Question & Answer: The crisis in Northern Uganda

from International Medical Corps
Published on 15 Jul 2004
The crisis in northern Uganda has been called "perhaps the most under-reported story in the world today," by Jan Egeland, the United Nations Under-Secretary-General for Humanitarian Affairs & Emergency Relief Coordinator. IMC provides this interview with its Country Director in Uganda, Henk Bruyn, to help explain the situation and the need for increased international response.
The situation in northern Uganda has been called "perhaps the most under-reported story in the world today." Why is it deserving of that distinction?

For nearly two decades, northern Uganda has been plagued by a civil conflict between a rebel group, the Lord's Resistance Army (LRA), and the Ugandan government. The conflict has displaced approximately 1.6 million Ugandans, but perhaps the most telling statistic is that, in some districts, 95% of the population is displaced.

Whereas displaced populations usually find some protection in camps, the camps in northern Uganda are actually magnets for rebel attacks because that's where rebels can find food, pharmaceuticals and children, an estimated 20,000 of whom have been abducted and forced into combat. Many child soldiers, in fact, have been forced to kill their families and neighbors, effectively preventing them from ever returning to their communities.

It's a situation that can't get much worse, but it seems very little of the outside world knows about it.

How else has such prolonged violence affected life in northern Uganda?

Imagine being born in a camp for internally displaced people, growing up in the camp, going to school in the camp - if you are lucky enough to live in a camp with a school - and seemingly not having a future outside the camp. The conflict has been going on for 18 years now, and many Ugandans have been displaced and living in "temporary" camps all that time. Many children have been born in the camps and do not know any other life; a generation is growing up without hopes and expectations for the future.

All social structures are in upheaval. In five districts in the north, 50% of primary schools are displaced. The teacher-to-pupil ratio is, on average, 1:200 and as much as 1:300 in some areas. Moreover, the local and regional economies have changed from balanced, rural-based economies to distorted, war-related and relief-influenced economies. In some places, 85% of the daily food intake is food rations, i.e. relief.

In addition, no one - traders, travelers, relief workers, government employees - can move freely. When they try to, they often get ambushed. Dozens of people are killed every month.

And because the camps themselves are targets, there are now about 35,000 "night commuters" - mostly women and children - who walk into main towns in the evening, seeking protection against violence and abduction. There, they spend the night in the open grounds of schools, hospitals and shops.

What are the health threats to those who are displaced?

Within the camps, sanitary conditions are abysmal. According to surveys, the availability of good water in many camps is only two liters per person per day, as opposed to the recommended 15. Also, people live very close to each other. There is a real risk for contagious diseases to spread very quickly once an infection has taken place.

But throughout the north, there is insufficient health care capacity. The government-run health centers are few and far between, and most are chronically under-staffed and under-funded. In Gulu and Kitgum districts, only 50% of health centers are functioning, and 40% of their health workers have fled because of insecurity.

So there is little in the way of prevention or treatment, and the health threats - acute respiratory tract infections, diarrhea, malnutrition, malaria, measles, HIV/AIDS, maternal and infant mortality - are almost too numerous to list. In the conflict areas, global acute malnutrition ranges from 7% to 21%; 10% signifies a nutritional emergency. And the HIV/AIDS rate in northern Uganda is 33% higher than in the rest of the country.

What has been the humanitarian response?

In general, the international community has taken on many activities and responsibilities. But there has been a general deterioration in service delivery in the health sector as a result of insecurity. Because of their drug supplies, most health centers - and their workers - have been among the targets of attacks. Many health centers have closed as a result.

It is important to note that this is not an ordinary conflict. There is no front or other clear demarcation. The rebels are everywhere, mixed in and amongst ordinary communities, and they cannot be recognized. Rebels roam around the countryside, hiding in the bush and living off the land or off what they loot from camps and settlements, and they can attack unexpectedly at any location.

Consequently, it is extremely unsafe, even by relief workers' standards. Despite the combined efforts, the humanitarian response is falling far short of the needs. Many camps are not being reached at all. Some others are reached but not often enough. The capacity of relief agencies is stretched to the limit or beyond.

What is IMC doing to improve access to health care and the quality of health care in the affected areas?

In Kitgum and Pader districts, IMC is operating mobile health clinics as well as supplementary and therapeutic feeding centers. IMC first responded in late 2003, and immediately began training government health workers in the delivery of primary health care and the management of therapeutic feeding centers. By the end of the year, it had trained nearly 50 Ministry of Health workers and more than 100 traditional birth attendants in the basics of primary health care, nutrition and reproductive health. As a result, more than 27,000 children received immunizations - a 20% increase in coverage - and the number of births supervised by skilled health workers jumped from 20% to 50%.

IMC will continue to be creative in finding ways to increase local health care capacity. While some might say there's no end in sight, we can only hope the situation improves. It's our job to hope, too.