are at least two fairly obvious reasons why institutional isolation is such a disaster here.

First, the isolation centers are useless, because they don’t slow the spread of coronavirus in Uganda. Second, those with corona are put at higher risk of complications and death and Third, this policy unnecessarily burdens and endangers healthcare workers.

1. The Policy Is Useless

Call me captain obvious but any policy designed to reduce coronavirus spread, should meaningfully reduce coronavirus spread. Nowhere have I seen the flow of thought as to how this policy can help the coronavirus situation in Uganda. Perhaps the WHO and Ugandan government wants to appear like they are acting, even while said action is useless. At first thought, locking people up with corona seems like it should help stop the disease spread but it doesn’t take much investigation to reveal that nothing is achieved.

The reason institutional isolation achieves nothing in Uganda, is because the vast majority cases in Uganda are still out there in the community and never get tested. This is because the number of daily tests in Ugandda is only enough to capture a small percent of all coronavirus cases. Uganda averages around 3500 tests daily, which has barely changed in the last 2 months even as the outbreak has exponentially grown. it’s difficult to secure a test even for sick patients with typical symptoms. As a doctor I’ve failed twice to secure people tests, even while they were sick with typical symptoms.  If anyone at home has typicalsymptoms and wants to test, there’s no pathway to a test unless you have lots of money.

Isolating a small minority of cases in quarantine is therefore a pointless endeavor, when most people with covid have never been tested. It’s impossible to accurately estimate the tiny percent of cases that actually test positive here, but I’m going to try. To estimate the proportion of those with covid who are actually testing positive, and being locked up we need to know the daily deaths and mortality rate of coronalvirus.


The ministry reports the number of daily deaths. This month in Uganda, we’ve had on average 1.3 deaths a day reported in Uganda. There will certainly be some covid deaths not picked up, but I’m going to be conservative and use the ministry’s official figures. The mortality rate however is harder to guess, so we’re going to have to rely on surrounding countries. Sub Saharan African countries have a super low Covid mortality rate, which has been estimated in these 3 countries below based on the percentage of the population which has covid antibodies when randomly tested. We haven’t yet had a similar study in Uganda.

CountryEstimated casesMortalityCases per death
Kenya1,600,0000.0044%22,700
Malawi2,200,0000.0005%200,000
South Africa12,000,0000.125%800

South Africa has high rates of obesity and demographics nothing like Uganda, so Malawi and Kenya are far better comparisons. These studies do have major flaw and in my opinion (for Kenya and Malawi at least) underestimate the mortality rate, but they are the best data we have. I’m going to be super conservative, and assume that the mortality rate here could be as high as 10 times that reported in Kenya, which means for every death we would expect 2000 cases. That means with 1.3 deaths per day, at minimum there are 2600 cases of coronavirus every day in Uganda. We currently test around 200 positive cases daily in Uganda, which means that over 90% of people who catch coronavirus in Uganda are never tested, and are out there in the community spreading the virus.  

So under 10% of people with coronavirus are actually tested, the rest are out there spreading.

And that’s where Ugandas policy comes in – forcibly isolating under 10% of cases. This achieves close to nothing, as over 90% of the cases are still out there freely spreading the virus

I’ve represented this tragedy visually below.

So the entire purpose of the institutional isolation – to stop virus spread is futile.  It’s bad enough sacrificing your time and freedom to help the country stop a virus spreading, but far worse that the sacrifice of the poor souls in isolation achieves nothing

It’s not like the Ugandan national taskforce doesn’t know this. Today Dr. Kobe, Ugandas Covid-19 “incident commander” estimated that 85% of coronavirus cases are never tested in the community, which is similar to my estimate of over 90%. Given that the MOH, WHO and Uganda coronavirus ask force know this, it’s bizzare and unconscionable that they continue to lock people up for no reason. 

2. Isolated patients could catch worse illnesses

It’s bad enough that their sacrifice is for nothing, but putting a whole lot of patients who aren’t very sick with coronavirus in a room together is worse than useless – it’s harmful. Secondary infections like TB (not uncommon in Uganda) and pneumonia can spread from patient to patient, especially while their lungs may be more vulnerable while they have corona. There’s no question asymptomatic and mild corona cases would be safer at home then this room in Namboole stadium, Uganda’s largest isolation center

“Do no harm” is a fundamental part of our Hippocratic medical oath. Us medical professions should not for any reason harm further those who are sick. The Ugandan isolation centers violate this fundamental principle, and put those with asymptomatic or mild corona at higher risk of life threatening infections – collateral damage of a useless policy 


3. Endangering Medical staff.

Not only are people with coronavirus put at risk of catching secondary infections, but medical staff all around Uganda are forced to babysit these people who aren’t sick, and therefore risk catching coronavirus as well. This has many negative consequences.

1. Medical workers catch corona.  Already 4 medical workers who were associated with isolation facilities have died of coronavirus. Just yesterday, a nurse at Kapchorwa hospital died because they probably caught coronavirus from someone with corona who they isolated in the hospital. Medical staff are our most valuable health resource and putting them in harms way for no gain is both unfair on the staff and just plain stupid..

2. Health services suffer. After 50 staff tested positive and one nurse died at Kapchorwa Hosptal, they have closed the whole hospital. This closure makes no sense. If all hospital staff in Uganda were tested, some staff would test positive at most hospitals across the country. The risk of spreading coronavirus is nowhere near as high as the risk of closing the hospital and stopping lifesaving services. Even though a nurse has died, the healthcare fallout from closing the biggest hospital in a region where health services are already massively stretched will be enormous. More than 1 person will die because of the closure. This is just one example of health services crumbling under the weight of a nonsense policy

The end result? Human rights abuse

Forcing coronavirus patients into a harmful situation to achieve nothing, is human rights abuse. These poor people with corona who aren’t even sick are removed from their families and put into open wards with many patients, while their children and families receive zero support.

The WHO (and others) are supporting the Ministry of health to abuse the human rights of Ugandans.

And it needs to stop now. It needed to stop a long time ago

Ths Solution is easy. Do what the rest of the world is doing – isolate people at home. As I’ve already shown, isolating people with Covid doesn’t achieve meaningful results anyway, but if the WHO and MOH want to feel like they are doing something to “control” the virus, then they could regularly call people, or even visit people at home to make sure they were complying with isolation.

I’ts my plea to the WHO and Ministry of Health to stop this policy now, and halt this strange and unnecessary episode of human rights abuse. I’ll send this blog to organisations that are supporting MOH efforts, and you never know –  someone might have a heart and respond.


NB anyone is keen to follow up with me (Nick) about this, I’d love to hear from you though the blog contact form.

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Move Slowly, Move Well

“God lead us to our footpath:
Lead us there where in simplicity
we may move at the speed of natural creatures
and feel the earth’s love beneath our feet
Nothing can be loved at speed.”
Leunig

I move far too fast, far too often.

This morning I learnt for the thousandth time the value of moving slowly and openly. Well slowly-ish at least. We bike everywhere here in Gulu. In some ways even biking is still too fast, you still miss a lot. You don’t stop and talk, you don’t cuddle the cat on the corner, you don’t notice anyone’s problems. But biking is slow and open enough at least to smile and greet along the way. It’s slow enough that God at least has the chance to speak.

It’s all too easy no matter where we are in the world to surround ourselves with walls. We leave our 4 walled house, enter our 4 walled car, go to our 4 walled work and then hit repeat. It’s easy to keep walls around your heart when there are always walls around your body.

This morning I biked to work, and had the great pleasure of greeting our community on the way. 7 times I shared a greeting , but 3 of them carried great weight, and I couldn’t get them out of my head.

A man smiled and waved “Otim, bin ka mato kongo” – “Otim, come have a drink with me”. And yes, by “a drink” he means an alcoholic beverage. And yes, it was 8:30 in the morning. I smiled back and yelled “Good morning, thank you” before rolling on. I was struck by how normal and open his brokenness was. Being drunk at 8:30am isn’t great. He wasn’t digging in the fields to make sure his family was fed, or selling chapatis on the side of the road. For whatever reason he was drinking with his mates on the side of the road. By 8:30am already I had already been moved by friendly brokenness.

A 12 year old girl yelled out “Icho Daktar Otim” – “Good morning doctor Otim”. I reflected how my title came before my name. Forget being white, forget being rich, just being a doctor alone grants me a status here that’s hard to fathom. My privilege is always before me, and maybe that’s healthy. By 8:35 am already been confronted with my status.

Lucy towers over Bishop Steve Minor, then NZCMS director

I’ve saved the best until last. Our neighbor Lucy spends her whole life moving slowly, because she doesn’t have the capacity to move fast. This bestows on her several advantages. She knows everyone in the community. People come to her every day for advice, or a story,  or a laugh, or for help, for a meal or sometimes all of them at the same time. While we shut our front door too often, hers is always open. In fact she’s usually on the veranda waiting to welcome the next visiting angel.

Every morning when I’m biking out of our compound, she smiles and commands,

Nick, Mot Lutwo” – Nick, greet the sick for me”. She doesn’t call me “doctor” like the young woman on the road, I’m Nick her friend, her neighbour . She commands me softly not to cure the sick, or work hard but to greet them and share our humanity. That first, we are a child of God, then everything else. Lucy reminds me that I’m not a machine mending other machines, but a human helping other humans. Today, my work isn’t just about solving problems, it’s first about meeting people where they’re at and offering what I can.

Lucy knows more than most what it’s like to be sick, what it’s like to suffer. She has a condition which means that every few months she suffers much pain and is admitted to hospital. “Greet the sick for me” comes from her heart, out of deep experience and empathy.

She teaches us to move a little slower, be a little more human, a little more alive.

Move slowly, move well.

Tessa, Lucy and Pablo puss!


(The whole Leunig prayer)

Dear God,

We pray for another way of being:
another way of knowing.

Across the difficult terrain of our existence
we have attempted to build a highway
and in so doing have lost our footpath.
God lead us to our footpath:
Lead us there where in simplicity
we may move at the speed of natural creatures
and feel the earth’s love beneath our feet.
Lead us there where step-by-step we may feel
the movement of creation in our hearts.
And lead us there where side-by-side
we may feel the embrace of the common soul.
Nothing can be loved at speed.

God lead us to the slow path; to the joyous insights
of the pilgrim; another way of knowing: another way of being. Amen”.

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5 Questions to ask before supporting Euthanasia

It’s high time to deepen the discussion about Euthanasia. Cards on the table, I’m against it, but what I’m most concerned about is that we have a serious conversation rather than reducing the discussion to “People have the right to choose” on one side, or “Doctor’s shouldn’t kill people” on the other, which are both unhelpful oversimplifications. Whether we are currently for, or against euthanasia, there’s a good chance we haven’t thought about it hard enough. Euthanasia is a complex and multifaceted issue, there’s no easy way out of the rabbit hole. Here are 5 questions I think we should all ask ourselves before we decide if we are really in favour of Euthanasia.


1) Why are most professionals who work with the dying against euthanasia?
Most medical professional associations in New Zealand that work intimately with dying humans don’t support euthanasia. It’s important to consider the thoughts and opinions of people who give themselves every day for those who are suffering and dying.

Why is there such a mismatch between the public, who are overwhelmingly in favour of euthanasia, and end-of-life professionals who are mostly against it?


2) Is one Mistake too many?
Mistakes are inevitable in any field, especially medicine. Although tragic, mistakes are acceptable while doctors attempt to save lives. Are mistakes OK while doctors end lives? Last year in New Zealand us medical professionals made many mistakes, including programming a pacemaker wrong which caused a cardiac arrest. One study suggested that 1 in every 25 people sentenced to death in America may be innocent. Is that OK? What if 1 in every 100 humans whose life ended through euthanasia didn’t really want to die? What if  perceived or real burden on their family drove them to euthanasia but they never revealed their true thoughts? Or worse received euthanasia after a mis-diagnosed terminal condition?

One 62 year old lawyer was ‘helped’ with assisted suicide in Switzerland after he was diagnosed with terminal bowel cancer. On autopsy he was found not to have cancer. He wasn’t going to die. Mistakes happen. Is there an acceptable mistake rate when it comes to euthanasia? Do you agree with famous British Surgeon Henry Marsh when he said “Even if a few grannies get bullied into it, isn’t that the price worth paying for all the people who could die with dignity?”

 

3) Would some people have changed their mind soon after dying?
Many people, after seemingly making the decision to end their life, change their mind and want to continue living. In Oregon, there is a different system from euthanasia where people get prescribed a lethal medication, which they then take themselves. It’s called “physician assisted suicide”. Since 1998, one in every three people didn’t take the lethal drug after being given a prescription. That’s 861 people who went through the whole process of paperwork and psychological evaluation, were given a prescription for the lethal drug then didn’t take it. Obviously it’s fantastic that they changed their mind and chose to keep living, but it disturbs me that so many people could change their mind after such a vigorous process. How many people might have changed their mind a week or a month later after they died of euthanasia?

Prescriptions written vs deaths.png

4) Could euthanasia abuse the vulnerable?
Of all vulnerable populations, elderly are most likely to be abused, mostly by those close to them. A 2015 New Zealand report showed that 1 in 10 people over 65 are abused. Rates among Maori are even higher.  Will abusive family members pressure elderly to be euthanised? Even in loving families, could elderly people opt for euthanasia because they silently feel like a burden? Disability rights groups have expressed deep concerns about Euthanasia. In the USA, most disability advocacy groups are strongly against Euthanasia, because they can see the potential for people with disabilities to die prematurely due to abuse of the system.

5) Is this really a Progressive vs. Conservative, or Religious vs Non-religious issue?I think it’s helpful to set aside labels, and ideologies. Euthanasia isn’t automatically a “progressive” or “liberal” win, nor a “conservative” loss. Martin “Bomber” Bradbury, a prominent liberal left wing blogger is against euthanasia. On the other hand a minority of christian organisations support euthanasia, for example “Christians for Voluntary euthanasia” in Australia. One Ex Archbishop of Canterbury (Head of the Anglican Church in England) now supports Euthanansia. Should we draw lines and divide into camps on this issue, or instead think deeply and open up respectful discussions with our family and friends?

I encourage you to think through these questions (and more) deeply before coming to a decision. Euthenasia is a complex issue that I’m not sure any of us can fully understand – but we should try our best before we enter the ballot box

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Why is coronavirus so bad in South Africa?

Yesterday South Africa suffered the 4th highest number of confirmed coronavirus cases in the world, clocking over 12,000 cases. This meant that 2 out of every 3  cases in Africa came from only one country, South Africa.

South Africa has a similar population to Uganda, yet has suffered from 300,000 coronavirus cases while Uganda has only just clocked 1000. When it comes to coronavirus in Africa at the moment, we really should focus on South Africa.

SOUTH Africa case corona

It may seem strange that a country with 5% of Africa’s population, made up 70% of the continent’s confirmed cases, but there are a number of  reasons which might explain why coronavirus is spreading so rapidly down south.


Why is South Africa suffering?

South Africa is radically different from many other African countries. In fact South Africa has many features similar to European and American countries which have suffered terribly form coronavirus. I hope there’s no-one out there who still thinks Africa is one country, but I’m sure you won’t after reading this!

1) South Africa’s Older Population.  Older people are not only have more severe disease, but are more likely to get infected with coronavirus. This nature article estimated that those over 20 years old are twice as likely to catch coronavirus than people under 20. As well as catching it more easily, older people also more likely to spread corona as they are more symptomatic. In South Africa, 4 in 5 people are over 20, while  only 2 in 5 Ugandans are over 20 years old! South Africa’s older population facilitates easier spread of coronavirus than in other countries. This lack of spread in younger people a should also make countries like Uganda be less worried than they are about opening schools, but that’s another issue.

2) Most South Africans live in cities. In South Africa, 2 out of every 3 people live in urban areas. Around the world, coronavirus has thrived in busy, packed cities – think of the disasters in Milan, London and New York. Here in Uganda only 1 in 4 people live in urban areas, a minority of the population.

3) Colder Temperatures. We know that hot weather doesn’t stop coronavirus, but it does slow spread a little. Here’s the forecast for Johannesburg this week, perhaps not what you would expect – lows of 3 degrees!!!

Screen Shot 2020-07-16 at 10.06.26 AM

4) Obesity Epidemic. South Africa has THE HIGHEST obesity rates in Sub-saharan Africa. More than 1 in 4 adults are obese, similar to Australia, Mexico and the UK. In  Uganda on the other hand only 1 in 20 adults are obese. Higher obesity rates increase virus spread as obese people are more likely to have symptomatic disease, and therefore more likely to spread it to others. Obese people are also more likely to catch influenza, and this may well be the same for coronavirus although there isn’t yet solid evidence to support this this theory. 

With all those factors driving the terrible outbreak, we hope South Africa’s public health measures and decent health system can control the spread soon. Unfortunately even if theyturn the corner in the next couple of weeks, it’s going to be many months before South Africa has coronavirus truly under control.

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