Ugandapanda

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”

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.

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 enemies, bless those who curse you, do good to those who hate you, and pray for those who spitefully use you and persecute you“

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.

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.

“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.

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.

(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”.

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.

• The Australian and New Zealand Society of Palliative medicine (Palliative Care Doctors)
• Palliative Care Nurses New Zealand
• NZMA – New Zealand’s largest Medical association
• Hospice NZ 

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?

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

Yesterday South Africa suffered the 4^th 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.

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!!!

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.

Our friend James has been at home from school for 3 months. His home situation is tough and while he’s been off school he got in with the wrong crowd, was taken to the police station and threatened with prison. He’s currently farming in the village learning nothing. Coronavirus has his life course is now teetering on the edge when  it was on the right track. All because schools are still closed.

Uganda’s decision to keep schools closed may be one of the worst decisions that the government has made in their recent history, yet few people are complaining. While the IMF and World Bank are lining the pockets of Uganda’s corrupt government, I haven’t heard of any call or any pressure from them or others in the international community pressuring Uganda to re-open their schools. There isn’t much complaint locally either, in the news or on the streets. It’s strange that barely anyone is protesting against a decision which will un-necessarily hurt Ugandans on a huge scale for years to come.

Before I start this thinly veiled rant well reasoned blog, I actually agreed with the decision to close all Ugandan educational institutions back in March. At the time, Covid was wreaking havoc around the globe and we didn’t know how it might affect Uganda. It was a bold, early decision that seemed prudent. But the outbreak here has not just been less severe than expected, it hasn’t even got off the ground. I’m not going to cover why exactly the outbreak might be so slow in Uganda. We really don’t know, but if you’re
interested I have mused about this elsewhere.

Coronavirus isn’t killing Ugandans’
Uganda has one of the slowest Co-vid outbreaks in the world – if you can even call it an outbreak. Only around 700 people have tested positive, and not one person has died!

Let me repeat that, not one person has died.

There is only one country in the world with a larger population than Uganda  (Vietnam) which also has no deaths. They have already re-opened their schools

To put this in context, in the 3 month period of Covid malaria may have infected around 3,000,000 Ugandans and killed 5000 people (estimated from global burden of disease). I tried to make a graph to compare the burden of the two conditions, but it didn’t work because the scale difference was so big. It’s kind of like those pictures where you compare the size of the Sun to the earth.

Yet out of fear of a disease which hasn’t killed one person we still have to wait one month to find out when schools are opening, or if they will open this year at all.

But why is closing schools such a big deal? If it can help prevent the spread of coronavirus why not be cautious? For a start we may have a year with no new doctors, nurses or teachers trained in Uganda, but the effects run far deeper. Here are just 3 of many reasons why closing schools for more than 6 months in Uganda is not just an inconvenience, but a disaster.

1) Children go BACKWARDS
Closing schools has a far more drastic effect than just lost education time. Children FORGET what they already know. This means they don’t start again where they left off, they instead have to RE-LEARN what they previously knew, but have now forgotten. This means that after 6 months off school, it might take another 2 or 3 months just to get back to their previous level. If Uganda closes their schools for 9 months, it may be equivalent to more than a year of lost education. This problem has been recognized even in countries like America, where unlikely Uganda most children are able to be home schooled.

2) INEQUALITY is exacerbated
Richer kids (especially in Kampala), can still learn when school is off. Their parents are empowered and able to teach them. They can learn on the internet. Their parents can buy them work books and reading books. They might even not go backwards, but can still progress while they are out of school.

The situation for poor kids in the village (75% of Ugandan children) is worlds apart. Kids have either sporadic access to educational radio, or no access to learning at all. They don’t have books to write in or read from. They dig every morning to provide food for the family, then play at home. They barely learn anything new, and will go backwards. Every month schools are closed, the inequality between kids in the village and kids in Kampala becomes worse. School closures causing exacerbated inequality has been well documented around the world, by developed and developing countries alike, and in Uganda will be as bad as anywhere in the world.

3) LIVES WILL BE SHORTENED.
There is a strong association between education level and reduced life expectancy. People with lower levels of education (primary school), live shorter lives on average than those with higher levels of education (secondary school or above). It’s impossible to prove that lower levels of education CAUSE lower life expectancy, but especially in developing countries like Uganda it makes sense that poor education means you are more likely to die younger.

Poor education leads to poverty, which means you are more likely to live in unsanitary living conditions, more likely to have poor access to healthcare, more likely to die in childbirth because you can’t reach a hospital. In Uganda even more so than richer countries where this link has been studied, less education may shorten your life. It’s entirely possible that the effect of lost education alone, may cause more lost years of life than coronavirus.

Figure from “Netherlands, health systems review: 2016” European Observatory on Health Systems and Policies

Other countries are reopening schools
The Co-vid situation in South Africa is ominous, with colder weather, large urban slums and an Obese population paving the way for a far worse outbreak than we will ever have here. South Africa yesterday suffered from 3174 cases with 74 deaths.  The way things are going in Uganda, we may not reach 74 deaths from Covid this year, let alone in one day. And what are South Africa doing despite the outbreak? They are opening their schools!  Their government knows how much more important education is than perhaps preventing a handful of coronavirus deaths. South Africa’s approach is mirrored by most countries around the world. Uganda is in a small minority of countries making the tragic decision to close schools for an extended period.

A solution?

I don’t usually like to write without proposing some kind of solution. Here it’s tricky, but there’s a few actions that just might push the government to open schools sooner than they would have otherwise.

1) The international community should pressure Uganda to re-open their schools.  Large organisations who grant loans and aid like the USA, the IMF and World Bank could use their leverage to force re-opening of schools.

2) The WHO should stress the importance of education and keeping schools open. At the moment they are only doubling down on contact tracing and lockdowns. They need to recognize the public health importance of education, and publically encourage countries to open as soon as possible when outbreaks are under control.

3) Most importantly, Ugandans need to demand that their government re-opens schools. Museveni is a populist. If enough Ugandans kicked up a fuss he might consider re-opening them, as it doesn’t hurt him at all. It might not even take that much fuss! At the moment motorcycle taxis are holding demonstrations around the country, but I haven’t heard a whisper about schools, and everyone has children. Everyone is affected.

Education is the key to Uganda’s future. The benefit of opening schools now would be enormous, while the consequences of keeping them closed are monumental. Let’s not let a virus which has killed zero people further cripple the future of the country.

This was the front page of Al-Jazeera yesterday, a Qatari news agency.

I’d hoped Al-Jazeera would be the one major news network not biased towards Europe and the US. Instead there are four geographical areas mentioned on their front page.

US
UK
Europe
The world….. Says it all really

News agencies are making 2 major errors that we need to wake up to, if we want to have a truly global perspective.

Error 1) Not shifting their focus to match the outbreak

As the focus of the outbreak shifts around the world, the focus of the news should shift with it. But it hasn’t. If you follow major news sites you would think that the biggest problems are still in Europe and the USA. But the virus has now gone global. It’s not all about Europe any more.

Yesterday, 12 out of the 15 countries with the highest number of cases were NOT European or the USA. This may surprise some people. Would you have guessed that India, Peru and Turkey are in the top 10?

Russia and Brazil daily cases have reached a staggering 10,000. This peak EXCEEDS the peak of any European country. Yes you heard correctly, Russia and Brazil right now suffer from more cases every day than Spain or Italy ever had. The front page of coronavirus news should be full of stories from Russia and Brazil. There is no shortage. In the last week 3 Russian doctors appear to have committed suicide by jumping out of windows perhaps due to stress and pressure from the government. You may wonder why you haven’t heard that story, but hopefully it’s becoming clear.

Error 2) Reporting like the coronavirus outbreak is improving 

Things are getting better right? Much of the focus of the media is about improving case numbers, flattening of curves. How countries are going to lift restrictions and  re-open their economies. How England is re-opening schools. How Spanish Children can now go outside, how German football is about to restart. Success stories are good and we should share them, but the media should not give the false image that the outbreak is getting better.

One headline on the Al Jazeera front page says it all “world gambles with looser lockdowns, risking coronavirus revival”. As if coronavirus has now improved, but could get worse if we aren’t careful. This is a gross misinterpretation of the global reality.

Because coronavirus on a global scale HAS NOT IMPROVED. For the last month, the daily number of cases has flatlined. Coronavirus globally as bad as it ever was.

Where are the reports on the escalating situation in South America? On the struggle to control the virus in India? On major outbreaks in Eastern Europe? The stories are there, but they aren’t on the front page of the news websites.

The media focus should shift with the virus. But it hasn’t. I guess that’s the world the media lives in. A EuroAmerican centric world. I had hoped for better from journalists around the globe.

But we don’t have to live in the false reality of the global media. We can seek out the stories that don’t get shoved in our faces. The stories are there if you dig just a little. One approach is to visit a tracking website like worldometer and see which countries have the most cases. After that you can google those countries “coronavirus in Russia” or “Coronavirus in Peru” and the stories are there. You’ll even find them on the major news networks, tucked in behind their Eurocentric front pages. Yes this is more effort than just typing in www.bbc.com but I think the world outside Europe and America deserves our attention too.

Let’s put in that little bit of extra effort to have a truly global perspective.

Uganda’s lockdown is killing people. That’s not a guess, or an opinion – It’s a fact. Every lockdown kills some people, whether in England, America or Uganda. People die through lack of access to medical services, through increased poverty. Through suicide and violence. In England, lockdown may have contributed do a doubling in deaths due to domestic violence. In Nigeria, security forces have killed more people enforcing the lockdown than the virus has killed to date.

Obviously lockdown SAVES many people as well through preventing virus spread. The best question to ask is not whether  lockdown is saving people OR killing people, because the answer is always both. A far better question is.

Will our lockdown save more people than it will kill?

This question should be asked by the public. It should be asked by analysts. Most importantly this question should be asked by policy makers – those implementing the lockdown. There’s no way to answer this question accurately, as we are forced to make many guesses with little data. Which extra deaths were really caused by the lockdown? What would the future have been like without the lockdown? How many cases of coronavirus would there have been? But we must try.

Will our lockdown save more people than it will kill?

In richer developed countries the answer is a resounding YES. Early comprehensive lockdowns have saved thousands of lives, while there is no indication that large numbers of lives have been lost through health service delays or increased poverty. Sweden did not lock down, and coronavirus has killed over 2000 people. The similar sized country New Zealand locked down hard and only 17 people have died. It’s inconceivable that the consequences New Zealand’s lockdown has led to the death of 2000 people, so New Zealand’s strategy of lockdown is to date a winner.

Will our lockdown save more people than it will kill?

In high income countries lockdown kills few people, because governments have enough resources to look after their citizens in a crisis. Health systems have the capacity to continue regular services while also dealing with a surge of coronavirus cases. Governments avoid severe poverty by handing out money or food to those who can’t work. The economic consequences of lockdown might be severe, but the immediate medical consequences are not devastating and few extra people die.

In Uganda on the other hand…

In Uganda, the situation is far more complicated. Lockdown kills people for many reasons, but these two are super important. Both affect people’s ability to access healthcare when they get sick. Lockdown reduces access to health services is by making transport to healthcare facilities difficult, and by squeezing the poor financially.

1) Reaching hospital is now VERY difficult. This is the biggest tragedy of Uganda’s lockdown. Usually when people get very sick in the village, most people will hop on a motorbike taxi to reach the hospital. Right now however in many areas the army and “local defence units” prevent any movement on motorbikes. Motorbikes refuse to carry people even if the situation is desperate, so if you get sick you are in big trouble. There is more and more flexibility compared to a few weeks ago, but this remains a major problem.

 2) Already poor people become destitute. When you have a dollar in your pocket, if your kid get’s a fever you might to your local clinic and pay for a malaria test. If you don’t have a dollar you might stay at home and just hope your kid improves. Sometimes they don’t.

But how many people is lockdown killing?

That question is the big problem. It’s relatively easy to quantify coronavirus deaths, but it’s extremely difficult to estimate how many people a lockdown is killing. Uganda doesn’t keep meaningful death statistics so it’s impossible to know for sure if more people are dying during this time.

So I’m going to do something a bit outrageous.

I’m going to guesstimate how many people the lockdown might kill every month. This is unscientific, flawed and I may even make mathematical errors, but I’m going to do it anyway to illustrate just how many people lockdown might be killing. How will I do it? I’ll use a baseline estimate of the number of deaths that would have happened anyway, and then add a small percentage which might be caused by the lockdown. I’ll include only 4 causes of death which are likely to have increased under lockdown. Infectious diseases, maternal and neonatal mortality, chronic disease and physical violence. 

I‘ll be super conservative and assume that mortality for each cause of death won’t increase by much. I’m going to assume that mortality will only increase by between 2% and 10% for each of these causes of death, with a best guess of 5%. For the baseline mortality figures, I use estimates for Uganda in 2017 generated in the peer reviewed Global Burden of Disease study.

Infectious diseases (Malaria, pneumonia and diarrhea)
Two weeks ago, I received a call from a nurse in a remote OneDay health center we operate. Our amazing nurse had identified that a 12 year old kid had severe malaria with anemia. He desperately needed blood. Motorbikes refused to carry him to hospital as they feared beatings, or the army confiscating their motorbike. After 8 hours an ambulance finally came, but it was too late. Rubanga-Kwo died soon after reaching hospital.

Besides deadly transport delays, mosquito net distribution has been cancelled this year due to coronavirus, and there is no insecticide spraying planned. It’s likely to be a horrible malaria season. Under a worst case scenario, WHO modeling has raised the possibility of a 100% increase in malaria deaths this year mainly due to lockdown consequences. 

But I’ll be conservative and not use the worst case scenario of a 100% increase. If the lockdown caused just a 5% increase in mortality rates of malaria, pneumonia and diarrhea, then in one month lockdown may have killed 203 people with these diseases.

Maternal and neonatal mortality
One of our nurses at a different remote OneDay health center delivered 4 babies last week. Before lockdown in the previous 12 months he didn’t deliver one baby. He isn’t properly trained or equipped to deliver babies, but was forced to as women couldn’t travel to the proper maternity centers and arrived to the facility late in the labour process. Fortunately the mothers and the babies are all OK, but the situation was high risk, and a recipe for disaster. We’ve now liaised with the district up a better system for referral, as well as equipping him for emergencies.

Besides the actual delivery process, getting antenatal visits to be checked up and receive iron, folate and malaria prevention has also become more difficult.

If the lockdown caused just a 5% increase in the maternal and neonatal mortality rate, then in one month the lockdown may have killed 118 people with these diseases.

Chronic diseases (Cardiovascular disease, diabetes and kidney disorders)
Last week, 7 people were supposed to come to my hypertension and diabetes clinic at St. Philip health center. Only 3 made it. The rest of course couldn’t get to the health center because they normally arrive on the back of motorbikes. Without their regular medications, those people  are at higher risk of heart attacks and strokes.

If the lockdown caused just a 5% increase in deaths due to these chronic diseases, then in one month the lockdown may have killed 123 people.

Physical violence
Under times of stress, domestic violence and suicide are likely to increase. In addition, in some countries army and police brutality to enforce lockdown is killing some people.

If the lockdown caused just a 5% increase in deaths due to suicide and interpersonal violence, then in one month the lockdown may have killed 38 people.

How many lives will lockdown save in Uganda?

This is just as hard to predict, and is based on estimating how many coronavirus cases lockdown could prevent. Based on Uganda’s young population, I’ve estimated a mortality rate for coronavirus of 0.75%. It’s hard to predict how many coronavirus cases there might be per month under a less extreme lockdown scenario, but given the relatively slow progress of the virus in Sub-Saharan Africa so far, I’ve estimated that in a worst case scenario, Uganda may experience 50,000 cases a month (average of 1600 cases a day), and 375 deaths. To give some context, so far,the most cases reported in a single day Sub-Saharan African country was 318 yesterday in South Africa.

Under a less severe scenario, coronavirus cases may not exceed 10000 monthly even without a severe lockdown

If Uganda suffered from 20000 cases a month (a midrange estimate), coronavirus might kill 150 people a month, which is far less than my dodgy (but conservative) estimate of 482 deaths caused monthly by lockdown.

This graph indicates the number of coronavirus deaths under different scenarios. First assumes the current status quo of lockdown, while the second assumes a far less severe lockdown with spread of coronavirus. The blue bar indicates the “best guess” number of deaths, while the black lines indicate the range of possible numbers of deaths under each scenario.

As you can see from the graph, there are a range of possibilities, most of which estimate that Uganda’s lockdown will kill more people than it will save. This could be the case even if Uganda’s lockdown prevented 50,000 coronavirus cases a month, which might be a surprise to many. Given this situation, it’s worth considering a serious revision of how lockdown works here in Uganda. A couple of changes could make a huge difference in reducing lockdown related mortality.

1. Allow transport for all sick people, without needing written permission from officials. If sick people could move with only a written note from their medical professional on official facility headed paper, the transport issue could be mostly solved. Of course this would be widely abused, but the deaths safe through prompt treatment of sick people would outweigh the extra risk of coronavirus spread.
2. Widespread food or cash distribution. If a government closes their country down, they are under obligation to provide for their citizens during the lean time. This is EVEN MORE IMPORTANT in poorer countries like Uganda, where many are struggling to get by at the best of times. Supplying people with food or cash will help relieve stressful social situations, and free up money to access health services. Unfortunately the Ugandan government is prioritizing vehicles, allowances and giving millions of dollars to MPs rather than providing for their citizens.

I want to stress that these calculations are more about raising the issue of balancing lockdown killings vs coronavirus killings, rather than an accurate indication of the current situation. I’ve opened myself up to very reasonable criticism as to whether it’s fair to even try and make these guesstimates, but I think the only way to get people to take this issue seriously is to try and quantify the number of people lockdown might be killing.

I would love corrections and comments on my math and estimates, so together we can improve this hypothetical analysis. If you want to understand my working better, please make a comment, or contact me through the blog.

Stay safe Uganda!

Is it too much to hope for? Can the poorest region of the globe escape the worst?

What’s happening right now in Sub-Saharan Africa is nothing short of astounding. We have porous borders, poor healthcare systems and people packed together in chaotic cities and informal settlements. By conventional wisdom, it’s a recipe for infectious disease disaster and you’d expect coronavirus would slam the region.

But no

Sub-Saharan Africa is the least affected region of the planet. By a long way. About a billion people live here. On Saturday 11^th of April only 509 cases were reported across the entire region in 24 hours.

Not 509 deaths, but 509 confirmed cases. Only 5 deaths were reported.

Including Russia, there’s about a billion people in Europe as well. On the same day East Africa reported 5 deaths, Europe reported 3143 new deaths. Sub-Saharan Africa is doing very, very well. Or so it seems. There’s a couple of obvious rebuttals to this apparent success story, which I’ll deal with with before I move on.

Isn’t it still early in the outbreak?
Yes, but this doesn’t explain the low numbers. At the same stage of the outbreak in Europe, countries did not have huge case numbers, but most countries saw case growth rapidly increase. Over the last 10 days in Sub-Saharan Africa, not only have countries been spared exponential growth, we have not seen significant growth at all! The number of daily cases for most countries is a flat line. Below I’ve graphed cases per day for the four Sub-saharan African countries with the highest total number of coronavirus cases, plus Kenya from East Africa  to really prove the point. I haven’t even included countries the raft of countries where nothing much is happening, like Uganda which had only two positive cases in the last 7 days!

Looking back a month at South Africa, the country with the most cases and the most advanced outbreak, they appeared just on the cusp of exponential growth before….. flatlining. Incredible. Wonderful!

Are countries not testing enough?
Yes many African countries have far less testing capacity than more developed countries, but while their testing capacity is INCREASING, the number of positive cases remains stagnant. Here in Uganda, we have gone from testing around 200 a day two weeks ago to testing 600 in a day. South Africa, the Sub-saharan African country with the most cases has increased testing capacity from 1000 to 5000 a day in the last two weeks. If the virus was spreading fast you would expect increased testing to increase case numbers which isn’t happening. Poor testing capacity isn’t the reason for the low number of cases.

So why is Sub-Saharan Africa doing so well?

We really don’t know. Wow that’s an unsatisfying answer, I’m sorry.

Over a month ago on the 6^th of March I predicted that coronavirus “would not devastate Uganda” My three reasons were Uganda’s young population, a rural population, and a history of avoiding flu outbreaks. Of these three reasons the young population and rural population are currently irrelevant, because coronavirus hasn’t spread enough for us to know whether our young population will lead to low mortality (no-one has died yet in Uganda!) or whether coronavirus will spread less to rural areas.  My historical observation was the unexplained phenomenon that neither SARS nor H1N1 swine flu touched Uganda, which bodes well. None of these observations however even begin to explain the tiny number of cases reported across the region.

So what could it be? Why so few cases?

Is it the weather?
There is evidence that hot weather reduces spread , but this alone doesn’t explain the lack of cases. In other hot countries like Malaysia and Brazil, coronavirus is spreading far more quickly than any African country, although still not as rapidly as in Europe. Also there are regions such as Johannesburg in South Africa where the temperature isn’t exceeding the mid 20s, yet those areas aren’t seeing large numbers of cases. We can’t praise hot weather alone!

Genetics?
Significant genetic protection from the virus seems unlikely given the high infection and mortality rates among African Americans. That population hasn’t been in America long enough (a few hundred years) for their genetic code to be significantly different from (mostly) the population of West Africans where they originally came from.

Immunity?
Could it be that exposure to many pathogens, or malaria, or some other specific disease leads to increased coronavirus immunity? This has been suggested, but there is zero evidence to back it up. I hesitate to even suggest theories with zero evidence, especially this one which has been doing the fake news circuit but we know so little that I’m clutching at straws.

Harsh lockdowns?
Restrictions on movement and gatherings are not the secret to Sub-Saharan Africa’s success. Restrictions here just can’t bring about the same degree of social distancing possible in richer countries. Families are packed together in small houses. People can’t afford to stockpile food so have to interact with sellers every day. Corruption and laxity at borders is rife.

In Uganda 13 people with coronavirus passed through the airport without being stopped, and went back to their communities. Some of them went to the market and  used public transport before they were advised to self-quarantine. As far as we know so far, those 13 only infected three people, all family members! If this kind of breach happened in a European country, it would have lead to hundreds or even thousands of infections.

Social distancing becomes a farce, as Kenyans fight to receive food in Kibera settlement.

I’m sorry I’ve come with observations and not answers, but I don’t have any.

So not only do we not know why coronavirus isn’t bad, I haven’t heard any great theories. Hopefully soon someone will come up with better ideas, although there are obviously more pressing matters in other parts of the world at the moment.

Before finishing, I want to make clear that the virus is taking a heavy toll in a different way. The effects of Lockdowns in Sub-Saharan Africa have already killed thousands of people, and continue to kill many more every day. These lockdowns have caused crippling economic and healthcare system breakdown, with wage workers struggling for food and sick patients unable to reach hospital. In Uganda lockdowns are almost certainly going to kill far more people than the virus will, and tragically perhaps more people than the virus would have killed even if there had never been a lockdown. I plan to write about this in more detail soon.

Make no mistake, Some countries in Sub-Saharan Africa will probably have outbreaks that will kill a lot of people. We may well be far from seeing the worst of Coronavirus here. But that aside, right now the coronavirus situation is more positive than any epidemiologist, doctor or even layperson could have imagined.

May the Sub-Saharan miracle continue.